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 biological functioning . That’s where effective addiction treatment comes in. Interestingly, a relatively new form of therapy- DBT -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:
- 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.
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.
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.
- Chapman, A. L. (2006). Dialectical Behavior Therapy: Current Indications and Unique Elements. Psychiatry (Edgmont), 3(9), 62–68.
- 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.
- 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.
- Dimeff, L. (2008). Dialectical Behavior Therapy for Substance Abusers. Addiction Science & Clinical Practice, 4(2), 39-47.
- 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.
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
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.
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 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
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.
By Lisa Simpson
According to figures from the National Survey on Drug Use and Health, 5% of pregnant women in the US use illicit drugs, which rises to just over 20% in the under 18 age group. While heroin is used by only around 0.1% of women during pregnancy, a further 1% admit to using opiate based medications for purposes other than pain relief; prescribed opiates include codeine, fentanyl, hydrocodone, meperidine, morphine and oxycodone. Women are usually asked about their use of drugs early in their obstetric care to identify those who, along with their developing baby, are at risk from this habit. Displaying erratic behavior, signs of intoxication or withdrawal are easy to spot, but waiting till later in pregnancy to seek obstetric care, poor attendance at appointments and below expected weight gain are also indicators that a woman may be using opiates.
Risks from opiate use
Women who continue to use heroin during pregnancy risk reduced growth of their developing baby, fetal death, separation of the placenta from the uterus and premature labor. While birth defects have rarely been observed in babies born to women using opiates during pregnancy, a number of studies have demonstrated codeine use during the first trimester is linked to heart abnormalities; though this has not been seen with other prescribed opiates that have also been studied.
Methadone program during pregnancy
As well as treating pregnant women addicted to heroin with methadone, a similar maintenance plan is starting to be used with addiction to other opiates; there is also evidence that buprenorphine may be used as a safe alternative for management of opioid use, so this option may be presented to women. The dosage of methadone is determined by addiction specialists, who adjust the dose as required throughout pregnancy to avoid withdrawal; symptoms of this include cravings, anxiety, difficulty sleeping, feeling irritable and nauseous. Not only does this prevent these unpleasant symptoms for the mother, but protects her unborn baby; while withdrawal from opiates is rarely fatal for adults who are in good health, fetal death may occur in women who do not seek help with their addiction and try to withdraw on their own.
However, as with others who access help with opiate addiction, therapy goes beyond the prescription of methadone for pregnant women; she will also receive dependency counseling and have access to other medical and psychological interventions, as well as any other services deemed necessary. This ensures that by engaging in a program for therapy, women are more likely to receive prenatal care, which reduces the likelihood that complications will arise during their pregnancy. It is possible for most pregnant women to attend a methadone program on an outpatient basis, though in some cases it may be advisable to initiate methadone during a short stay at an opiate treatment center. While maintenance with methadone is preferred to withdrawal during pregnancy – even when medically supervised – due to the high risk of relapse, if participation within a methadone program is refused by a woman, the second trimester is the safest time for her to withdraw under the guidance of a specialist.
Neonatal Abstinence Syndrome
Although treatment with methadone is more likely to lead to a healthy pregnancy than if illicit opiate use was to continue, her newborn baby is at risk of developing a condition known as neonatal abstinence syndrome, which affects the nervous syndrome. As a result a baby’s sucking reflexes are uncoordinated, which interferes with feeding, and they are also more prone to be irritable. Babies who were exposed to methadone in the uterus usually develop withdrawal symptoms within their first three days after birth and while in some cases this may only last for a matter of days, in other infants they may remain for weeks. It is protocol for babies born to women who took opiates during pregnancy to be monitored for this syndrome so that treatment can be initiated as necessary; the obstetric and pediatric team work closely to ensure that the newborn receives optimal care to achieve normal feeding, weight gain and sleep patterns. As neonatal abstinence syndrome can be successfully managed and does not appear to have any lasting adverse consequences to physical or mental health, the advantages of initiating methadone in pregnancy far outweighs the risks.
All About Addiction has profiled stories of college addiction in the past, but most have centered on illegal drugs and the rampant problem of alcohol abuse. Education blogger Valerie Harris joins the community today to talk about a very disturbing new trend: the rise of “study aid” dependencies, usually in the form of prescription ADHD meds like Adderall. Valerie writes a student resource website for those looking into different college and grad school options, and is an expert in many of the issues modern students face. As prescription drug abuse is a major problem in our society, a specific focus on prescriptions relevant to college studentsis noteworthy.Study Drug Addiction Plagues Students From Masters Programs to Community College Illicit Adderall usage on college campuses has been on the rise in recent years, mostly stemming from its use as a study aid. The amphetamine salts that make up Adderall accelerate the heart rate and increase alertness, enabling students to put in long hours of continuous and focused study. However, due to its amphetamine base, Adderall can also be addictive, leading some students to use the drug as a crutch, causing long term issues both academic and social.
A 2009 article in the Cornell Sun stated that Adderall was estimated to be used by 6% of college students, while a 2011 survey in the journal Addiction reported that on some campuses, as many as 25% of students were abusing the drug. A study conducted by the National Survey on Drug Use and Health found that 15% of college students have illegally ingested Adderall, Ritalin or another stimulant in the past year, while only 2% of these hold a prescription for the drug. This suggests that there might be an overall increase in Adderall abuse although longitudinal data from single sources is relatively scarce.
In light of this possible increase, and the problems associated with it, universities are beginning to fight back. Recently, Duke University added “the unauthorized use of prescription medication to enhance academic performance” to its student conduct policies that equate to academic dishonesty. Wesleyan and Dartmouth have also amended their policies to include a ban on prescription drug abuse, while students with ADHD prescriptions at George Washington University are told to purchase a safe for their dorm. Other schools more aggressively target potential dealers.
The Illusion of Safety
Due to its prescription drug status, many college students believe Adderall to be safe and non-addictive. It’s true that when used with a prescription and with the supervision of a doctor, Adderall can be safe. However, when used without a prescription Adderall use is essentially akin to unregulated speed abuse. As an amphetamine drug, Adderall is listed by the Drug Enforcement Agency as a Schedule II Controlled Substance, meaning anyone caught with pills not prescribed by a doctor is subjected to the same criminal charges as those possessing opiates or methamphetamine. Schedule II drugs involve an extremely high risk of addiction and overdose, as well as a potential to lead to depression or heart failure.
A University of Pittsburgh newspaper notes that side effects can include irregular heart rate, increased blood pressure, headaches, sleep deprivation, and loss of appetite, among others. When abused, the adverse effects of the drug can be substantially exacerbated. Instances of acute exhaustion or psychosis during withdrawal have been documented, and when it’s mixed with alcohol, Adderall can even cause death. Among young people with developing prefrontal cortexes, the effects can be even more pronounced and long-term, essentially changing the chemistry of the brain.Safer SolutionsPerhaps the biggest hurdle schools and medical professionals face in weaning students away from prescription drug addiction in their genuine effectiveness. Still, statistics show that students using Adderall illicitly are often far from the highest achieving, with an average GPA among abusers of less than 3.0. The fact that the vast majority of students who take Adderall use it legally and likely suffer with learning disabilities clearly affects these performance numbers, but it is clear that Adderall is not a panacea. Students who truly achieve long term success usually do so by disciplining themselves and utilizing time effective time management skills. “The most important thing to have for time management is some kind of system” says Kelci Lynn Lucier, author of The College Parent Handbook. “Some students use the calendars are their phones: others use things like Google Calendar; others still use the classic paper-calendar model.”Lucier also asserts the importance of maintaining a regular and appropriate sleep schedule. “While it may be common among college students, a lack of sleep is more detrimental than you might think,” says Lucier. “It can throw everything out of whack: your mental health, your physical health, your stress level, and, of course, your schedule.”There is no doubt that Adderall offers a short-term solution for students that are behind in their studies, their sleep, or generally overwhelmed by their many burdens. However, the adverse effects of continued use on one’s mental and physical health, as well as the potential risks towards one’s education and future success, can prove devastating. Students who are genuinely invested their academics and career training are often best served by taking the time to study while maintaining a disciplined and manageable lifestyle.
Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.
Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.
The effects of expectation, motivation, and impulsivity when quitting smoking
Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.
As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.
The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…
The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.
The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.
The take-home: Quitting smoking is hard for different reasons in the first week and later on
If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.
It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.
Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.
Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.
Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?
Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.
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The first thing to note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.
The take-home: Quitting smoking is hard for different reasons in the first week and later on
If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.
Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?
Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.abstinence, activation, brain function, bupropion, cognitive, cognitive interference, cotinine, expectation, experiment, impulsivity, medication, motivation, nicotine, nicotine assocciated cues, nicotine associated, nicotine replacement, quit, quit attempt, quitting, quitting smoking, quitting smoking hard, relapse, research, smokers, smoking
The tool has separate sections for parents who fear their kids may be trying drugs or for those who know for sure.
Check it out, it’s a great tool that can help a lot in terms of educating, guiding, and informing parents who are having trouble with teens, drugs, and parenting. NIDA also has a new tool called Family Checkup, developed by the Child and Family Center at the University of Oregon, that is aimed at helping parents communicate effectively with their kids when it comes to drugs.
More than anything, research has shown us that communication around the topic of teens and drugs and even more generally communication between parents and their kids about taboo topics, can be effective for reducing problems and for finding help sooner (see here for smoking related research).
Okay, I’m not in as good a mood about the whole “Psychology Board-quitting drinking alcohol” experience this time… The not drinking alcohol part has not proven to be an issue until now although it has certainly come up a few times, especially around my upcoming anniversary and the question of whether I can sip champagne or not (obviously the answer is no). It certainly brings up the fact that so many of our social ceremonies involve alcohol and whether I like it or not, those notions are part of my view of social interaction. But that is seriously not the part that pisses me off the most.
Here it is – I am going into a helping profession, meant to support those in our society that need help. I myself have belonged to that group and still see someone on occasion, but I think I’ve come a long way in the last 12 years or so. But not only am I now forced to call in every morning (an ordeal for someone with ADHD anyway) and report for testing during work hours, but the payment for these things is absurd! Each test is going to cost between $50-$75 and I will initially be tested 4-5 times per month for a total of $200-$375 per month or $2400-$4500 per year! and that doesn’t include the $1000 per year in probation costs! That means that for a crime I committed 12 years ago, spent time in jail for and served 5 years of probation time, the CA Board of Psychology will now ask me to spend another $10,000-$14,000. Now, I should be able to afford the cost (barely) but here’s the rub the way I see it: These sorts of limitations and expenses are an endlessly difficult and probably nearly impossible hoop for a whole slew of people to jump through. By placing these sorts of demands on people with a past, no matter how distant, the California Board of Psychology is essentially squeezing out possible clinicians who may have dealt with drug and alcohol issues in the past. Even my Board-assigned probation monitor told me that she thinks this is excessive, but as usual there “isn’t much [she] can do about it.”
Money is the instrument by which we control people in this society, and that issue comes up again and again for me when I listen to rich politicians (yes, Romney) telling us that if we all just paid less taxes and if government just spent less money than we would all be better off. But that’s a lie – government provides services specifically for those of us who can’t afford to provide them for ourselves. Romney may be able to build a private road to any of his many houses but the rest of us need the government to build that road otherwise we’d only be able to drive where the rich allow us to… and they wouldn’t let us drive on their private roads anyway. So government helps the rest of us with education, transportation, food, and health care because its job is to equalize the playing field a little bit. That might seem like a digression, but here:
If people with an addiction or criminal past are made to pay $10,000-$15,000 in addition to satisfying every other requirement to become lawyers, psychologists, physicians, therapists, and more then aren’t we in essence saying to them that we don’t want them in these jobs? Aren’t we telling them that due to their past they are now damaged goods and aren’t really welcome where the rest of society lives? And if we’re telling them that when they try to become part of the helping professions aren’t we also saying that they are either unable to help or that we simply don’t want their help?
If that is what we’re saying then I think our system is fucked up. If we’re telling a portion of our society that even if they achieve everything someone else has they are not worthy of the same recognition then I think we need to take a long hard look at ourselves. Society survives and thrives because its members play together and help each other out – when we start drawing lines around what people are worth and what they’re allowed to strive for we disenfranchise exactly the portion of society we pretend to want to rehabilitate.
So I’m going to walk through this, proudly and successfully. I am going to stop drinking and I am going to pay the fees. But I am also going to speak my mind and make sure that the injustice and absurdity of the whole thing is heard, even if only by a few thousand dedicated readers. I’ve worked too hard to just turn the other cheek and say thank you. This is my life, I’ve earned the respect they can’t seem to find, and I’m going to claim it.