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Is there a scientific basis for this?


At the start of this article, I want to say that it is different from others I have written.  While I usually try to present facts and minimize my personal opinion, this paper is one where I express solely my own thoughts and opinions.  I have had success communicating these ideas to my patients. Many have said that it helps them understand some of the concepts so often thrown about by people in recovery.  I want to point out that I have not suffered from an addiction and hope that this allows me to approach spirituality from a more objective viewpoint.  Many people feel strongly about some of the following concepts.  I apologize to anyone who objects to any interpretation I have made.  There is no absolute definition of spirituality and everyone should follow the concept that helps him or her the most.  I only hope this article helps some people who may have had difficulty relating to the concept of spirituality in their own recovery.

Spirituality is a concept that permeates the treatment of addiction.  I often hear recovering persons speaking about there own spirituality and how it changed them.  It is widely discussed in academic conferences.  Some brave soul gets up in front of a crowd of hundreds of health care providers and relates his or her own experience with substance abuse and recovery and then credits some spiritual revelation that allowed them to enter recovery.  Everywhere I turn, there are so many people giving spirituality paramount importance.  Even state agencies require it to be discussed during addiction treatment.  The assumption is that if a person is not spiritual, they cannot be in recovery.  I almost envied recovering people for the life tragedies that gave them understanding of this concept.  Without such an understanding of spirituality, I felt that I would always remain an outsider working in this field.  And what was worse, I would not be able to impart insight to my patients.

Like many people who are in early recovery, I initially thought that spirituality had to do with religious devotion and practice.  As someone with only a moderate religious upbringing and having my own doubts about the core beliefs implicit in religion, I could not picture giving anyone insights into a spirituality that I did not feel I possessed myself.  I have found many persons, who are beginning treatment, express similar doubts about AA since the concepts of “spirituality” and “higher power” are so significant in AA practice.  They feel these are religious concepts making AA a quasi- religious institution


As I thought about this concept over the years, I observed various things and asked various questions.  Why does talking about things make us feel better?  Why do we feel good after seeing a sad movie as long as we identify with the characters?  I wondered if these experiences were similar to what people experience in a 12-step meeting.  At other times, I recalled certain feelings of contentment when I was among a group of people with whom I felt I belonged.

I thought about human evolution and the fact that there have been millions of years that we, and the species from which we evolved, lived in small tribal units.  There needed to be some connection between one member of a tribe and another in order to establish a unity that allowed coexistence and cooperation for a common goal.  This connection is probably similar to that which exists between members of a family.  I believe that there is a biological need for this connection, a need that has evolved over millions of years. It is as strong today as ever.  The connection is obviously not a physical one.  For lack of a better description, I say it is an emotional connection.  It is my belief that this is the same as the spiritual connection.

In most people, the emotional connection seems to be to other people; however some people can connect to an activity of some type.  Many people emotionally connect within their religious activities.  Religion has been society’s answer in providing for this need but it is only one solution.  Do not confuse the need, which is for spiritual or emotional connection, with a solution, which is religion.  I believe the confusion stems from the fact that profoundly religious people, described as spiritual leaders, are often interacting with others on an emotional level.  Also, spiritual is an adjective often used with religious activities.  However, I feel spirituality exists outside of religion.  12 step meetings also provide forums for the spiritual connection. 

Addiction is often described as a spiritual disease and I agree with this assessment.  Emotional isolation is just about a universal problem in addiction.  The patients I meet are amazed how I pick up on their isolation after a single brief meeting. They do not realize that I assume that such isolation is present in all my patients.

While I feel AA is extremely important, I have also seen people maintain recovery even though they do not participate in AA.  They have managed to become emotionally connected in some way.  Perhaps, they have become attached to a new person in their life.  Perhaps they reconnect to a spouse, child etc.  Perhaps, they have found an activity they are truly passionate about.  Many do find comfort in traditional religious beliefs and activities.  Yet, however they do it, they emerge from their emotional isolation.  This emergence is necessary for contentment and contentment is necessary for recovery.

We connect emotionally when we identify with a movie character.  We connect emotionally when we talk about our problems.  And, hopefully, we connect emotionally when we share or listen to the stories at 12 step meetings.  We relax within our sense of belonging to the AA group.  We feel contentment and feel better about ourselves.  I feel that the spiritual person is the person who is able to consistently connect with others on this emotional level.

As for the concept of higher power, I object to the term higher.  I, personally, do not think of this as connecting to God or some other religious or cultural figure standing above us.  But I feel that when we connect emotionally, it seems that we connect to an outside power.  It is the power in the love and support that we receive from the people who surround us and care about us and give us that sense of belonging.

People who are in recovery are my favorite people.  There is a sense of contentment about them even in time of stress.  They can make you experience that contentment just by talking with them.  An emotional or spiritual connection is made and you just feel good.  And when you feel good, it is easier to resist the drug cravings that threaten to drag you down.


what is Recovery

an opinion piece

 This is another of my articles that is less technical but nevertheless ties together some very significant points.   There is no clear definition of recovery- people each have their own definition.  There are no physiological tests to tell.  It all seems to be defined by behavior and a state of mind.

Why do people stay clean?  This is a different question from why they present for detox.  People present for detox for a variety of reasons reasons. All with one theme: they want to escape the negative consequences that the drug is having on their life.  Some are physically unwell, some in financial distress.  Their families are yelling at them or they are in trouble at work.  Many have legal issues.  

Patients constantly tell me that they won’t go back to using because it is too much trouble. I’ll laugh to myself because that’s beside the point. Avoiding negative consequences is a fine motivation for starting treatment.  But it won’t help long-term.

Fears have a habit of becoming less intense as time goes by.  Unfortunately, this effect is coupled with a temporary insanity where the person feels that the outcome following the next use of drug will be different from those following prior uses of the drug.   

So why do people stay clean?  The simple answer is: They stay clean and sober because they like being clean and sober.  They like their life because most of the time they feel good. 

I once read that, in marriage, if 80% of the moments were positive, it is enough to carry you through the negative moments.  I believe that something similar goes on in recovery.  If we feel good most of the time, we can tolerate periodic frustrations and other negative feelings.  

It is impossible to feel good while holding negative feelings.  One cannot be angry and feel good.  One cannot be resentful and/or envious and feel good.  And certainly one cannot be depressed and feel good.  Even if these feelings are appropriate, we cannot hold them and feel good.  If we have been victimized and do not learn to forgive, eventually the negative feelings will overwhelm us.   

Many people have psychiatric problems that will be discussed elsewhere on this site. The treatment of such problems is necessary to feel good and to obtain long-term abstinence.   When we feel bad, we may stay clean for a while, but eventually we will give in.  

Bad feelings are associated with certain fluxes in our neurotransmitters that increase our desires for drugs.  At some point we get a case of the “fuck its”. If I am feeling bad anyway, fuck it; I may as well get high.  I will use a drug especially since my temporary insanity will allow me to ignore the consequences of doing so.   

One way to feel good is to stay emotionally connected.  Whether we connect to religion or to other people, this is a mechanism often used.  I feel that spirituality refers to this ability to connect emotionally.  AA and counseling are other avenues to provide emotional connections.   

How do we know when we are in a good place?  When we experience gratitude. If we feel good, we are thankful for our life.  If we feel bad, we are not.  I often say that if we can be truly thankful for our current life when we awake in the morning, we are in recovery. 


Tolerance and Physical dependency

Most persons confuse tolerance and/or physical dependency with addiction.  While they are components of addiction, addiction is much more.  In fact tolerance and physical dependency  occur widely in many fields of medicine

Drug tolerance is a state of adaptation in which exposure to a drug over time results in a diminution of one or more of the drug’s effects (euphoria, pain relief, anxiety relief).  Some examples are as follows: Vicodin no longer gives me the pain relief I used to get.  He can tolerate a dose of alcohol that will kill you or me.  Hytrin (a blood pressure drug) does not make me as lightheaded as it once did.  My Nitro patch is not as effective at relieving my chest pain as it once did.  Tolerance is a physiologic phenomenon that occurs with many drugs in many settings.  It will develop to most controlled drugs if the medication is used with any degree of regularity.

A crucial concept in order to understand how people get into trouble involves the understanding that the brain is composed of many different areas.  Each area may develop tolerance at a different rate. They will develop tolerance to the euphoria they get from a pain pill before they develop tolerance to its pain relieving effect.   Tolerance to nausea occurs over a different time frame.  Tolerance to fatigue occurs over yet another time frame   People almost never develop tolerance to the small pupils caused by opiates. 

Physical dependence refers to the occurrence of drug specific withdrawal symptoms.  It  almost always includes tolerance.  These withdrawal symptoms are different from those caused by the original disease process.  Examples are: Neurontin used for pain may cause seizures if stopped suddenly.  Catapres, used for blood pressure control, may cause a rebound increase in blood pressure if stopped suddenly.  This rebound is far greater than the original blood pressure abnormality.  Opiate and sedative discontinuations cause other symptoms.

The take home point is that these phenomena are physiologic consequences to ongoing exposure to the drug.  They represent adaptations at a cellular level.  They do not signify addiction.  A patient taking Suboxone may be tolerant and will have withdrawal if he stops taking it; however; however, if he is working, supporting his family and happy with his life, he is not addicted.


The role of counseling

Does it add value?

This article is going to get me into trouble.

For the longest time, drug treatment was counseling, whether provided by professionals or obtained through 12 step meetings (a form of group counseling)  There was a role for doctors at the onset of treatment who would get a client through acute withdrawal.  Afterwards, we were thanked and asked to move aside.  Even the term Medication Assisted Treatment suggests that the doctor's role is secondary as we assist with counseling.

Over the years, there were attempts to medically treat addictions.  They often failed , or worse, made the clients addicted to other drugs.  We did not know what we were doing and programs like AA had the better outcomes.

However, in recent years, we have slowly gained a better understanding of how the brain is diseased and we have better interventions.  Doctors can now help.

It is pointed out that patients who participated  with both counseling and Medication have the best outcomes.  This  is not in doubt; however, is it that the combination  produces the best outcomes OR are patients who are destined to do well use more likely to use both interventions?

In order to answer this question, people are randomly assigned to counseling, medication or both.  Most studies dhow client having more success with medication vs. counseling.  The addition of counseling to medication did not show better results,

It is easy to dismiss counseling based on theses studies.  This would be unfortunate.  A study done several years ago showed that we have over simplified counseling as an intervention.  Apparently, in a large clinic population, it was noted that some therapists had consistently better outcomes than others.  They were able to categorize therapists on a scale of empathy.  Highly empathetic counselors had the best out comes;  the showed improved outcomes when added to medication than medication alone.    Not only  did counselors with low empathy do worse than their counterparts,  they did worse outcomes that not having counseling.  It showed that poor counseling harmed clients.   

The difference between high and low empathy rested on a few ways they interacted with the clients; these were techniques that could be taught.  Yet it demonstrated that some patients benefited, others were harmed and these two outcomes negated each other so that most studies saw a no net effect of counseling.

I am unable to tell you if  new counselors are being appropriately trained or if older counselors are being monitored and retrained.  However, it does show , that counseling , done well,  adds value to treatment.

I am often challenged when a patient does not follow up with counseling.  It is assumed i am enabling them.  Shouldn't I mandate counseling.  Counseling and medication  as two separate interventions.  An equally valid question would be how a therapist can provide counseling only and  not mandate their clients be on meds?   It is clear to me that some clients  benefit enough only from medications,  others benefit enough only from counseling and some will require both   I encourage counseling but do not require it.    As long as the patient feels well and lives a productive life, they are doing well in treatment no matter which modality/ies is/are being provided