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Addiction medicine, Home detox, Suboxone & Vivitrol , eating disorders

Thoughts on Substance Abuse

Thoughts on Substance Abuse

The practice of Addiction Medicine has changed in the last few years.  When I started in this practice, I could keep patients in the hospital for 14 days and  everyone got rehab.    Everyone was expected to go to AA or NA.  The use of psychiatric medications was frowned upon.

Additionally, after the detox period, I was expected to leave the patients care; the counselors became the main providers of care.  Counselling was the sole treatment emphasized.  If a patient felt this was not the best treatment for them, they were labelled as resistant or in denial.  The counselors would than attribute the responsibility for failure solely to the patient.  It would never occur to them that the treatment provided was insufficient or wrong.

The scene has changed. 

These days, managed care severely limits inpatient detox and rehab treatments.  Patients often have to make due with very short stays.  After a brief stay, the patient is referred to an outpatient counseling program with little to no medical follow-up.  Many patients require more services.  They often relapse when they have no one to turn to.

While this is unfortunate, it is not only the insurance companies fault.  It has been difficult to show that inpatient treatment leads to improved outcomes compared with outpatient treatment.  However, inpatient treatment is clearly more expensive so the insurance companies cut back on this first.  In addition, many patients pursue inpatient treatment like it's a magical solution without really being motivated to change their behavior.  A lot of patient also pursue inpatient treatment to satisfy legal or job requirements and not because they are ready to change.  Lastly, in this economy people cant stop working.  For these reasons, inpatient treatment has become more more difficult or impractical to do.

This is the situation in which I have been practicing for years.  To make up for a lack of inpatient detox, I have adapted various detoxification protocols for outpatient use.  I treat both the intense, early physical withdrawal syndrome as well as the milder physical and psychological syndromes seen weeks or months later.

Another big change in Addiction Medicine has been the use of Suboxone and Vivitrol.  This has made the long term treatment of opiate addictions a chronic medical problem.   The counsellors are now forced to work with physicians like myself.  Since I am more involved in chronic treatment, I also identify and treat co-occurring medical and psychiatric problems.  

Another  role for the doctor has emerged in addiction treatment.  There has been an explosion in the understanding of the mechanisms that lead to drug and alcohol cravings.  Multiple areas of the brain are involved.  Imbalances in these areas lead to an abnormal "hunger"  for a substance.  We now can clearly state that there are identifiable anatomical abnormalities that cause this disease of addiction  These imbalance can be addressed with medications.  These medicines should be combined with counseling to achieve maximal outcomes.

In my website, I have tried to explain how the various drugs of abuse work.  I describe the abnormalities of the brain that predispose to drug use.   I list the various treatments and medications that help as well as review the mechanisms by which they work.  I also discuss side effects.

These treatments do make a difference.  You can be helped.

A changing view of overeating and obesity treatment

I used to have a level of contempt for weight loss doctors.

I saw it as a gimmicky practice where doctors gave out potentially addictive drugs which worked for only a couple of months.  Was there really a difference between these drugs and other abused stimulants like cocaine?  Additionally, they often prescribed liquid diets, sold vitamins and got involved in other endeavors that made me wonder whose interest they were looking out for.

When redux and Fen/phen were on the market I saw so many capitalistic doctors develop a "boutique" approach.  Patients were treated as long as they were able to pay for treatment privately.  This bothered me.  If obesity was similar to other health conditions, it seemed immoral to charge the patients extra (at least we should first determine if their insurance would cover such treatment).  And I chuckled to myself when these doctors went out of business after the heart consequences of the drugs were learned.

In addition, I struggle with weight as well.  How can I tell my patients to do that which I have found to be so difficult.

I have since learned a few things.

Several years ago, I attended an addiction conference; one session asked whether overeating was like other addictions.  Lets consider this.  Other drugs cause a temporary increase in neuro-transmitters like dopamine and b-endorphin.  These effects are similar to those caused by alcohol and cocaine. (see  Why we use drugs)  Not only does this cause a pleasure effect, it may also lead to imbalance in the brain which lead to depression, irritability and cravings.  These bad feelings may motivate us to eat more.

What about the types of food we eat?  Carbohydrates have recently been recognized to be very problematic in weight control.  They clearly cause a burst of dopamine and B-endorphin.  This can lead to the development of addictive tendencies.  Remember, the use of highly refined carbohydrates is a relatively new invention- we did not evolve eating this food.  Fatty foods have similar effects.

During that conference, the result of a fascinating experiment was presented.  Lab rats, all with extremely similar genetic make-ups, were given different diets.  Some were fed with naturally occurring, unprocessed food.  An unlimited food supply was left in the cages.  Nevertheless, those rats given healthy food  ate only modestly.  They maintained a normal weight; they were healthy and active.

Other rats were given  highly processed carbs and junk food.  They ate too much, gained weight and were fat and lazy.  Clearly, there was something about this diet that led them to ignore their bodies' signals.  Was there abnormal brain function causing abnormal food desires?  

What is really scary is that we give these foods to our preschoolers, many of whom want more and more.  Are we setting the stage for food addictions early?  This clearly is one reason we have such a problem with childhood obesity.

Over the years, the practice of addiction medicine has focused on reducing cravings for drugs.  We prescribe medicine to patients who are drug free in order to prevent relapse.  This is a regular part of my practice.

These patients have often lost weight.  Of course, I reasoned that the weight lost was due to the patients maintaining sobriety and being more disciplined.  But maybe, these drugs directly worked on food cravings.

Several new weight-loss drugs have been in development.  They incorporate the same medications that I have used in treating other addictive disorders.  They have clear-cut success in promoting weight loss.  In one published study, certain combinations of medication was associated with an average weight loss of 37 pounds.  Many patients lost more than that.   Of course, there are side effects and the drugs require monitoring, but they do work.

I have tried these varied medical approaches on my primary care patients who do not have drug abuse histories.  More than 50% have achieved weight loss of 10-20% of their body weight.  Often, the patient has to take several medications.  After all, we treat high blood pressure and diabetes with multiple agents; we need to take multiple agents for this as well.  There will not be major weight loss with any one medication because the body adapts to it; multiple medicines can work on several brain mechanisms at the same time and maximize weight loss.  And what is more, combination therapy prolongs the length of time that patients are losing weight.

If a patient can be disciplined and stick to a diet of their choosing, they do not need these services (although there might be a possibility that some medicines increase metabolic rate)  If they can't maintain a diet, than these approaches increase the ability to remain compliant.


Thinking about drug and food cravings

This article was written many years ago and is somewhat redundant to more recent articles

Anyone familiar with the difficulties of addiction knows that staying clean is the primary difficult in beating drugs.  I view relapse as interplay of two factors: the cravings for a drug and the ability to resist the craving.  Some people have  very severe cravings.  Other people continue to relapse despite having relatively mild cravings for drugs.  They either are not motivated to stay clean and/or they cannot resist any type of impulse.  This category includes younger people, those with ADHD or another type of psychiatric problem, and those who are mandated into treatment against their will.

In this article, I want to focus on cravings.  A craving is a hunger for a drug.  In the disease of addiction, the appetites for food and water get hijacked into appetites for the drugs.  As anyone who has been on a diet know, our appetites change and can be related to factors other than the last time we ate.  What makes us “hungry” for the drug?

As a clinician, I recognize three general categories of cravings: exposure related, stress related and cue related.  If a former heroin user takes painkillers for a medical condition or if an alcoholic takes cough medication with alcohol, they will have cravings for their substance of choice.  These are examples of exposure related cravings.  An example of stress related cravings is when some one experiences a fight in the house or stress at work and wants to get high.  Cue-related cravings are often the most pervasive and long lasting.  This means when we see people, places, things or images related to substance use, we want to get high.  Routines may also be cues.  A person who always has a cigarette after dinner will miss this cigarette in particular. 

Other articles on this board have focused on the central role of dopamine release in the Nucleus Accumbens or pleasure center of the brain.  A drug exposure leads to an increase in dopamine and endorphin, which is intrinsically pleasurable.  This is why we get high.  We want to repeat the experience.  This is why we develop an addiction.  However, can we explain the mechanism of all the different types of cravings solely by looking at dopamine?

I have made certain assumptions about dopamine and endorphin and cravings.  These are supported by scientific evidence even if the assumptions represent gross oversimplifications.  

The first assumption is that a dopamine/endorphin surge for any reason leads us to want another surge.  Since the addict knows the drug gives him this feeling, he will crave the drug after experiencing any dopamine surge.  This is true even when such surges occur from causes other than using drugs.

The second assumption is that any reduction in baseline dopamine/endorphin activity levels will make us more irritable and depressed.  It will also make it more difficult to resist any dopamine/endorphin surges and subsequent cravings. The person with low activity levels will therefore have more intense cravings.

It is easy to explain exposure related cravings.  Every one knows that the use of a drug usually increases our desire for more of the drug.  The first drink leads to the second and than to the third.  The release of dopamine/endorphin in the brain rewards us and leads us to repeat the drug using behavior.  If the dopamine/endorphin release were blocked, we would not have the desire to continue using.  This is the secret behind the use of naltrexone which helps with control of opiate, alcohol, marijuana and overeating.

What about stress-related cravings- why does it make us want to use?  The biology of stress is complex with multiple areas of the brain and body involved.  In fact, acute stress increases dopamine levels.  This does not make sense if we think of dopamine only in terms of causing pleasure and euphoria.  But it makes perfect sense if we consider that the main role of dopamine is to help us learn.  We always want to learn from a stressful situation.

In another article, I talked about two circuits: the goal directed circuit and the habit circuit,   Stress seems to motivate us to act and we tend to use out habit behaviors more often,  This unfortunately leads to drug use in addiction

Cue related cravings may occur in the absence of stress.   However, impulses from cues are quickly modulated through the brains switching area (the ventral tegmental area) where it seems to preferentially engage the habit circuitry and lead to addictive behavior.

Depending on which craving mechanism  is in effect, different treatment strategies are more effective,    Blockers such as naltrexone are effective for exposure related cravings.

Treating negative emotional states will certainly reduce stress related cravings  The use of anti-depressants, anti-anxiety drugs such as alpha and beta blockers as well as the judicious use of major and minor tranquilizers may all minimize this.  Counseling to develop coping strategies will be helpful

The best way to treat cue related cravings is to weaken the habit circuit.  Meds such as Campral, low dose ondansetron and N acetyl cysteine weaken this circuit.   Treating Attention  Deficit Disorder in appropriate patients will strengthen the goal directed circuit which will, in turn, weaken the habit circuit,  Counseling  to avoid triggers and rehearse appropriate behavior would also be beneficial.