Category: <span>Addiction and Treatment</span>

Woman Seeking Addiction Treatment in NYC

How To Choose the Right Psychiatrist for Addiction Treatment

By Samuel Glazer, MD

Addiction is understood as a brain disease that is multidimensional, and, to this point, there are still very few effective treatments. What we also know is that addiction responds best to a combination of both medicine and psychotherapy for the addiction, as well as its underlying causes (only once the substance use stops). Unfortunately, though, there is still a great deal about addiction and its treatment that is misconstrued by both patients suffering with addiction and many psychiatrists and therapists treating them. Though there are many excellent therapists and skilled psychiatrists with variable levels of training, the following are some suggestions by our New York City addiction psychiatrist on how to find a psychiatrist who can best help you treat this very complex condition.

Evaluate the Training of an Addiction Psychiatrist

A psychiatrist is a physician who has completed medical school and has then spent four years as a psychiatry resident in training. The American Psychiatric Association (APA) and the American Board of Psychiatry and Neurology (ABPN) are the two organizations overseeing training and certification of Psychiatrists in the United States. The only certification that they endorse for treatment of substance use disorders is that of Addiction Psychiatrist. To become an Addiction Psychiatrist, a general psychiatrist must be accepted into, train in, and complete an ACGME accredited fellowship in Addiction Psychiatry. After successfully completing an Addiction Psychiatry Fellowship, the candidate must then pass a written exam to become Board Certified and must maintain a certain level of Continuing Medical Education credits, self-assessment and performance improvement in medical practice modules to maintain their status as a Board Certified Addiction Psychiatrist. It sounds like a lot, and it is. Essentially, to become an Addiction Psychiatrist, one needs to graduate college, then medical school, complete a 4-year General Psychiatry Residency program, and then successfully complete a Fellowship of 1-2 more years in Addiction Psychiatry.

Do No Harm: Look for Dangerous Signs

There are some psychiatrists (I know a few) who have great instincts, personal or family experience and understand addiction well, despite not having official ABPN certification in Addiction Psychiatry. Unfortunately, though, there are many who are truly ignorant (for lack of a better word). This can actually be dangerous. Things to look out for include any psychiatrist or psychotherapist who thinks they can medicate or give therapy for underlying depression or anxiety and the addiction will go away (this was actually the thinking decades ago and has since been proven wrong.)

Though self-medication of depression or anxiety is often the road that leads to a substance use disorder; once developed, addiction must be handled as an entity of its own. Once addiction is stabilized, the underlying condition can be treated. To only treat the underlying condition will only perpetuate the addictive behavior, sometimes amplify it, especially if habit-forming medications are prescribed.

Another potential pitfall is any treatment center or doctor who offers a “quick fix.” In my twenty-five years of practice, I have seen many new treatment approaches come and go. Some with good intentions, some truly just motivated by profit. But I would be careful of anything novel without years of trials in the general population. Whether it is a hallucinogen, hypnosis, or some other drug or approach, I have never seen anything that takes addiction away. The process of healing from addiction is just that, a process that takes effort, time, and skill.  To be seduced by a rapid effortless solution can be harmful in that it perpetuates the addiction by appealing to the need for a quick fix, or, at worst, be toxic to the brain.

Does My Addiction Psychiatrist Treat with Psychotherapy and Medications?

Addiction can now be effectively treated with medications, and once stabilized, there are many helpful medications for underlying conditions such as anxiety disorders, depression, ADD, OCD and other mood disorders. A research-proven fact is that medication combined with psychotherapy is the gold standard of treatment and most effective. Many psychiatrists, these days (because of poor training and lack of reimbursement from insurance companies), only prescribe medication. However, because of the complexity of having an addiction and an underlying condition, to get split treatment (having a separate psychotherapist) can be confusing at best and potentially harmful. The best Addiction Psychiatrists I know mostly do both psychotherapy and medication management in the same setting.

What Support Network Does my Addiction Psychiatrist Have?

With addiction being such a complicated condition, it can be helpful if your Addiction Psychiatrist has a support network of his/her own. Many of the best psychiatrists I know that treat addiction are often part of a group practice. Teaching at a medical school, having a relationship with a hospital and being a member of professional organizations such as the American Academy of Addiction Psychiatrists (AAAP) and the American Psychiatric Association (APA) are indications that your Addiction Psychiatrist is plugged in, staying fresh, have appropriate people to refer to, are keeping up to date, and are supported by others in their profession.

The Most Important Person in the Office is the Patient

The essential concept I have learned from my patients, over the years, is that as an Addiction Psychiatrist, I am an expert enlisted in helping the patient meet THEIR goals. Not everyone wants to be completely sober, some want harm reduction and moderation, some want to use medication, and others only want therapy. Some patients are open to trying AA, but others would rather do anything but try AA. I believe the best psychiatrist for addiction treatment is one who has a broad-based understanding of addiction (see paragraph 1), but can be flexible, humble, and caring enough to form a strong alliance with the patient to achieve the goals that are important to them.

These are a few suggestions that can help you choose the right psychiatrist for addiction treatment. I hope that it helps!

Seeking addiction treatment in New York City? Dr. Glazer and the doctors at Fifth Avenue Psychiatry provide private, sophisticated addiction treatment for professionals and executives in the Manhattan, NYC area.

What is Kratom? | NYC Kratom Addiction Psychiatrists

Kratom: Harmful or Helpful?

By Dr. Ronnit Nazarian

There is little information on Kratom, and there is much misinformation out there. Some people believe Kratom is a safe drug to use because it is legal, easy to obtain, natural, advertised heavily, and has “claimed” to treat many illnesses from anxiety to diabetes to opioid withdrawal symptoms. However, the consequences of Kratom use have shown that the drug can create dependence and addiction similar to the effects of opioids (e.g., pain relief and euphoria) and stimulant properties. In some cases, Kratom can actually create Opioid withdrawal symptoms and lead to opiate use disorders or even mimic them.2

Our New York City addiction psychiatrists are here to help provide the following information:

  • What is Kratom?
  • Why it is addictive?
  • The dangers of using Kratom
  • The recommended treatment approach

What is Kratom?

Kratom leaves come from a tree in Southeast Asia. Traditionally, Kratom has been cooked in food and brewed in teas as medicine for treating coughs, diarrhea, opiate withdrawal, chronic pain, and to boost energy and sexual desire. As of lately, it has become a recreational drug as well as drug that people have used to self-treat various emotional and behavioral problems (e.g., anxiety, ADHD, opiate withdrawal). Now, Kratom can be consumed by being ground up in pills, crushed, smoked, mixed into liquids, and produced into various products (e.g., soap bars).2

Is Kratom Addictive?

Kratom has the potential to cause dependence and addiction. This potential risk may be due to people using the drug for:

  • Reward-seeking behavior
  • Prevention of exhaustion
  • Improvement in energy
  • Improvement in productivity

Relatively recently, the phenomenon “drug instrumentation” was posed to discuss non-addictive drug consumption, such as Kratom, that are meant to be used in a purposeful and goal-directed manner. Though substances that fall under this category (e.g., Kratom, Nicotine, Marijuana, pain killers, alcohol) are meant to be used purposefully, they increase potential prolonged use and, consequently, addiction because of the positive effects they experience (e.g., completing tasks, focusing for extended time).2,5 In addition to the positive effects, people have relied on Kratom to assist as a harm reduction tool in place of using other substances (e.g., opiates). Using this as a harm reduction tool causes reliance and overstimulation. There is concern that because Kratom affects the same opioid brain receptors (like morphine), it can lead to risk of addiction, abuse, and dependence.4

What are the Side Effects of Using Kratom?

  • Nausea
  • Constipation
  • Sleep problems
  • Temporary erectile dysfunction
  • Itching
  • Sweating
  • Hyperpigmentation
  • Tremor
  • Anorexia
  • Weight loss
  • Hair loss
  • Addiction potential
  • Cognitive impairment
  • Enhanced punishment tolerance
  • Reward-seeking behavior
  • Organ system injuries (kidney injury, arrhythmia, lung injury, acute respiratory distress syndrome, hepatic injury)1,2

Dangers of Kratom Use

The misinformation regarding the content and potency of Kratom is a large reason for the dangers of Kratom use. Similar to other substances (e.g., Cocaine, Marijuana), Kratom is an unregulated substance that does not have regulatory oversight. The lack of oversight to ensure the authenticity, purity, quality, potency, and safety of Kratom has a negative impact on preparations and consumptions.2 For example, while Kratom products are being advertised as natural and safe, some products have been found to carry contaminations such as heavy metals (e.g., lead) and salmonella. In fact, in 2018 Kratom supplements were linked to an outbreak of salmonella.Users can potentially be at risk for Kratom toxicity, illnesses, and other potential risks because of the lack of regulation on this substance.

What are the Signs of Kratom Toxicity?

*(Kratom toxicity particularly occurs when Kratom powder has exceeded 8 grams)

  • Agitation
  • Tachycardia
  • Drowsiness
  • Confusion
  • Seizures
  • Hallucinations
  • Coma
  • Death2

What are the Withdrawal Effects from Kratom?

  • Muscle aches
  • Irritability
  • Mood disturbances
  • Runny nose
  • Diarrhea
  • Muscle jerking1

Treatment for Kratom Use

While there currently is no published guidelines on the treatment of Kratom, it has been beneficial to approach treatment similar to treatment for patients with opioid use disorders. Treatment includes: stabilization, alleviation of symptoms during acute withdrawal, and long-term maintenance of sobriety.2

Our New York City Addiction Psychiatrists Provide Evidence-Based Treatment

At Fifth Avenue Psychiatry, addiction psychiatrists in New York City can provide more psychoeducation on Kratom and meet you where you are in your treatment. Whether you would like to reduce your use or become completely sober. We can provide you the tools to assist you in understanding the role Kratom plays in your life and ways to replace it with healthier options. We provide tools for treatment that include everything from helping with motivation, Cognitive Behavioral Therapy for opines and opined like substance (Kratom) and Pharmacological treatment of Kratom Dependence and underlying disorders.

  1. Cinosi, E., et al. (2015). Following “the Roots” of Kratom (Mitragyna speciosa): The Evolution of an Enhancer from a Traditional Use to Increase Work and Productivity in Southeast Asia to a Recreational Psychoactive Drug in Western Countries. BioMed research international, 2015, 968786. https://doi.org/10.1155/2015/968786
  2. Eastlack, S. C., Cornett, E. M., & Kaye, A. D. (2020). Kratom-Pharmacology, Clinical Implications, and Outlook: A Comprehensive Review. Pain and therapy, 9(1), 55–69. https://doi.org/10.1007/s40122-020-00151-x
  3. https://www.fda.gov/food/outbreaks-foodborne-illness/fda-investigated-multistate-outbreak-salmonella-infections-linked-products-reported-contain-kratom#time
  4. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom
  5. Müller, C. P., & Schumann, G. (2011). Drugs as instruments: a new framework for non-addictive psychoactive drug use. The Behavioral and brain sciences, 34(6), 293–310. https://doi.org/10.1017/S0140525X11000057

Understanding the Harm Reduction Model (Controlled Drinking)

By Dr. Britt Gottlich, Psy.D.

According to the National Survey on Drug Use and Health performed by the NSDUH, “[A]bout 7.3 percent of adults ages 18 and older who had Alcohol Use Disorder in the past year received any treatment in the past year… People with Alcohol Use Disorder were more likely to seek care from a primary care physician for an alcohol-related medical problem, rather than specifically for drinking too much alcohol” (NIAAA). Why? Seeking help for substance abuse can be overwhelming and scary.

Often, clients report that coming in for the initial appointment is the hardest part due to the unknown of this type of treatment program. What clients often do not expect, is that substance abuse treatment can be flexible and meet them at a common ground. We like to call this approach “harm reduction.”

What is Harm Reduction?

Harm reduction is a term used to represent “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs” (National Harm Reduction Coalition).

The concept behind harm reduction is meeting the client where they are in terms of their commitment and motivation to change. Abstinence is a very overwhelming concept for individuals, which can often push them away from seeking or continuing treatment. Therefore, this approach allows the client and their treatment team to come up with a specific plan that allows them to use their substance of choice in a moderate and safe way.

Harm Reduction for Alcohol

We often find that clients seeking alcohol treatment are interested in a harm reduction model. This is likely due to alcohol being both legal as well as socially acceptable. Imagine, as a young adult, you are aware that you drink too much and want to seek help. Likely, the concept of abstinence would be overwhelming, as alcohol is a major part of our culture. We see alcohol in the media, at events/parties, and at dinners and happy hours. Expecting someone to potentially cut those events out of their lives to reduce the exposure to alcohol is not always realistic. According to research, “Many individuals experiencing problems related to their drinking (e.g., college students) are not interested in changing their drinking behavior and would most likely be characterized in the precontemplative stage of the transtheoretical model. Harm reduction provides a good method for matching these individuals at that stage and providing motivational incentives (e.g., discussing the negative consequences the person is experiencing) to motivate their desire for positive change” (Marlatt & Witkiewitz, 2002).

Therefore, for those clients who find complete abstinence to be overwhelming, we will come up with specific rules around their drinking. “It is essentially a practical approach; success is not measured by the achievement of an “ideal” drinking level or situation (i.e., abstention or low-risk levels), but by whether the introduction of the prevention measure reduces the chance that adverse consequences will occur” (NCBI).

How Does Harm Reduction Work in Therapy?

In regard to my therapeutic approach to harm reduction as a clinical psychologist, I usually start by understanding my client’s goals for drinking. We then start the process by monitoring their drinking as is, to understand the baseline they are starting at. This will include logging numerical data, but more importantly, triggers and impulses behind those drinks to better understand their motives. Together, we will come up with specific rules to help decrease their consumption. This could include the number of days they drink per week, the number of drinks they have at a time, specific types of drinks they allow themselves to drink, as well as building awareness behind the types of emotional drinking they may engage in. Most importantly, this treatment model provides accountability, where clients are working weekly and sometimes more with their providers to monitor their progress.

Harm Reduction VS Abstinence

While harm reduction can be effective and successful in helping a person be more cognizant of their drinking behaviors and therefore decreasing them, it is not for everyone. While, of course, no one is perfect, and we expect “mistakes” or “hiccups” along the way, there are some individuals who try harm reduction and are able to recognize they cannot exercise this type of self-control. In those cases, harm reduction can be a helpful tool as a last resort, to help the individual come to the conclusion themselves that abstinence is the right avenue for them, rather than having it enforced upon them at the start of treatment.

Is Harm Reduction Right for Me?

It is important to know when seeking treatment for substance use that there are options. A field that used to be very black and white in its approach has many areas of gray that may be a good fit for you. Reach out for help and engage in a conversation with your provider about all the treatment options that are available to you.

Dr. Sam Glazer, a NYU professor of Psychiatry, and his team at Fifth Avenue Psychiatry provide private alcohol addiction treatment in the Manhattan, New York City area and offer controlled drinking programs.

References:

  • G.A. Marlatt, K. Witkiewitz / Addictive Behaviors 27 (2002) 867–886

Cannabis: A New Drug Epidemic?

By Dr. Olga Megwinoff

During the late 1990’s when I was a psychiatry resident at NYU Langone Medical Center, the opiate epidemic was just beginning. We were taught that if a patient had pain, you had to give them prescription painkillers. At the time, “research” showed that they were necessary to control pain and did not have addiction potential when used to treat people for pain. This didn’t make sense to me, but who was I to question my teachers or “the research?” I was but a lowly resident.

The mood about marijuana reminds me of the early days of opioid painkiller use. Though I don’t believe marijuana will ever be understood to be as dangerous as prescription painkillers have proven to be, I do believe we are in a similar period of time that predated the opioid crisis. There are many market and industry powers that are working together in the same way to encourage more and more people to use marijuana, promote false medical claims, and reduce fear of any risk associated with use.

The Risks Involved with the Use of Marijuana

Currently, as an addiction psychiatrist working in a New York City outpatient addiction treatment center, I hear from patients how they perceive little risk in their use of Marijuana. It seems that as it has been medicalized, decriminalized, and now legalized, the message that most people get is that marijuana is a very safe drug, in fact “safer than alcohol which is legal” seems to be the catchphrase now.

This concerns me, however, because as an addiction psychiatrist, I am very well aware that Marijuana, though perceived as very low risk, actually does have addiction potential, can be abused, and can have major psychiatric consequences that include:

  • Aggravation of anxiety
  • Mood disorders
  • Psychosis
  • Dependence
  • Brain damage (in adolescents and young adults)

The Market Forces vs the Medical Field’s Perspective

In this blog, I’ll attempt to point out the different market forces pushing to legalize cannabis for medicinal and recreational use, in contrast to what is known in the medical field.

To start, legal cannabis sales in the U.S. passed $17.5 billion in 2020, a 46 percent increase over sales in 2019. Sales are expected to skyrocket to approximately $40 billion by 2025 (1). In terms of legislation, state governments are promoting legalization of cannabis because legal revenue will translate to huge taxes, instead of this money being lost to the black market. Legislators also hope to lower policing expenses and reduce the racial disparity in marijuana arrests – African Americans are four times more likely to be arrested for possession of cannabis than white Americans (2).

I will establish, first, that “Medical Marijuana” is a misguided industry term used in legislation, not a scientific medical term (3). As of 2021, 36 states have legalized marijuana for “medical” purposes and 18 states have recreationally legalized cannabis. Yet, in sharp contrast, on the federal level, research is limited regarding cannabis since it was a schedule I substance until December 2020. According to the DEA, “a schedule I drug has a high potential for abuse and the potential to create severe psychological and/or physical dependence. These drugs are determined to have no accepted medical use” (4). 

            As of May 2021, the FDA, responsible for approving treatments after appropriate and rigorous study, has not yet approved the cannabis plant as safe or as an effective drug for any medical indication. The only FDA approved cannabinoids products are Marinol, Syndros, and Cesamet (synthetic THC, cannabinoid analogs). They have been approved for the treatment of three different seizure disorders, chemotherapy related anti-nausea, and as a cancer related appetite stimulant. Nevertheless, the market has gone way ahead of the science resulting in a lot of concerning unknowns. There is ongoing scientific trials planned but interestingly enough, there’s little funding for them (3).

The media plays a large role as well. It promotes a narrative that transforms public reactions and reinforces drug policy implementation (5). It is of concern that cannabis legalization is promoted by the media without a critical lens; cannabis is promoted as a “magical fix,” and “safe” despite the lack of scientific evidence for it.

There are many unestablished facts about cannabinoids. Studies reveal there are more than 500 compounds in the marijuana plant, the majority of these are unknown. In addition, scientists don’t know basic details about the drug, such as what a standard dose should be. It is suggested that cannabis at low doses could help with anxiety, but at higher doses is anxiety provoking. Quality is also not controlled. Many CBD preparations in the market are contaminated with THC and other compounds, including Benadryl.

Furthermore, newer cannabis strains developed in the 1990’s have increased THC levels. Prior to the 1990’s, top grade pot had 20% THC levels. Newer products have concentrations as high as 40-80%. Moreover, synthetic cannabinoids and cannabis concentrate products can contain up to 80-90% THC (6). With these stronger strains we are seeing new afflictions. For example, Hyperemesis Syndrome (severe nausea and vomiting syndrome) was a rare occurrence in the emergency rooms and is now quite common.

Many patients with psychiatric disorders use cannabis with the idea that it may be helpful for treating primary depressive disorders, general anxiety disorders, post traumatic stress disorder, or psychosis to name a few. However, very low quality studies suggest that cannabis could lead to small improvements in anxiety, but there are no other quality studies thus far.

Potential Medical Complications Caused by Marijuana Use

Furthermore, exposure to cannabis can induce medical complications such as cardiovascular and respiratory problems. It can even impair brain function. Marijuana is a sedative and can reduce someone’s ability to drive and it decreases cognitive and memory function. There is some indication that there may be white and grey brain matter and cortical thickness alterations. In addition, cannabinoids cross the placenta and can affect pregnancy outcomes and neurodevelopment of the fetus (6).

In other words, inhaled herbal cannabis contains mutagens and can result in lung damage, exacerbations of chronic bronchitis and certain types of cancer. (7)

Cannabis is one of the most commonly used drugs in the global market, only second to alcohol and tobacco use (8). Similar to other psychotropic drugs, cannabis has the potential to produce rewarding/reinforcing effects by enhancing dopamine signaling in the addiction pathways in the brain (9). The rewarding effects of cannabis are directly associated to the actions of THC on cannabinoid CB1 receptors in the brain (9).

Understanding Cannabis Use Disorder

Cannabis Use Disorder, characterized in the DSM-5 diagnostic manual, consists of a pattern of cannabis use that causes significant psychiatric distress and social impairment within the context of repeated attempts to stop using. In other words, prolonged and sustained cannabis use is associated to an insidious addiction that is very hard to break. This addiction is often associated to psychiatric symptoms of anxiety, depression, and insomnia. These all can have profound effects on careers and relationships. In the words of Dr. Glazer (2020), “People go nowhere slowly.” In 2019, 4.8 million Americans ages 12 and older were diagnosed with Cannabis Use Disorder.

Other DSM-5 diagnostic disorders such as Cannabis Intoxication consists of the following:

  • Euphoria
  • Increased appetite
  • Tachycardia
  • Altered judgement
  • Possible anxiety
  • Psychosis

Cannabis Discontinuation Syndrome has been well established in the medical literature and consists of symptoms of the following:

  • Anxiety
  • Dysphoria
  • Sleep disturbance
  • Irritability
  • Decreased appetite

Evidence shows that cannabis use and Cannabis Use Disorder have increased in recent years in states that have legalized marijuana. These epidemiology studies have estimated that around one in six (1:6) of those who use cannabis during adolescence and one in two (1:2) of daily cannabis users will meet the criteria for Cannabis Use Disorder. This is of concern because in addition to the addiction aspect, epidemiological data proposes that recreational cannabis use is positively associated with psychotic disorders, depressive and anxiety symptoms, including panic disorder. Cannabis has also been negatively associated with bipolar disorder, it leads to lower remission rates and early onset of symptoms. To be specific, frequent use of high-potency cannabis has been associated with increased paranoia and elevated risk of psychotic disorders among individuals with no psychiatric history (11).

 THC vs CBD

It is speculated that many of cannabis’ negative effects are associated with THC. However, some patients with psychiatric disorders that use cannabis can see some possible improvements that are most likely due to its CBD component. CBD (cannabidiol) is the second major component of marijuana and is more promising for therapeutic use as mono therapy (6).  It is still unregulated, mislabeled, and it is frequently contaminated. Only 30% of CBD products that are available commercially are accurately labeled and many have THC.

Some evidence suggests that CBD may be anti-seizure, neuro-protective, antipsychotic, and anti-inflammatory.  Positive observational studies on social anxiety shows that it can decrease anxiety. In one study with cancer patients, fewer depressive symptoms were shown. Nevertheless, there’s no evidence that CBD can help people sleep and any topical application claims are false because it is not absorbed in the blood this way. CBD has a mostly pharmacologically benign profile, but it exhibits liver toxicity (10) at doses of at least 1,500 mg a day. CBD also has drug-drug interactions, specifically with morphine, epileptic drugs, benzodiazepines, some antidepressants, etc. Nevertheless the possible positive association to CBD, more rigorous and larger studies are needed to know for certain its effects on people.

Dr. Olga Megwinoff’s Perspective on Marijuana Use

My last point is that in my personal experience, it is very difficult to treat clients with chronic cannabis dependency. Marijuana is quite addictive and there is no good treatment or MAT (medication-assisted treatments) for Cannabis Use Disorder. In the last few years, only CBD has been suggested as being helpful with cravings and withdrawal symptoms.

In my opinion, the implications of legalizing marijuana remain to be seen, but it is clear that there are numerous contradictions in practice, policy, and scientific knowledge. Besides, the huge economic incentives driving the consumption of cannabis corrupt any well intended motivations of the market.  I’m concerned about the morbidity of prolonged cannabis use within the context of this widespread accessibility.

I do believe Marijuana should be legalized. The real issue is that there is an overwhelming amount of misinformation, mislabeling, and false claims as this drug is pushed into the market. This misinformation understates the risk and exaggerates the benefits of cannabis. Decreased perceived risk and overstated benefits led to an epidemic of prescription painkiller abuse. I fear the same may be true for legalized and “medical” marijuana.

Sources:

  1. Alfonso Tortolani, P. “Why the Pandemic Was a Breakout Moment for the Cannabis Industry”. com, May 31, 2021
  2. ACLU, (June 2013) “Report: The War on Marijuana in Black and White.” Retrieved from:https://www.aclu.org
  3. Hill, K., Williams, A.R., and Watkins,“Clearing the Smoke: Cannabis and Mental Health”, APA and AAAP Webinar, April 8, 2021
  4. deadiversion.usdoj.gov
  5. Rothstein, R. and Finnigan, R., “Marijuana and The Media: The Influence of Media Narratives on Legislation Outcomes”, sociology.ucdavis.edu, n.d.
  6. St. Marie, R. and Leo, R., “Cannabinoid-Based Medications for Pain”, Current Psychiatry, Vol.20, No.5, May 2021
  7. Ghasemiesfe, M., Barrow, B., Leonard, S., et al. “Association Between Marijuana Use and Risk of Cancer: a Systemic Review and Meta-Analysis”, JAMA Network            Open 2019;2(11)
  8. Carlinger, H., et al, “Cannabis Use, Attitudes, and Legal Status in the US: A Review”. Prev Med, 2017
  9. Zehra, A., et al, “Cannabis Addiction and the Brain: A Review”, Focus Vol 17, No 2, Spring 2019
  10. Ewing, L., Skinner, C., and Koturbash, I., “Hepatotoxicity of a Cannabidiol-Rich Cannabis Extract in the Mouse Model”, Molecules 2019 May;24 (9):1694
  11. 11. Sabioni, P. and Le Foll, B., “Psychosocial and Pharmacological Interventions for the Treatment of Cannabis Use Disorder”, Focus Vol 17, No 2, Spring 2019
Alcohol and Anxiety | Manhattan Alcohol Addiction Treatment

Anxiety and Alcohol Use

By Ronnit Nazarian, Psy. D

A common theme that I have found while speaking with patients who overdrink has been that they also experience an underlying anxiety disorder. Moreover, they have mentioned having difficulty finding something that helps them disconnect from their stress and anxiety that works as well as having a drink. To most people looking in from the outside, a person who experiences anxiety and a person who experiences drinking problems are often viewed as two separate individuals. Contrary to common belief, however, research shows that approximately 50% of individuals who experience alcohol problems also meet the criteria for one or more anxiety disorders.1 Alcohol use and anxiety are strongly linked and often called co-morbid disorders that interact with each other. One of the major contributors to an increased alcohol intake is a person’s level of anxiety.4

At Fifth Avenue Psychiatry, we recognize that many people who have an increased alcohol use will drink in order to cope with their anxiety (e.g., work stress, social stress, etc.). While alcohol may be used to help cope with anxiety, it can also have long-term consequences in increasing a person’s level of anxiety in the long term. In this blog, we discuss the ways anxiety and alcohol are linked, the consequences of using alcohol as a coping mechanism, alcohol-induced anxiety, and treatment approaches for dual diagnosis of anxiety and alcoholism.

Using Alcohol as a Coping Mechanism (Self-Medication Model)

A mild amount of anxiety is typical for anyone to experience as a reaction to a stressful situation. When someone suffers from an anxiety disorder, their reactions to stress can impact their daily functioning, relationships, sleep cycle, and work production. Those who struggle to cope may turn to the use of alcohol and drugs, engaging in compulsions, and avoiding events to decrease the anxious feelings.

Below are some of the ways people use alcohol to cope with anxiety:

  • Drinking at a party to feel confident, less shy, and to socialize
  • Drinking at the end of the week to destress
  • Drinking to numb negative thoughts and emotions
  • Drinking to feel included and connected to others
  • Drinking to relax
  • Drinking to forget bad memories
  • Drinking to feel happy
  • Drinking to no longer feel in control
  • Drinking to no longer make decisions
  • Drinking to take a break from reality
  • Drinking to fall asleep

What drinking starts as “liquid courage” or a “way to let loose” for a person, it easily becomes a way of self-medicating as it becomes a means of coping. Research shows that most individuals who experience drinking problems and self-medicate with alcohol also experience a generalized anxiety disorder, social phobia, and panic disorder.More specifically, it appears that alcohol problems begin after the onset of anxiety disorders. Many individuals who experience social phobia and agoraphobia have reported initially using alcohol as an attempt to control anxiety. Active alcohol use can exacerbate symptoms of anxiety, which plays a significant role in the difficulty of diagnosing anxiety disorders in the face of active alcohol use. The lines blur with distinguishing between symptoms of alcohol withdrawal versus anxiety disorders when symptoms of withdrawal appear like symptoms of anxiety. 3

Over time, as individuals continue to self-medicate with alcohol as a coping strategy, they may require increasingly higher doses of alcohol. Consequently, this can result in an individual developing an independent substance use disorder. Individuals who self-medicate with alcohol are at risk of increased psychiatric co-morbidity, suicidal behavior, levels of stress and dysfunction, and lower health-related quality of life.5

How Alcohol Increases Anxiety Levels (Substance-Induced Anxiety Model)

Using alcohol to cope with anxiety can in turn significantly increase anxiety levels. While alcohol can diminish feelings of anxiety and provide short-term relief, it can lead to increased anxiety. Specifically, alcohol can act as an “Anxiogenic,” which creates feelings of anxiety and panic attacks when withdrawing from alcohol. This feeling can lead someone to continue to drink alcohol to decrease those uncomfortable feelings. This leads to a vicious cycle in which alcohol and anxiety play off each other and makes it no longer clear which disorder (anxiety or alcoholism) is the operating cause.2

Treatment for Co-Occurring Anxiety Disorders and Alcohol Use Disorders

There are many treatment models available to assist individuals with co-occurring disorders. The selection of treatment approach depends on the way in which, and the reasons why a person uses alcohol to cope. For individuals who use alcohol to cope with social anxiety, a combination of Cognitive Behavior Therapy (CBT) and Exposure Therapy can be helpful to challenge thoughts and behaviors surrounding events that cause anxiety. Individuals who use alcohol to cope with stress or intense emotions would benefit from Dialectical Behavior Therapy to learn how to regulate their emotions and tolerate distress. At the root of all treatment models, it would be critical for patients to develop new healthy coping strategies to replace their unhealthy behaviors, such as drinking alcohol. Alongside engaging in therapy, it may be beneficial for the individual to receive pharmacological treatment to decrease the feelings of anxiety that drive a person to drink.

When developing a treatment plan, it is important for the clinician to understand the individual’s presenting problems and determine which of the problems should be the primary focus of treatment. A majority of treatment typically begins with the elimination of alcohol use first.  With alcohol out of the way, one can gain a better understanding of the primary reasons that drive a person to drink.  Sometimes with the reduction of alcohol use, many symptoms such as anxiety and depression are actually reduced. Ultimately though, in many cases, challenging and treating anxiety symptoms that resulted in overdrinking is the ultimate goal.

  1. Anker, J. J., & Kushner, M. G. (2019). Co-Occurring Alcohol Use Disorder and Anxiety: Bridging Psychiatric, Psychological, and Neurobiological Perspectives. Alcohol research: current reviews40(1). https://doi.org/10.35946/arcr.v40.1.03
  2. Brady, K., Tolliver, B., & Verduin, M. (2007). Alcohol use and anxiety: diagnostic and management issues. The American journal of psychiatry, 164 2, 217-21; quiz 372 .
  3. Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. The American Journal of Psychiatry, 147(6), 685–695. https://doi.org/10.1176/ajp.147.6.685
  4. Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: comorbidity and treatment considerations. Alcohol research: current reviews34(4), 414–431.
  5. Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and anxiety35(9), 851–860. https://doi.org/10.1002/da.22771

 

What is an Addiction Therapist | Manhattan Addiction Therapist

What is an Addiction Therapist?

By Tracey Bassett Psy.D.

Deciding to take the step to seek addiction treatment is a very important and often difficult step. It can be complicated by the overwhelming amount of treatment centers, treatment modalities, and types of professionals that say they specialize in addiction. Today, our Manhattan addiction therapists will explore the different types of addiction treatment professionals and how to decide what is best for you.

Types of Addiction Treatment Professionals

Addiction Psychiatrist (MD)

A psychiatrist is a doctor who went to medical school and then specialized in mental health. Psychiatrists conduct evaluations for treatment planning and diagnosis, prescribe medication, and sometimes, but not always, conduct therapy as part of their practice. There are general psychiatrists who treat a wide range of issues and psychiatrists who focus on specific niches. A Board Certified Addiction Psychiatrist has undergone additional training and study and has passed board examinations to demonstrate a specialty in treating addiction.

Psychologist (PhD or PsyD)

A psychologist holds a Doctorate in Psychology and a Master’s degree in Psychology or a related field. Through graduate school education and multiple clinical internships working with clients, psychologists are trained to conduct diagnostic evaluations, work with multiple modalities of therapy, including group and family therapy, and assess various disorders through psychological testing. A practicing psychologist has to undergo specific education, meet clinical hour requirements, and pass an examination to possess a license. Specialties and areas of training and interest can vary widely.

Licensed Master Social Work (LMSW) and Licensed Clinical Social Worker (LCSW)

A LMSW has completed a masters level education examination and is working towards meeting clinical hour requirements. A LCSW has completed a masters level education, examination, and has supervised clinical experience. Social workers can perform a variety of functions, including therapy, needs assessments, advocacy, case management, and coordination of treatment planning among other things.

Licensed Mental Health Counselor (LMHC)

A LMHC holds a Master’s Degree in Mental Health Counseling. This person has met a combination of educational experience, clinical training, and examination requirements for licensure. A LMHC is trained in assessment and treatment modalities for mental health.

Substance Abuse Counselor

A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) has met licensing requirements by the state that includes training courses and supervised experience through a certification process. A CASAC does not have to hold an advanced educational degree, nor a college degree. A CASAC’s experience is more geared specifically toward substance use and not the treatment of co-occurring mental health diagnosis.

Sober Coach

A sober coach does not have to hold any specific license or degree, although some do. A sober coach can be an important member of a treatment team that works directly with the client one on one outside of therapy and can provide support through coaching during triggers and cravings, ensuring clients get to appointments, helping develop routines, changing habits, advocating for clients, and many other aspects of sober living. A sober coach sometimes lives with clients or can assist with specific activities that have been identified as important to the recovery process.

Things to Consider When Seeking Addiction Treatment in Manhattan NYC

When seeking addiction therapy, there are a few important questions to ask yourself, including the following:

Are you looking for treatment to focus on only addiction or on other social, emotional, or behavioral factors that may be contributing to the cycle of addiction?

According to research, “As many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs—i.e., tobacco and alcohol” (NIH, 2018).

If you believe that your substance use may be influenced or impacted by anxiety, depression, or other mental health disorders then working with a professional that is trained to treat both substance use and mental health concurrently would be a key component in your recovery.

Would you benefit most from therapy or a combination of therapy and medication management?

This is often a difficult question for an individual to answer on their own. Typically, a consultation with a psychiatrist can help to answer this question. Although medication can play an extremely important role in the detox process, maintenance off of some substances, providing a barrier to use, and treating underlying mental health diagnosis, often medication alone is not the best treatment plan for long term recovery.

Therapy should be a key aspect in a well-rounded treatment plan.  Research has shown that “combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach alone” (NIH, 2018).

Does the professional that you are looking to work with specifically state that they have training and experience to treat substance use?

The treatment professionals described above undergo required education, clinical experience and examination requirements to possess a license in their given field.  However, specific expertise in the diagnosis and treatment of substance abuse is not a requirement of any of these licensing bodies. It is extremely important to specifically ask the treatment professionals that you are considering working with if they have training and experience with this specialty. Although some general therapy and clinical knowledge is relevant, treatment of alcohol and substance use disorders is a specialty that requires a specific expertise. Without this knowledge, clients can be misdiagnosed or mistreated leading to less-than-optimal addiction treatment outcomes.

Fifth Avenue Psychiatry’s Manhattan Addiction Doctors Provide Discreet Treatment

There is no one-size-fits-all for every person. By considering how your specific needs and goals align with the type of professional addiction treatment that is available, hopefully you can make a more educated decision in what type of professional support is best for you.

Fifth Avenue Psychiatry provides fully confidential, private treatment for professionals and executives.   


Sources:

  • Principles of Drug Addiction Treatment: A Research Based Guide (Third Edition) (2018). Retrieved from: https://www.drugabuse.gov/download/675/principles-drug-addiction-treatment-research-based-guide-third-edition.pdf?v=74dad603627bab89b93193918330c223

 

The Importance of In-Person Addiction and Alcoholism Treatment During the COVID 19 Pandemic

There have been many mental health challenges during the COVID-19 pandemic, including increased depression, anxiety and exacerbations of PTSD as a result of isolation, changes in lifestyle and fear. Along with increases in suicidality and domestic abuse, one of the most dangerous mental health effects of the pandemic has been increased substance abuse.1Along with all the dangerous effects of substance abuse there have been “an increasing number of reports from national state and local media,” including New York, of “an increase in opioid and other drug related mortality.”2

What is the Cause of Increased Substance Abuse During the Pandemic?

The cause of increased substance abuse is many. More people are using illicit drugs and alcohol to cope with their symptoms or to “self medicate.” Boredom, unemployment, as well as lack of structure in school and work are all triggers to increase alcohol and drug use. Traditional forms of treatment have been all but shut down, with many 12-step meetings and traditional outpatient programs transitioning to Zoom. Many mental health practitioners are unavailable for in-person treatment, and many residential rehabs are full.

Isolation is a Contributing Factor to Substance Abuse

Addiction and alcoholism thrive in isolation, and the pandemic has done all but assured that most people in New York are much more isolated. Although Telehealth is better than nothing at all when it comes to addiction treatment in Manhattan, we have found the results are much greater when in-person addition treatment is available. The limitations of a Telepsychiatry or Zoom meetings are well established by now.

We Provide Outpatient Addiction Treatment in Manhattan, New York

At Fifth Avenue Psychiatry, we have taken appropriate measures to provide in-person outpatient treatment for addiction and alcoholism in New York City. Our offices have good ventilation through open windows and air-purification systems. Our staff have seen the positive results of in person meetings and in balancing the health needs of our patients have agreed to provide “live” treatment. We provide counseling, medication management for depression, anxiety and OCD and PTSD, as well as Manhattan outpatient detoxification for alcoholism and opioid dependence. MAT is available for opioid use disorders, including Suboxone and Vivitrol.

For more information or to get in touch with our Manhattan, NYC addiction psychiatrists, please call 212-734-0506.

  1. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1.
  2. Reports of increases in opioid- and other drug-related overdose and other concerns during COVID pandemic, American Medical Association, Issue Brief, October 6, 2020.

Treatment Approaches Designed for Women with Addiction and Alcoholism

By Britt Gottlich, Psy.D.

Through years of training and practice in the field of substance abuse, I have noticed some interesting gender differences. First, I have found that more men tend to seek substance abuse treatment than women. Second, I have noticed that often the core of what began the substance abuse problem is often different between men and women. Third, it has become evident that men and women do not always gain the same benefits from the same treatment approach. This month, my blog explores these interplaying factors and introduces addiction treatment approaches that may better fit the needs of female clients.

Women May Be Less Likely to Seek Substance Abuse Treatment

According to research, “Surveys in the early 1980s estimated the male/female ratio of alcohol-use disorder as 5:1, in contrast to more recent surveys that report a ratio of 3:1.” 1 Given these statistics, there is clearly a higher number of men seeking treatment for substance abuse. Supporting research, and my own clinical experience as Manhattan clinical psychologist shows that women may internalize more shame as part of their use, therefore making it less likely they will enter into treatment. For example, hormonal changes, body image issues, increased stress, and stressors or a history of trauma can all play into an individual’s perception of themselves and therefore willingness to seek treatment. So, it is not that there are fewer women who struggle with substance and alcohol use, but perhaps they are just less likely to ask for help.

The Link Between Sexual Trauma and Substance Abuse in Women

One specific area that has been researched extensively is women with a history of childhood sexual trauma. “Clinical studies have found elevated rates of childhood sexual abuse (CSA) in women seeking treatment for alcohol or drug abuse”. 2 Oftentimes, individuals who report a history of abuse describe feelings of guilt and other uncomfortable emotional responses. Substances can act as a means of coping with unresolved trauma and difficult emotions. It is oftentimes an effective form of self-medication for individuals to “numb” the memories or emotional experience that those memories provoke. Research often focuses on sexual trauma in women and substance abuse specifically; however, in my experience, there is a link between any type of trauma (physical, sexual and/or emotional) and substance use.

Understanding Dialectical Behavioral Therapy

Despite the type of trauma history or emotional stressor that leads a woman into substance abuse, one of the most effective forms of treatment for these women is Dialectical Behavioral Therapy (DBT). DBT is a therapeutic approach that helps provide individuals with life skills that help manage emotions and interact with people more efficiently. DBT consists of four modules:

  • Mindfulness
  • Distress tolerance
  • Emotional regulation
  • Interpersonal effectiveness

DBT was initially created for people with Borderline Personality Disorder, however, research shows it can be used for a number of different disorders including substance abuse. 3

I personally use different elements of DBT with nearly every person I work with, as I believe DBT skills can be beneficial for everyone (myself included!) in any given situation. DBT allows us to learn how to be more in touch with our emotions and control them in times of stress. Often times women that present to individual therapy for substance abuse disorders present with emotional dysregulation. Regardless of the reason behind their emotional regulation (any of the reasons mentioned above), I usually find that approaching therapy through a DBT skill-based lens is the ultimate first treatment approach.

In addition to individual therapy, DBT skills groups can be a helpful treatment approach. These groups allow individuals to learn and practice skills with the help of other members. Group members will be given skills and homework which are then revisited in the group, where group members will provide encouragement and support to each other.  Encouragement, support, and a sense of community are just a few of the many benefits that group work can provide, as my colleague Dr. Tracey Bassett highlighted in her blog last month about the importance of group work in treatment.

Our Manhattan Addiction Treatment Team Can Help

In being able to acknowledge that female clients have different needs than male clients and that perhaps they struggle differently with treatment barriers, we can begin to take a step in creating more informed and supportive treatment practices. In working in an informed way, we can offer the appropriate skills and support that each person needs. It is my belief, that once an individual can learn to manage their emotional reactions, they will feel less likely to resort to unhealthy coping skills, therefore not having to rely on substances to cope, and learning that they can rely on themselves and the support built around them.

Our addiction treatment team in Manhattan is ready to help. Call Fifth Avenue Psychiatry for science-based treatment.


  1. Greenfield SF, Back SE, Lawson K, Brady KT. Substance abuse in women. Psychiatr Clin North Am. 2010;33(2):339–355. doi:10.1016/j.psc.2010.01.004
  2. Maffei, Cesare & Cavicchioli, Marco & Movalli, Mariagrazia & Cavallaro, Roberto & Fossati, Andrea. (2018). Substance Use & Misuse Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment: Findings Based on an Open Trial Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment: Findings Based on an Open Trial. Substance Use & Misuse. 53. 10.1080/10826084.2018.1480035.
  3. Wilsnack, Sharon & Vogeltanz, N & Klassen, A.D. & Harris, T. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of studies on alcohol. 58. 264-71. 10.15288/jsa.1997.58.264.

 

Group Therapy for Executives with Addiction

Group Therapy for Executives with Addiction

By Dr. Tracey Bassett

In deciding what to write about this month, I drew from Dr. Glazer’s most recent post in which he said, “I now understand that my most important role as a physician and therapist for alcoholism and addiction is to help provide a safe space, a trusting, mutually respectful relationship where I can help guide a person through their own recovery process.” I could not agree more.

One of the things that I think makes our practice so unique is that when we meet with a client for the first time, we conduct an assessment for what the client really needs. Which therapist will they work best with? Which modality of treatment will they respond the best to? What do they feel like they need? We then take all of these factors into consideration and make a treatment plan that works for them. We try to create a plan in which the individual client is getting what they truly need in an environment in which they can feel respected, connected, and supported.

The Benefits of Group Therapy in Addiction Treatment

In working to identify key aspects in recovery, we started to see a gap in treatment. A majority of clients seeking substance use treatment report something similar—feeling that no one in their close circle quite understands what they are going through. As a result, they often feel alone in the process. As doctors, we try to validate and normalize these common feelings. Sometimes this is enough, but a lot of times it is not.

In addition to individual therapy, some clients work well with 12-step or other peer-led recovery programs as part of their recovery process. For example, 12-step meetings can be a really great place for social support and validation, which subsequently reduces isolation, guilt, and shame. This is one of the reasons that these programs can work to support sustained recovery. However, I have found that a lot of clients want the peer support that meetings provide, but they are turned off by other aspects of the program that they feel are too “all or nothing.”

In starting to research alternative options that provide peer support, I’ve found that there is not a lot. Small cohesive group work in a private practice setting for high functioning clients is missing from the treatment landscape. As doctors, we are able to provide a safe supportive environment in our office, but what about an environment in which peers can support each other through mutual experiences?

So why is this so important? Among other things, groups are helpful as they provide the following benefits:

  • Positive feedback and support
  • Decreasing isolation
  • Sharing useful coping mechanisms
  • Challenging self-judgment and negative self-talk
  • Giving the opportunity to witness the recovery of others
  • Providing support to members should they stumble in recovery

A cohesive group can be a very powerful tool in recovery.

Our Manhattan Addiction Treatment Doctors are Backed by Experience

I, along with my colleague Dr. Gottlich, have had the pleasure of seeing the benefits of cohesive group work first-hand. After a lot of thought and planning, we started our first group at the practice in September 2019. After six months, the group is going strong. We have been witnesses to the type of unconditional support, and subsequent rewards, that a group can provide. Although Dr. Gottlich and I are able to provide the space, it is truly the work of the group members that provide a safe and supportive space to navigate the ups and downs of recovery. I feel lucky to be a part of the process, and I hope that we can continue to build group work as a larger part of the practice, as it is a powerful tool that allows a lot of people know that they are not alone in their recovery.

At Fifth Avenue Psychiatry, award-winning doctors provide unique, individualized treatment of alcoholism and substance abuse in a discreet, private setting.


Substance Abuse Treatment: Group Therapy (2005). Retrieved From: https://www.ncbi.nlm.nih.gov/pubmed/22514847

 

 

The Lack of Evidence in “Evidence Based Treatment” for Alcoholism and Addiction

By Samuel Glazer, MD, Clinical Assistant Professor of Psychiatry, NYU Langone Health

Many “for profit” treatment programs, both inpatient and outpatient, tout “Evidence Based Treatment” (EBT) as their approach to treat alcoholism, addition, and other substance use disorders. This label can be misleading, and though EBT sounds effective and backed by research (thus justifying the high cost of their programs), many “evidence based treatments” are actually associated with very poor outcomes.

As a skeptical addiction psychiatrist in Manhattan, I have observed and communicated to many of my patients and colleagues that though labeled “evidence based,” and considered the standard of care for addiction, many evidence based treatments have either very little or no evidence or extremely biased research showing efficacy. I am grateful for the many conversations with my patients and colleagues about this concept that have provoked this blog post.

The Common Misconception of Evidence Based Treatment for Addiction

The concept of Evidence Based Treatment (EBT) in addiction treatment actually derives from the movement in health care towards Evidence Based Practices. In fact, when physicians use Evidence Based Practices in delivering healthcare, it tends to be a very good thing. In the Evidence Based Practice of medicine, decisions are based on real data (not gut reactions), minimizing cost and unnecessary morbidity and leading generally to better outcomes. But, like many things you hear about in the addiction treatment world, Evidence Based Treatment is not what it seems.

The reality is that many treatment modalities for substance use disorders, though considered “evidence based,” often have very weak evidence behind them, in some cases none, and often are misused and/or administered by clinicians who do not have the training, experience or education to appropriately suggest them, let alone administer them. If one looks closely at the research, no medication or type of psychotherapy, even including Cognitive Behavioral Therapy, stands out as truly being effective or close to a cure for most addictions.

Types of Treatment for Substance Use Disorders

Treatment for substance use disorders falls into two categories:

  1. Psychosocial: Includes individual and group psychotherapy (the most studied being Cognitive Behavioral Therapy).
  2. Medication-Assisted Treatment: Includes medications that help with everything from detoxification, symptom relief, treatment of craving, and enhancing abstinence.

A few of these treatments really do work if used appropriately by the right people on the right patients in the right circumstances. But most do not show any statistically significant difference from placebo, and at best are comparable to AA, which is free and accessible to just about anyone anywhere in the world.

Naltrexone is a wonderful example of an evidence-based treatment that is clearly effective for the treatment of Opioid Use Disorder. Naltrexone is an opiate blocker, meaning it binds to the opiate receptors in your brain so that if you take an opiate (prescription painkillers, Vicodin, Percocet, Oxycontin and heroin to name a few), you are not affected by it. Given monthly as an injection in the form of an extended release injectable suspension (Vivitrol) in combination with psychosocial treatments, it is clearly proven useful as an effective treatment in preventing relapse and enhancing abstinence from opiates in people in treatment for Opiate Use Disorders.1 But Naltrexone is also a wonderful example of how a minimally helpful treatment actually has been falsely promoted, poorly studied, and wrongly executed as an evidence based treatment for Alcohol Use Disorders.

Naltrexone, an “Evidence Based Treatment” for Alcoholism

Naltrexone is currently considered an “evidence based” drug treatment for alcohol use disorders and alcoholism. It is often referred to as the first line drug treatment for alcoholism by many journals and clinicians. There are studies and methods published in many journals and referred to in media as “evidence based treatments” for alcohol use disorders.

Naltrexone is prescribed by many doctors to help people “control” or cut down on their drinking. Alcoholics are given the injection form when they are at rehab and outpatient programs to “help with long term craving” before they are discharged. There is even an entire program that has received a great deal of publicity called the Sinclair Method, which claims a 78% success rate in helping people control drinking with the use of naltrexone.

Unfortunately, a recent systematic review of the literature found that Naltrexone (or any other drug for that matter including nalmefene, acamprosate, baclofen and topirimate) show very little efficacy in controlling drinking and what little efficacy they show come from studies with a high risk of bias.2

The History of the FDA’s Approval of Naltrexone

In order to understand how this misinformation on naltrexone for alcohol use disorders was established, one needs to look into the history of how it became FDA approved as a treatment for alcoholism.

In the 1990’s, some studies showed that naltrexone could actually help a group of people in general cut down on their drinking. The FDA, desperate for some type of medication to help for alcoholism, and lobbied by big Pharma, approved naltrexone (brand name: Revia) as a pill indicated for alcoholism. If one reviews these studies, it is clear that the studies were not robust and were highly biased and conflicting.

In fact, many of these studies actually showed naltrexone has no effect, at all, on alcohol use. Looking more closely at the data, most studies show it has no effect on rates of alcoholism, almost all show it has zero effect on craving, and a few show that a few people out of the group may drink a bit less over the period of time that they are taking it.

The Truth About Naltrexone as an Evidence Based Treatment

In summary, naltrexone is a first line EBT in alcohol use disorders. Naltrexone is prescribed to control drinking, help with craving, and even extinguish the desire to drink.

Perform a web search and you will find many treatment programs boasting about their results with naltrexone. But, in reality, though there may be very scant evidence that it may cut down on the amount of drinking some people do, naltrexone cannot help people control drinking, demonstrates no effect on craving, and has zero effect on rates of people with alcohol use disorders in general.

Cognitive Behavioral Therapy as an Evidence Based Treatment

Some of you may be thinking, we all know Pharma influences medicine, what about behavioral treatments? Most programs (including our own) tout CBT or Cognitive Behavioral Therapy as part of their program.

CBT is an EBT that is often contrasted to spiritual or self-help treatment. CBT is a therapy that was designed by psychologists to be easily studied, and there are many studies of the effects of CBT in substance abuse treatment. It is believed to be the gold standard of therapies for addiction but, in line with all psychosocial interventions for substance use disorders, abstinence rates are low and unstable overall.

Although difficult to study, more and more evidence suggests that self-help and many other forms of treatment can be a first line treatment that is as effective as CBT. In fact, of all types of treatment, Contingency Management seems to stand out as being the most effective across the spectrum of substance use disorders. While CBT seems to work best for cannabis use disorder3, abstinence rates are still low.

Addiction Treatment is Not a One-Size-Fits-All Approach

As time goes on, and I add more entries to this blog, I hope to explore in more detail the limitations as well as efficacy of other treatments. But, suffice to say, there is no one size fits all. Though there are many types of both pharmacological and therapy-based treatments, most are limited in efficacy, often falsely advertised, or just misunderstood.

A major qualification that I do want to make clear, is that though there are some charlatans in the addiction treatment world, and some who are too arrogant to understand their limitations (I know of one therapist who claims he has a 100% success rate in treating addictions!), I do believe most clinicians are in it for the right reasons and are looking for any thread of evidence that can help them help their patients. Though there is only modest evidence behind even the most effective of treatments, we as Manhattan addiction therapists use what we can to help people.

The point of this blog is to shed some light on a highly misunderstood and stigmatized brain disease and the confusing information conveyed about its treatment mostly by for-profit programs preying on desperate and vulnerable people suffering with substance abuse disorders.

Our Manhattan Addiction Psychiatrist, Dr. Glazer, Provides Individualized Treatment

I was recently asked by a new patient who was consulting with me for his alcohol abuse what I could do for him to help him stop drinking. I thought about his for a minute and said (drawing on 20 years of experience treating substance use disorders and teaching at NYU Langone Health), “Not much.” I now understand that my most important role as a physician and therapist for alcoholism and addiction in Manhattan is to help provide a safe space, a trusting, mutually respectful relationship where I can help guide a person through their own recovery process.

Every person I see in my consultation room is unique. Nobody is an “addiction” for which “an evidence based treatment” will cure them. Rather I join with my patient and collaborate to find what motivates and what will be most effective for them.

For some, CBT is a great fit, for others, medication helps too, insight oriented or supportive therapy are best suited for some people, and others of course, are better off with twelve step programs.

For most people, it is a combination of these different modalities as a part of a commitment to growth and life change. Everyone has their own path. As one of my former patients likes to say, “I had to pay hundreds of dollars an hour to go talk to a fancy Upper East Side psychiatrist so that over time, he could help me find the help I really needed for my addiction in AA.” (The last I heard from him he was sober many years and was recently engaged to be married).

Thanks for reading, and a special thanks to Charlie Silberstein, MD who is a wonderful friend, mentor, and writer, and whose own writing inspired me to start blogging.


Sources:

  1. A Randomized Trial Comparing Extended-Release Injectable Suspension and Oral Naltrexone, Both Combined With Behavioral Therapy, for the Treatment of Opioid Use Disorder. Sullivan MA, Bisaga A, Pavlicova M, Carpenter KM, Choi CJ, Mishlen K, Levin FR, Mariani JJ, Nunes EV. Am J Psychiatry. 2019 Feb 1;176(2):129-137. doi: 10.1176/appi.ajp.2018.17070732. Epub 2018 Oct 19.
  2. Pharmacologically Controlled drinking in the treatment of alcohol dependence or alcohol use disorders, a systemic review with direct and network meta- analysis on nelmefene, naltrexone, acamprosate, baclofen and topiramate. bY Palpaccuer Et Al. Addiction, Feb2018 113(2) 220-237.
  3. Psychosocial interventions for cannabis use disorder, Gates PJ1, Sabioni P, Copeland J, Le Foll B, Gowing L. Cochrane Database Syst Rev. 2016 May 5;(5):CD005336. doi: 10.1002/14651858.CD005336.pub4

 

Woman Seeking Addiction Treatment in NYC

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