Category: Addiction and Treatment

Addiction and Treatment • • By PSYCHIATRY NYC 0 Comments

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 and other Substance Use Disorders. This label can be misleading, and though EBT sounds effective and backed by research, justifying the high cost of their programs, many “evidence based treatments” are actually associated with very poor outcomes. As a skeptical addiction psychiatrist 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 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.

Treatment for Substance Use Disorders falls into two categories: Psychosocial – which would include individual and group psychotherapy,( the most studied being Cognitive Behavioral Therapy), and Medication Assisted Treatment which 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 statistical 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. 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. It 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

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 1990s some studies showed that it can actually help 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, were highly biased and conflicting. Many 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.

So 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. Do 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.

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. CBT 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. CBT seems to work best for Cannabis Use Disorder3 but even in this case abstinence rates are low.

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 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.

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 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, 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.

SG

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

Addiction and Treatment Alcoholism and Recovery • • • By PSYCHIATRY NYC 0 Comments

Meditation and Mindfulness for Alcoholism and Addiction

By Olga Megwinoff, MD

There is so much referring to meditation and mindfulness. Every mental health guru speaks of mindfulness and the media outlets are saturated with everything meditation. It is definitely trendy, in fact, even in my neighborhood in the non-trendy suburbs we started a meditation group. When something is so trendy it can be easy to dismiss as a valuable and important tool in psychotherapy. I am ever grateful that I pursued this method of treatment and it changed my views and opened the door for me to the great teachings and understanding of the mind from the eastern psychology perspective.

The main goal of meditation in the Buddhist and Hindu traditions is spiritual enlightenment. Nevertheless, western psychology has appropriated a version of it for the treatment of mild to moderate Anxiety and Depression, Obsessive Compulsive Disorder (OCD), and Addiction. Meditation’s benefits on the mind are difficult to ignore given that at even the beginner’s level, it’s participants get a good glimpse of these benefits.

In this, my first blog, I will try to explain in simple terms a novel theory of why mediation works for anxiety, depression, OCD and addiction.

Beyond the effect of slowing down the nervous system via purposeful control of the respiration and its secondary effect on slowing down the heart rate, (the “fight or flight” response) meditation also has immense and immediate effects in the brain.

The first goal of meditation at the beginner’s level is to draw attention to the breath in an attempt to get rid of any other thoughts. It doesn’t really matter what you focus on, it can be your big toe or your right ear. The objective is to chose a part of your body you can feel, therefore you don’t think. The focus is on the feeling, on the somatic sensation of this body part. The only purpose of this initial learning phase is to train the mind to focus on only one thing fully.

A lot of people say, “I can’t do this”, “I have ADD”, “it’s too much work”, but I am fully convinced that if you have a brain, you can certainly develop the ability to meditate. It does take effort and discipline (maybe this will be the topic of my second blog, I find this is the aspect that most people struggle with, the discipline to practice every day, NOT with the ability to sustain attention).

If the participant can focus on the breath fully, and therefore clear the mind of any other thoughts, for a few seconds, the relaxation is immediately palpable. This was a big surprise for me, that the mere absence of thoughts created relaxation in the mind. My training in psychiatry was heavy on psychoanalysis and Cognitive Behavioral theory, the basis of anxiety and depression is understood as a conflict arising from conscious and unconscious thought (psychoanalysis) and/or distorted thoughts (CBT). Therefore, the content of thoughts are indirectly considered ever present.

However, in meditation, if you achieve the goal of having an absence of thought, (not a resolution of any unconscious conflict, or the identification and correction of a distorted thought pattern), just a quiet mind for a few seconds, this relieves symptoms for those few seconds.

Eastern psychology is not as invested in the content of the mind as western psychology is. The target, at these early levels, is absence of content. If a patient is able to achieve this for a few minutes every day, they can ultimately achieve relief from these symptoms during a greater period of time.

As you continue to progress in meditation, you can “open” the mind to thoughts and feelings, and as you ‘notice” the thoughts and feelings, the participants learn that they don’t have to react to them, introducing some distance from negative thoughts and feelings and realizing that they do not define you.

There is a lot of research demonstrating correlations between the positive effects of meditation with changes in particular brain structures like the medial prefrontal cortex, the posterior cingulate cortex, the amygdala, the hippocampus and limbic system. However, there is not a global hypothesis integrating all these structures functions and meditation correlates. The first such theory I have read about comes to life with the “discovery” of the Default Mode Network (DMN). The DMN was identified via neuroimaging in 2001 by Marcus Raichle, a neurologist at Washington University. He published his findings in the Proceedings of the National Academy of Sciences. See also Randy L. Buckner, Jessica R. Andrews-Hanna, and Daniel L. Schacter, “the Brain’s Default Network,” Annals of the New York Academy of Sciences 1124, no1 (2008). It is important to note that the concept of the default mode network is not yet globally accepted.

The DMN forms a critical and centrally located locus of brain activity that links parts of the cerebral cortex to deeper and more primitive structures involved in memory and emotion. It is stipulated that the DMN is responsible for wandering, daydreaming, rumination, worrying and self-reflection. It is also involved in mental constructions, moral reasoning and the concept of “the self”, among other functions. Some neuroscientist call it “the me network”.

Self-reflection can be responsible for powerful thinking and understanding but it can also be responsible for destructive forms of self-regard. Psychologists have identified a strong correlation between unhappiness and time spent in wandering, a principal activity of the DMN.

The DMN stands opposite to the attentional networks, when one is active, the other goes quiet, and viceversa. Scans of experienced meditators brains show the the DMN activity decreases significantly. (Judson Brewer, a researcher previously at Yale, now at the University of Massachusetts Medical School, Center for Mindfulness).

A theory by the British neuroscientist, Robin Carhart-Harris, is of ‘the spectrum of cognitive states”. He describes high-entropy mental states (psychedelic states, infant consciousness, early psychosis, creative thinking) and low-entropy mental states (rigid thinking, addiction, obsessive-compulsive disorder, depression, anesthesia and coma). Carhart-Harris suggests that the psychological disorders at the low entropy end of the spectrum are not the result of lack of order in the brain (as the established theories postulate), but rather an excess of order.

When self-reflective thinking becomes excessive, heavy self-consciousness gradually shades out reality, this may be the result of a hyperactive default mode network, which can trap us on repetitive and destructive loops of rumination – this is a substantial part of addiction, obsessions, anxieties and depression.

With a regular meditation practice, many people with Substance Use Disorders, Anxiety, Depression and OCD can transform their minds by lowering the volume of the DMN and therefore quieting the self-consciousness, ruminations, and worrying that so characterizes these disorders.

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Post Traumatic Stress Disorder and Addiction 

By Britt Gottlich, Psy.D.

I often meet with people who say they are unsure of whether they have experienced trauma or not. So what is trauma? Most people define trauma based on how trauma is portrayed in the media. But in reality it is a very subjective experience. Something that may be traumatic for one person may not be traumatic for another. The American Psychological Association defines trauma as “an emotional response to a terrible event like an accident, rape or natural disaster.”

The way I like to understand trauma is based on an individual’s interpretation of the event. As children we live under the assumption that ‘good things happen to good people and bad things happen to bad people.’ When we experience a trauma, often our interpretation of this rule becomes clouded and confused. For example, it could change to, ‘if good things happen to good people, and this happened to me, then I must be bad.’ Therefore, a person’s reaction to a traumatic experience often affects the way they see themselves, other people, and the world around them.

We can’t change or erase a traumatic experience, unfortunately. But what we can do is change the way we interpret it and ultimately the way we understand the world around us as a result of that event. This is where Cognitive Processing Therapy (CPT) can be a useful treatment modality. It helps us identify the cognitive distortions that are derived from our traumas, and using evidence and facts, combat those thoughts with rational ones. 

CPT has been a very effective treatment modality which is often used in treating Veterans with Post Traumatic Stress Disorder or PTSD. CPT is a 12 session behavioral psychotherapy. It has been found to be highly effective in treatment for PTSD. A study conducted in 2017 that studied the effectiveness of CPT on Veterans found that Veterans who completed the 12 session treatment had a significant difference in their symptoms and had a decline in Post Traumatic Stress Disorder Checklist scores than Veterans who did not complete or comply with treatment. Other treatments that are used for PTSD are Eye Movement Desensitization & Reprocessing (EMDR) and Prolonged Exposure (PE). In my experience and training with all the above modalities, I have seen the most improvement and success with CPT.

While there are treatments such as CPT that are very effective in treating trauma, one of the most important pieces in this type of therapy is rapport. It is important in all therapy to have a positive relationship with your therapist where you feel comfortable and not judged. But especially when disclosing a trauma, and going deep into the event, feelings, and cognitions related to it, it is important that you feel trusting of the person providing that treatment.

From my experience working at a VA and currently here at Fifth Avenue Psychiatry, I see that there is a high comorbidity for substance abuse and PTSD, especially when PTSD goes undiagnosed or untreated. VA statistics note that more than 2 out of 10 Veterans with PTSD also have a substance use disorder, and 1 out of 3 Veterans seeking treatment for substance use disorders also meet criteria for PTSD. The American Addictions Center reported that 55-60% of individuals who suffer from PTSD have comorbid addiction or alcoholism. They also note that “people who suffer PTSD are between two and four times more likely to also battle addiction than their peers who do not also struggle with PTSD.”

Again, traumas are not something that can be erased, but they can be something you can learn to live with. You can begin to see the world, people, and yourself in healthier ways again. You may never fully believe that ‘good things happen to good people,’ but eventually you may believe that ‘bad things sometimes happen to good people.’

https://journals.sagepub.com/doi/abs/10.1177/0033294117727746?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=prxa

https://americanaddictioncenters.org/ptsd

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Cognitive Behavior Therapy (CBT) for Addiction and Alcoholism, An Evidence Based Treatment

By Tracey Basset, PsyD

Making the decision to seek help for a substance use problem is challenging enough.  On top of that, for a lot of people, they face the challenge of choosing where to go, who to see, and what type of therapy will benefit them most.  This can be a very confusing and daunting process.  My aim for this post is to provide some useful information about the benefits of one type of therapy, my favorite type of therapy, Cognitive Behavioral Therapy, or CBT.  

CBT is based on the notion that the way we think influences how we feel, and then subsequently how we behave.  Think of it like a domino effect- something happens, you have a thought or a belief about that event, that thought creates a feeling and that feeling creates an action.  For example, if you try to reach out to a friend or family member and they do not have time to see or talk to you, then you might think that you are not important to them, that you are not worthy of their time, or maybe that you are not good enough.  That thought can lead to feelings of loneliness, rejection, sadness, or even anger.  Those feelings could lead to the desire to escape, which could ultimately lead to using a substance.  Then substance use leads to more isolation and less connection.  The cycle starts again, and builds.  

In CBT, we explore these triggering events and identify patterns.  We explore the thought patterns, or belief systems, and we challenge those patterns that may be problematic.  Some beliefs are true and we work to problem solve and change them.  Others are not true, and are simply believed to be true, because they have been ingrained for a very long time.  We learn to explore where beliefs come from and we learn to challenge them.  In CBT we learn strategies to cope with the uncomfortable feelings, and strategies to help reduce the likelihood that certain feelings will trigger use.  

This is just one example of how CBT can play out in therapy.  There are dozens more.  CBT can be a great therapy for individuals struggling with substance use along with co-occurring anxiety and/or depression because it provides tools, strategies and a roadmap for how to gain control when you feel out of control. If you are someone that struggles with anxiety and/or depression in addition to substance use, it may feel like there are too many things to tackle, and you may even feel stuck, helpless or hopeless.  However, CBT works on exploring, challenging, and changing the relationship between symptoms of depression, anxiety and substance use.  Therefore, it is a very practical, effective and efficient approach to tackling co-occurring substance and mental health needs that feel complex in nature. 

So, why is CBT my favorite type of therapy?  Because there is a lot of evidence to show that it works.  CBT is empirically based, meaning that there are a lot of research studies that consistently show that it helps individuals to reduce anxiety and depression, and successfully address substance use.  

In closing, I will leave you with a quote.  It is one that I recently stumbled upon in my personal life and I instantly connected with it because it just made so much sense to me given my predisposition to think of life through the lens of CBT.  So, despite what you may be going through, and my guess is that it may be something quite challenging since you are here reading this page, the good news is that at any time you can choose to take the steps to change your destiny.  

“Watch your thoughts; they become words. 

Watch your words; they become actions. 

Watch your actions; they become habits. 

Watch your habits; they become character. 

Watch your character; for it becomes your destiny. 

– Upanishads”

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Why Outpatient Treatment for Addiction and Alcoholism may be a better choice than Inpatient Rehab, and why you rarely hear this

This is my first blog entry and my hope is that through monthly posts, I and my associates, Dr.s Megwinoff, Bassett and Gottlich can help shed some light and insight on our various expertise and experiences in addiction treatment. In listening to my patients and their families, I realize that there is a great deal about addiction and its treatment that is misunderstood. There are many misconceptions about addiction treatment. Often, people looking for help for addiction are hopeless and vulnerable to exploitation. Many messages are misconveyed in order to justify expensive and unnecessary treatments. Inpatient rehab and its utility is one of them. Read more

Why More Attorneys Are Searching for an Addiction Therapist Near Me
Addiction and Treatment Mental Health • • By samuel glazer 0 Comments

The Lawyer: The Partyer and the Alcoholic

It’s a tired popular media trope: the attorney, burdened by the stresses of work, pours a glass of bourbon at the end of a long day. Maybe he is waiting for a verdict to come in after an impassioned speech in front of a jury, maybe she is prepping for a long day at the Supreme Court ahead. Alcohol as a coping mechanism in pop culture is as old as television itself. Read more

Opiate Detox for Lawyers, Even Attorneys Get Hooked on Heroin
Addiction and Treatment • • • By samuel glazer 0 Comments

The Path to Opioid Abuse for Attorneys

Popular culture portrayals of the legal profession may draw young people to law school: giving impassioned arguments in front of a jury, laying out a compelling case in front of a judge. A promising young law student may enter school with hopes of helping the disfranchised or aiding in the reform of the criminal justice system. However, once they exit the hallowed halls of their law school, reality paints a grimmer picture. Read more

The Wolf of Wall Street
Addiction and Treatment Mental Health • • By PSYCHIATRY NYC 0 Comments

Why Financial Execs Can’t Manage Stress, Leading to Addiction Treatment

The world of financial executives has long been the subject of fascination. The Wolf of Wall Street, a movie starring Leonardo DiCaprio based on a memoir by Jordan Belfort of the same name, tells a compelling story of a financial executive’s meteoric rise and equally spectacular fall. Read more

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Can You Treat Drug Addiction with Vivitrol?

As people, we may be different for a variety of reasons. But a common denominator amongst us is the existence of stress in our lives and how it impacts mental health. Oftentimes, it isn’t the stress itself that causes us harm but how we choose to perceive it or how we cope (or not) that poses the most risks.
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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, …

Meditation and Mindfulness for Alcoholism and Addiction

By Olga Megwinoff, MD There is so much referring to meditation and mindfulness. Every mental health guru speaks of mindfulness …

Post Traumatic Stress Disorder and Addiction 

By Britt Gottlich, Psy.D. I often meet with people who say they are unsure of whether they have experienced trauma or not. …