December 2019

Thinking beyond medication; “Just give me medication”; consumerism and loving yourself

In SAVVY, ASAM’s revamped definition of addiction and finding the balance between medication and psychosocial treatments. Consider effective alternatives to medication. In SKILLS, what to do with requests for medication for chronic pain and addiction. In SOUL, Santa, shopping and self-love. Adam Roa on “How to Truly Love Yourself”.

savvy

We live in a society and culture where the first intervention patients and physicians often think of is medication. I joke that some people don’t want to pay their co-pay if their doctor doesn’t give them a prescription for a medication: “He didn’t do anything. They didn’t give me a pill for my symptons. I’m not going to pay for this visit!”

In addiction treatment, the opioid crisis and the knowledge that addiction is a brain disease, has contributed to a focus on medication in addiction treatment. For some, this focus on medication has resulted in neglect of psychosocial treatments that are essential in achieving long-term recovery. 

In September, 2019, the American Society of Addiction Medicine revamped its 2011 definition of addiction.“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”

“….complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences” reminds us that addiction is not just a ‘brain’ disease, but like all chronic medical diseases is biopsychosocial in its etiology, how it manifests in people’s lives, and in what is essential in treatment to promote long-term recovery.

TIP 1

Find the balance between medication as treatment versus medication and psychosocial services

  • Too many treatment providers are not using effective medications for Opioid Use Disorder and other manifestations of addiction (alcohol and nicotine). They need to balance their focus on psychosocial treatments with consideration of medication for their clients and patients.
  • But the reverse is true too where too many prescribers are seeing addiction treatment only as using medication.

While there are effective medications for alcohol, nicotine and opioid use disorders, the hunt is on for medications effective with stimulant use disorders. In a December 16, 2019 editorial comment by William Haning, MD, DFAPA, DFASAM, Editor-in-Chief, ASAM Weekly, Dr. Haning presents a balanced view of a December 11 article by Phillip O. Coffin, MD, MIA; Glenn-Milo Santos, PhD, MPH; Jaclyn Hern, MPH; et al. in JAMA Psychiatry that suggested a medication, mirtazapine, is effective in the management of methamphetamine use disorder.

Here’s what Dr. Haning said: 

“…. it would be hard to imagine a mood-altering medication that has not been considered or deployed in the effort to reduce rates of methamphetamine use: bupropion, selegiline, n-acetyl cysteine, ondansetron, modafinil… and then re-deployed, as mirtazapine was a decade ago and is again now.” 

Then he goes on to comment on how effective these medications are or not (remember addiction as a biopsychosocial disease): 

“….they generally have some benefit over placebo, though not universally. This may reflect reliance on diagnostic criteria that remain phenomenological, and unable to account for cultural, genetic, or other influences. Recommendations for the employment of cannabis and even psilocybin, while not wholly irrational, suggest desperation or Hail Mary plays. Not excluded from consideration are agents that have shown promise in some clinical trials but not as yet definitively, such as methylphenidate.” 

Finally, Dr. Haning concludes:”….the mainstay of therapy remains psychotherapeutic, whether in individual, group, or milieu settings, whether cognitive-behavioral, motivationally-enhancing or other.” 

TIP 2

Review a variety of non-medication treatments in behavioral health that are just as effective as medication.

1. Mindfulness; John J. Miller, MD; Psychiatric Times Vol 36, Issue 12 December 11, 2019 

Over the past 3 decades clinical medicine and psychology have integrated the basic principles of mindfulness into many diverse treatment modalities. …..Given the general nature of the practice of mindfulness, not surprisingly, it has found its way into numerous applications. 

These include:

  • Mindfulness based stress reduction
  • Pain management clinics
  • Mindfulness based cognitive behavioral therapy* Dialectical behavior therapy
  • Addiction treatment
  • Acceptance and commitment therapy
  • Augmentation of individual psychotherapy”  

2. Yoga Worth ‘Serious Consideration’ for Major Depression; Batya Swift Yasgur, MA, LSW 

Medscape Medical News November 27, 2019 about a study published online November 13 in the Journal of Psychiatric Practice. 

Yoga practice consisting of physical postures and breathing techniques can be helpful in improving symptoms of depression and anxiety in patients with major depressive disorder (MDD), new research suggests.

“Yoga and regulated breathing practices have been used for thousands of years in diverse cultures to manage stress, anxiety, depression, pain, and many other conditions,” study coauthor Patricia L. Gerbarg, MD, an assistant professor in psychiatry at New York Medical College in Valhalla, told Medscape Medical News.

“Clinicians should seriously consider including mind-body practices such as yoga and coherent breathing in their treatment recommendations for patients with depressive symptoms,” she added.” 

3. Non-Drug Therapies May Be More Effective At Easing Dementia-Associated Agitation, Research Suggests. 

Canadian researchers at Li Ka Shing Knowledge Institute within Unity Health Toronto of analyzed over 163 studies involving nearly 25,000 patients. Their analysis suggests that “symptoms of aggression and agitation in dementia patients may respond better to non-drug therapies such as massage, touch therapy and outdoor activities.” Investigators “found that outdoor activities were more effective than antipsychotic medications for treating physically aggressive patients.” Also, in terms of “verbal aggression, massage and touch therapy were more effective than the patients’ usual care.” The findings were published in the Annals of Internal Medicine.” 

One more study, just in time for the holidays: 

4. Dark Chocolate for Depression; Chris Aiken, MD; Psychiatric Times Volume: 36 Issue: 11 September 5, 2019 

Dark chocolate lowers the risk of depression, according to a cross-sectional survey of over 13,000 US adults. The study compared self-reported chocolate consumption with self-reported depressive symptoms, as measured by the PHQ-9. People who ate dark chocolate in the past 24 hours were 70% less likely to report depression.”

skills

“Just give me medication” – two clinical situations; and how to discuss medication in chronic pain and in addiction treatment.

TIP 1:

Distinguish between wanting chronic pain help or wanting addictive medication 

Clinician: “Good morning, how can I be of help?” 

Patient: I have severe chronic pain and need Oxycontin (oxycodone). 

Clinician: “Well let’s do an evaluation of your pain and see if that’s the best treatment for your pain?” 

Patient: It’s the best treatment alright, I’ve tried everything else and that’s the only thing that works.

Clinician: “So you’ve done physical therapy and some other no-medication treatments like mindfulness and massage?” 

Patient: The only thing that works for me is Oxycontin and I’ve run out and need a new prescription.

Clinician: “I can hear and understand your concern for medication; and I am not saying I won’t give you medication. But first, we should re-evaluate your pain; what treatments you have had and what worked or not; and then collaborate on a plan that has the best chance of improving your pain.” 

Patient: The only thing that works is Oxycontin. Are you going to give it to me or not?

Clinician: “As I said, I’m not saying I won’t give you medication if you need it and it is part of an overall plan for your pain. But are you wanting help for your pain, or are you just wanting Oxycontin?” 

Patient: Yes, of course I want help for my pain, but I need Oxycontin. I don’t need all these other treatments you are talking about.

Clinician: “If I’m going to help you with your pain, I need to re-evaluate your pain and past treatments and then collaborate with you on the best plan going forward.” 

Patient: Are you going to give me Oxycontin or not? I don’t have time for all this evaluation. If you’re not going to give me a prescription, I’ll find someone who will.

Bottom line Tip: If the patient was willing to re-evaluate their pain with you, I would continue the Oxycontin even if I thought they were addicted to the medication. To cut them off precipitously would only push them out of treatment before you have enough time to form a better relationship with them and use motivational enhancement therapy to engage them in a more holistic plan. 

TIP 2:

Try a “discovery” plan for the person who wants medication for addiction, not psychosocial treatments 

Clinician: “Good morning, how can I be of help?” 

Patient: I have an alcohol problem and my wife is mad that I lost my job and I need help.

Clinician: “That’s great that you realize you need help. A lot of people with addiction don’t reach out. 

Patient: Well yes, but I don’t want to go to any treatment program or AA.

Clinician: “So what help do you want for your alcohol problem?” 

Patient: Well isn’t there some medication or pill you can give for this?

Clinician: “Yes, there are medications that can help people with alcohol addiction. But treatment is more than just medication. It is about changing your lifestyle and attitudes and who you hang out with and other behaviors.” 

Patient: Well, as I said, I don’t want to go to a treatment program or those AA meetings. I just want the medication you talked about.

Clinician: “Are you wanting to keep your marriage and find another job? If you do and if your addiction is messing up your marriage and work, I don’t think medication alone is going to fix that.” 

Patient: I just want medication. Maybe if that doesn’t work, I’ll talk about treatment and AA, but I just want medication.

Bottom line Tip: After trying to educate the patient about addiction and recovery, if he still just wants medication, I would start with the “just medication, no treatment groups or AA” Discovery plan. After agreeing on how to track if that plan is working or not (involving his wife in the planning to see if the relationship is improving or not; random alcohol and other drug testing, tracking progress in finding a new job), the plan is a medication-only plan with frequent visits to track outcomes. If all is going well, we continue with the medication-only plan. If marital and job-hunting problems flare up, the therapeutic relationship is established to explore changes to the treatment plan and eventual psychosocial strategies and meetings.

soul

How much did you spend on Christmas or holiday gifts this year? 

Statistics from the World Economic Forum predicted:

  • Americans will spend over $1 trillion on Christmas this year.
  • US consumers tell Gallup pollsters they plan to spend an average of $942 on Christmas gifts this year – $57 more than last year.
  • More than one-third say their gift-buying will top $1,000, one-third higher than last year’s top spenders.
  • The average American spends 15 hours shopping for Christmas.

Around Thanksgiving, my sister-in-law, Annette, shared a YouTube from “a cool poet in his mid 30s, Adam Roa…I find him engaging” she said. I do too. See what you think

In this time of consumerism, the message is ‘you are not enough’ so:

  • “Buy this to feel attractive”
  • “Buy this to to feel better”
  • “Buy this to be better”

Unless you are narcissistic person, it is easier to give to others than to give to yourself; to empathize with their needs rather than fully embrace your own needs.It comes down to mixing up selfishness with self-love: 

Empathizing with others:

“Why was I so stupid to make that mistake.” 

           Don’t be so hard on yourself, no-one’s perfect.

We all make mistakes.“Yes, but I should have known better. This is not the first time I gave in so easily.”

            I know, we often shoot ourselves in the foot. But it’ll be a good learning experience to help prevent the next time hopefully. 

Self-talk and being hard on yourself when it comes to self-love:

“Why was I so stupid to make that mistake.”

            Yes, how come I did exactly the same thing again. I didn’t learn a thing from last time.

“Yes, I know. I’m such a sucker. I gave in so easily.”

            I sure did. What’s wrong with me? I’m such a loser. 

The only relationship you will have for life until the day you die, is the relationship with yourself. So Adam Roa’s message is so important: 

Treat yourself like someone you love. Or in the Christian biblical tradition, love your neighbor as yourself.

November 2019

Lessons learned from my journey to India and Japan; travel tips; Laughter Meditation; Sharing Solutions

In SAVVY and SKILLS, I share some observations from my trip to India and Japan; and implications for Behavioral Health.  

In SOUL, what I learned from Laughter Meditation in Pune, India.

SHARING SOLUTIONS about behavior design for addiction professionals.

Read More

October 2019

Two STUMP THE SHRINK questions on passive compliance and substance use while in treatment; customer-focused and friendly

Welcome to the October edition of Tips and Topics (TNT). This edition combines SAVVY and SKILLS to address two STUMP THE SHRINK questions that encompass several relevant attitude, knowledge and skills issues.

Read More

September 2019

What are social determinants of health? Aging providers and the next generation

Welcome to the September edition of Tips and Topics (TNT). My heartfelt thanks to the many readers who took the time to write and share their support and feelings about the August all-SOUL edition.
This month in SAVVY, the focus is on social determinants of health.
In SKILLS, it is important to assess and include social determinants in treatment planning, not as an afterthought or “discharge planning” task.
In SOUL, a guest contributor asks “how do we capture our faith, skills and experiences in order to share and pass them along to the next generations of professionals?”

Read More

August 2019

All SOUL – grief, loss, and moving forward. Perspectives from my children and me.

Read More

July 2019

Behavior Contracts – the good, the bad and how to move away from them; Surpises about food and the environment

In SAVVY, we focus on the advantages and disadvantages of Behavior Contracts.
In SKILLS, I invite you to delete Behavior Contracts from your clinical toolkit.
In SOUL, I was shocked to learn that that a quarter of the world’s greenhouse gas emissions come from putting food on the table.

Read More

June 2019

What to do about addiction clients with prescribed, potentially addictive medications; Pickleball anyone?

In SAVVY and STUMP THE SHRINK, I respond to a question on what to do about psychiatric prescriptions for benzodiazepines and amphetamines in addiction treatment.
In SKILLS, assessment needs a skilled clinician who is savvy about addiction and mental illness who can evaluate specific diagnostic and treatment questions.
In SOUL, I was introduced to Pickleball and now exercise could actually be fun for me.

Read More

May 2019

Lying and dishonesty in Treatment Courts and what to do; using ACCEPT with dishonesty; update on my grief process.

Welcome to the May edition of Tips and Topics (TNT). A special welcome and thanks to those readers who have been with me from the beginning and wrote to express their appreciation through all the years.

In SAVVY and STUMP THE SHRINK, I respond to a question on what to do about lying and dishonesty in Drug Courts – what is the role of sanctions?

In SKILLS, what is the role of treatment and judges and court teams when participants lie? Using ACCEPT as a structure to guide what to do.

In SOUL, I update where I am in my grieving process. It helps me to reflect and I hope helps you understand grief too.

Read More

April 2019

What to do with poor outcomes: ACCEPT; my top 10 “Unvarnished Truths”

Welcome to the start of the 17th year of Tips and Topics (TNT). Most of you were not a reader from Day 1 when I started writing TNT, April 2003. If you were, please write and let me know.
In SAVVY, I’m introducing an acronym to help think through what to do when a client, patient or participant is not doing well in treatment – ACCEPT © David Mee-Lee 2019.
In SKILLS, what is a poor outcome for your client in addiction treatment?
In SOUL, whether you are thinking about retirement or not, “21 Unvarnished Truths about Retirement” is a worthwhile list from which I highlight my favorites.

Read More

March 2019

Guest writer Tips on Sports Betting; one more SOUL on losing my wife and grief

SAVVY and SKILLS – March is Problem Gambling Awareness Month, which is why this edition comes to you earlier than usual, so you can be aware. Having a guest writer was good for me as I continue in the acute phase of grieving over the loss of my wife a few weeks ago.

SOUL – A bit more on grief and loss this month and then I’ll leave that alone for a while – in Tips and Topics, not my life.

Read More

January 2019

Addressing racial disparities; Unconscious bias and Nonviolent Communication; Africa and a cultural experience

Welcome to the New Year and the January edition of Tips and Topics (TNT). In this edition, the focus in SAVVY is on race relations, unconscious bias and the foundation for nonviolent communication.
SKILLS raises consciousness about systems barriers and biases which work against racial equality and ways to break down walls.
SOUL is about the adventure in Africa this month that will place me face to face with a very different culture.

Read More