All posts by pjdhanoa

Jamie Moyer’s Crusade – By Joe Schrank

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The Future Hall of Fame pitcher isn’t just the oldest player to toss a win, he’s also the most active crusader against addiction in the game—both in and out of the locker room.

When future Hall of Fame pitcher Jamie Moyer pitched his first big league baseball game, Ronald Reagan was president, cell phones were the size of TVs and Johnny Carson was hosting The Tonight Show. He was starting for the Chicago Cubs in June, and won a pitcher’s duel against aging Phillies ace Steve Carlton, who at 42 was considered one of baseball’s eminence gris. This April 17, the 49-year-old Moyer notched a victory for the Colorado Rockies, breaking the record as the oldest starting pitcher to win a major league game.

Moyer has been on the diamond long enough to see an entire generation of pros struggle with addiction in the locker room. His rookie year, the New York Mets won the World Series with a roster that would come to look like a rogue’s gallery of substance abuse: Darryl Strawberry, Dwight Gooden and Lenny Dykstra have all battled demons. Moyer witnessed first-hand the rise and fall of the Steroid Era, an epidemic of amphetamine abuse, the advent of Human Growth Hormones, and enough booze to rain out a stadium.

But longevity isn’t the only thing that makes Moyer stand out. He and his wife, Karen, started The Moyer Foundation, which helps kids who are battling addiction or who come from troubled homes. Knowing that 95% of adult addicts start to use drugs before the age of 20, the Moyers have decided to intervene before that happens, and launched a treatment franchise called Camp Mariposa as a refuge for kids who come from addicted homes, or who are starting to land in trouble. Moyer opens up about how he going into the treatment world, how he managed to stay in the game so long, and what baseball can do to help players who are struggling with their own demons.

Joe Schrank: First of all, congratulations on being the oldest major league pitcher to win a game. I’m 43 years old and I can barely make it up the subway stairs anymore. Your victory at 49 is an inspiration to a generation of middle-aged fat guys.

Jamie Moyer: You’re too kind.

You and your wife, Karen, have taken real strides in addressing a serious problem in the US: that children are a forgotten casualty of alcoholism.

Absolutely. That’s what the Moyer Foundation grew out of. The whole point of Camp Mariposa is to reach out to kids between nine and twelve years old, because there’s nothing out there for them. And unfortunately, there’s 8.3 million kids in this country living under the roof of a parent in need of treatment for alcohol or drug abuse. That’s a large number, and growing up in this environment means they’re three times more likely to be abused and four times more likely to become an addict. Here’s the shocker: 95% of adult addicts started to use drugs before the age of twenty. So we’re trying to stop that cycle early on. What we do at the Camps is reduce the feelings of isolation, fear, guilt, loneliness. Addiction is not their fault. We need them to recognize that and help them make the right choices from the get-go.

How many Camps are there?

Five so far—in Washington State, South Bend, Bradenton, Florida, and in Philadelphia, not far from where I grew up.

The Betty Ford Clinic and the Caron Foundation have children’s programs, but beyond that, and the Camps, we’re a culture that really doesn’t address this subtext.

Life is all about making choices, right? But for a kid 10 year old kid in an alcoholic household, where they see some of the bad choices being made by adults, it’s hard to pin it on the kid. So if you put them in an environment with other children, and they realize they’re not alone in dealing with this, they can learn from each others’ experiences. That’s how you address it.

We say that all the time in rehab that when a patient goes home, they set new boundaries. If that means you have to move out, then you move out. Well, when you’re nine that’s not an option.  

At that age, it would be tough to make that decision when you’re that young.

One of the things that we’ve we’ve written about in The Fix is The Dry Tailgate Party, which you host at Notre Dame. How did that become an event?

When you have big sports events and you serve alcohol, you’re also condoning the abuse of alcohol. We thought a great way to get a message across is to have a dry tailgate. When you think about a tailgate, people are having a good time, they’re having food, and maybe they’re drinking, and hopefully, if they’re drinking, they’re drinking responsibly. But that’s not always the case. At a dry tailgate, there’s food and people are having a good time—but there’s no alcohol. And we’re trying to create an awareness of Camp Mariposa and the positive effects that we can have on a community.

Is it going to continue and be an annual thing?

As of now, yes. I mean we’ve done it in South Bend at Notre Dame, and I think we’re going to continue that, and as model grows we’ll expand. That’s the plan..

Well, I’m going to be there this year. I promised your wife, and I have a feeling people don’t say no to your wife.

I know that people have found it hard to say no to her.

Baseball’s had trouble dealing with drugs and alcohol. But there are exceptions. The Texas Rangers have been really supportive of Josh Hamilton and Ron Washington as they struggle with addiction. They seem to handle it better than any other franchise. Why do you think more people aren’t taking that leap?

That is a great question. This case is two people—Ron and Josh—who have been adult enough or man enough to stand up and say, “Look, I have a problem.” And I think the organization is lucky that it’s run by Nolan Ryan, who was an teammate of mine. I know him as a person, and I know that if he sees a problem, he’s going to address it and set a positive example. That’s exactly what’s happening. In Josh Hamilton’s case, I think at some point he realized his life was going down the drain. So he had two choices: either continue the spiral and lose his family, his career, and everything else, or be a man and step forward and take care of his issues. And I think it started when he was in Cincinnati. They had somebody who traveled with him and helped him out. Obviously, he’s chosen to take the high road. I thought was really cool when the Rangers won in the playoffs the first time, their teammates were celebrating with beer, but when he entered the room, they celebrated with soda and ginger ale. I thought, “Wow, what a great message.”

But that didn’t just happen. Somebody had to say, Look, let’s be supportive of him and spray ginger ale on each other instead of champagne. Even with Ron Washington testing positive for cocaine, the Rangers said, We’ll roll with this. People are not disposable just because they have a problem. 

I get it. It’s a great example, and kudos to the Texas Rangers for not turning their backs on them, and for taking a negative and turning it into a positive.

Yeah, and even when Josh tripped up the Rangers supported him. He has done exactly the right thing. He’s owned it. He’s not blamed anybody.

Exactly. I think it’s important to realize that the Texas Rangers have taken this issue and done something with it. Why aren’t other clubs doing it? I don’t know. When you have a problem like this and you do either publicly come up front and talk about it, or you have the problem and you’re afraid to address it,  an individual needs to know there’s support out there. And that’s what we’re trying to create with our foundation. But we need financial help and we need to educate people. Hence the dry tailgate.

Right.

There’s going to be plenty of people that stick their noses up to it. But when they’re in need, they’re going to say, oh my gosh, there is an organization out there or there’s many organizations out there that I could go to for help. And that’s what we’re trying to create with these kids and with Camp Mariposa that, you know, let’s help these kids who probably right now at the ages of nine to twelve don’t know where to go for help.

No, they don’t and there’s limited resources that they get.

You’re exactly right. So being able to partner with the Penn Foundation is a huge privilege. It’s going to take time and finances, but over time we can make a difference in children’s lives.

And the community. I always thought, well, if I just don’t drink I’m helping the world because I’m not clogging up the judicial system. I’m not going to get stitches and take up space at the ER.

I think the way our society deals with alcohol is why some of these kids drinking. Take a beer commercial on TV: it talks about drinking responsibly, which is great. They’re doing their due diligence with that. But think about it: What’s the first thing you think about when you go to college? You party.

It’s always been that way.

Even though high school kids are underage, they’re still finding alcohol, they’re still finding drugs. Asking them to drink responsibly is asking a lot. Potentially, the solution starts in our government. I know our government has been working hard at the problem for years—I watch the TV shows of Feds catching people at the border transporting bales of marijuana and bricks of cocaine and all that kind of stuff. They’re very interesting and intriguing shows to watch, but the drug trade is a huge, huge business. People have figured out ways to make money off of it, and that’s what it’s all about.

A Black Hawk helicopter is $20 million and they’re used to defoliate coca fields in Colombia. And nobody stays sober because of that. And what could you do for kids with $20 million?

Exactly. You could actually set up programs in schools, in preschool, in high school, and meet in the middle and re-educate people, show the problems, and teach people how to make better choices. Also, give people better alternatives to drugs and alcohol. People use those things to forget their problems. And when they eventually sober up they realize their problems have not gone away.

Or, they’ve been exacerbated by the drinking. I always say, well look, if you drink, then you’re going to have two problems. You know you’re going to have the drinking problem.

Exactly.

The San Francisco Giants will be hosting Recovery Night at AT&T Park this year. Do you think that other teams will take that lead or take interest?

Well, I’m sure organizations will be watching how that goes. The community of San Francisco has a lot of street people, a lot of drugs—there’s drugs everywhere unfortunately—but the Giants are taking the initiative, and I think that’s awesome. I think there will be some organizations that follow their lead.

Baseball is really intertwined with beer. You must know, since you pitch for the Rockies, who play at Coors Field.

True.

So let me ask you, should Coors be giving the Moyer Foundation $1 million to help these kids?

I like how you think.

There are lots of people who are not impaired by using that product. But a byproduct of their profit could very well be an abusive father parked on the couch drinking Coors. Tobacco companies contribute to cancer research; shouldn’t alcohol companies help with this?

That makes total sense.

There have been a lot of drug-related fatalities in sports lately, especially with avoidable tragedies like the new York Rangers’ Derek Boogaard. What should be changed?

Well, I’m going to answer that, but I’m going to veer off a little bit and get back to it.

Sure.

A lot of Major League teams have taken alcohol out of the clubhouse. So organizations are noticing that there are problems—whether it’s a responsibility issue or a liability issue or what. At the Rockies, we have no alcohol in our clubhouse. And the name on our sign is Coors Field! So our club has taken that initiative. I think the Cardinals, who are owned by Anheuser-Busch, don’t have beer in their clubhouse anymore. Don’t hold me to that. But there are clubs that allow it—they believe it takes the pressure off, after a game, to have a drink. I don’t know if there is a definite answer out there.

The Medical Subspecialty of Addiction Medicine – Scott Bienenfeld, M.D.

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I could not have been more excited to read the article “Rethinking Addictions Roots, And Its Treatment “, that was published in The New York Times  on July 10, 2011.  The article highlights the fact that The American Board of Addiction Medicine (ABAM) has implemented 10 medical residency programs in the field of Addiction Medicine at major national medical centers throughout the country, including one that is here in New York City at St. Like’s Roosevelt Hospital.  This move represents a significant push by the medical field to provide extensive residency-type training in Addiction Medicine to doctors in a variety of specialties – something that has not been seen before. [i] It is also an acknowledgement that not only is Addiction Medicine an important medical specialty worthy of advanced study by doctors in a variety of fields, but also that the disease model of addiction is one that the medical field takes seriously, and understands as a major public health problem.

As I have pointed out in earlier posts, advancements in neuro-imaging technology have clearly identified addiction as a medical illness that results in measurable brain changes, both as a result of the illness and also in response to effective treatments.  That, combined with the introduction of new medications that are being used in the fight against addiction, have placed Addiction Medicine on the same level as other medical subspecialties, and as such, it requires subspecialty training.

Currently, the ten Addiction Medicine “residency” programs are more like fellowships, in that the doctors who are enrolled must have first completed a primary residency in another specialty.   However, the article points out that the ultimate goal of all of this is to one day have Addiction Medicine residencies qualify as primary medical residencies, open to anyone who has graduated from medical school.  Once that happens, I believe there will be a fundamental shift in the way medical students are taught about addiction, and that could lead to significant change down the road.  As it stands now, most medical students receive little or no formal training in addiction medicine, and most graduate medical school with the idea that those who suffer from addiction are either “bad people” or have brought their problems on themselves because of “immoral thinking” or “character defects”.  Only a minority of medical school graduates on to become educated about the chronic disease model of addiction and the array of treatment options available.

My hope is that as the field of Addiction Medicine becomes more formalized, and residency training becomes more extensive, clinicians-in-training receive a well-rounded experience and develop an extensive knowledge base which, in addition to the medical model, incorporates other effective modalities such as involvement with Twelve-Step Programs (AA, NA, GA, Al-Anon, etc…), motivational interviewing, Dialectical Behavior Therapy and relapse prevention therapy.

— Scott Bienenfeld, M.D.


[i] The American Society of Addiction Medicine – ASAM – has existed for years, and provides certifications for doctors in all fields who practice Addiction Medicine, but they do not have formal residency training programs.

The American Academy of Addiction Psychiatry – AAAP – offers fellowship training and board certification only to doctors who have successfully completed a residency in General Psychiatry.

Joe Schrank’s Interview With Tom Horvath

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To some, it might come as a surprise that Bill Wilson’s innovation, the 12 Steps, aren’t the only organized path to recovery. In fact, there are a handful of alternatives, some of which require abstinence from drugs and alcohol, and others that preach a more moderate approach, often referred by the umbrella term of “harm reduction.” There is LifeRing, Moderation Management and Rational Recovery. To many members of the “Anonymous” groups—that’s AA and NA, et al—these alternative programs are inferior products, ineffective and saddled by controversy. Moderation Management, for instance, has been criticized because, among other things, its founder, Audrey Kishline, renounced the program publicly in 2000 and relapsed, killing two people in a drunk driving accident. Bill Clegg, the memoirist who wrote Portrait of the Addict as a Young Man and 90 Days, said in an April interview with The Fix that harm reduction is “the first stop for people on the way down.” When it fails, he says, “you are driven into a more serious program and probably just keep on going down the stairs until you get to the basement with the rest of us.”

Maybe so, although psychologist Tom Horvath, the owner and operator of Practical Recovery, in San Diego, has a very different view. The two Practical Recovery rehabs he runs instead espouse something called Smart Recovery, an organization he calls “the leading non-12-Step, self-empowering support group,” with around 700 meetings worldwide. Smart Recovery doesn’t require abstaining from chemicals, nor does it embrace the concept of powerlessness central to working the 12 Steps. So what does he believe? It all starts with taking your will and your life back.

What is the main difference between most rehabs, which generally use the 12 Steps, and Practical Recovery?

The fundamental split is between self-empowerment and the powerlessness approach—from a technical perspective these both hinge on the psychological variable called “locus of control.” Think about your expectations of the future. If you have an internal locus of control, you expect that the future is going to be what you make it. If you have an external locus of control, you expect the future is about what happens to you.

Okay.

In reality, life is both of these things. The serenity prayer actually captures it very well. AA is a serenity, powerlessness and acceptance kind of program. The self-empowering approaches are based on courage, activity and empowerment. These mean that if you have cravings, rather than going to meetings I am going to learn how to deal with cravings. If I have problems, I am actually going to solve them and do the best I can with them. In a Practical Recovery facility, we work on identifying the problems people have, which always include craving and always include motivation; then, whatever their personal problems are, changing their situations, improving their relationships and achieving lifestyle balance.

We also work on identifying a deeper sense of purpose and meaning, and getting on with life. Sometimes it does not happen very quickly. I am not claiming that we are better than anybody else in terms of ultimate outcomes. Maybe we are and maybe we are not. I have no data to claim that we are better. I do think we are better for some people, in that they can work with this approach better than they can work with the powerlessness approach.

In New York City and Los Angeles you couldn’t swing a cat without hitting an AA meeting. Why aren’t there more Smart Recovery meetings?

Maybe we just haven’t been around long enough. I think that if people had an equal opportunity to choose between a 12-step meeting or Smart Recovery—just based on a couple of situations I’m aware of—I think they would split around 50/50. If we had more groups—let’s say when we have more groups—then we will be a very important option for half the population that will go to a support group. Of course, many people will not go to a support group.

To say to somebody, “AA is the only thing that works,” is the height of unethical behavior in our field. It is unethical because it is not factual. There are many roads to recovery. Most people who recover do not get any kind of services. They do not go to support groups or any kind of treatment. They do it via that mysterious process we call “natural recovery.”
Is addiction a disease?

That is one of the big questions, isn’t it? Practical Recovery has recently taken the same position on this that Smart Recovery takes, which is that we will work with you regardless of what you think. The answer doesn’t really matter to us.

Right. It really doesn’t matter what we call it.

Our treatment plan is not going to change either way. If it is a disease, how do people actually recover? It includes things like exercise, lifestyle balance, healthy eating, getting proper sleep, and identifying and resolving your underlying problems. Getting social support and improving your relationships. There is a lot in recovery that is pretty consistent for people who are successful.

That sounds a lot like the 12-Step process.

That certainly could be a 12-Step process. The crucial difference is that powerlessness aspect. If people call me and they have never been to a 12-Step group, I tell them they should go. If you can work with that approach, it is easily available. There is a lot of support for doing it. However, there are a lot of people who just will not do it. They just will not go to AA. Rather than telling them that they have to, we are presenting an alternative. There are about ten rehabs around the country now that do Practical Recovery. Plus there are these five alternative support groups, Smart Recovery being the most prominent. I believe that over time, it may take two or three decades, the self-empowerment approach will become about 50% of the marketplace, which is roughly what it is in the rest of the world. The United States is anomalous in terms of the dominance of AA.

So, can alcoholics learn to moderate their drinking?

Absolutely. Some of them. The Federal Government data is very clear on this. If you Google the phrase “Alcoholism is not what it used to be,” you will come up with a summary of the National Epidemiological Survey on Alcohol Related Conditions (NESARC). It finds that around half of the people who have had a diagnosis of alcohol dependence end up moderating successfully. That is a pretty high number.

Is that one of the goals of Practical Recovery, to teach moderation?

No. Our goal is to help people make sensible decisions and act on them effectively. We take no position on moderation or abstinence, regardless of the seriousness of your problems. We help you make a decision and implement it. We are not an advocate of either one.

What about other substances? Can crack smokers moderate crack smoking?

That is an interesting question. Probably some of them can. They have not come much to the attention of scientists. We know, and the Centers for Disease Control and Prevention knows, that some heavy smokers are able to moderate their smoking. When I read that years ago, I realized that, at least in theory, this was possible for anybody. The crucial distinction is that most of the people who get the treatment are already at the pretty severe end of the spectrum. As a default position for other substances, my default position is abstinence. What other people choose to do after treatment is up to them.

Twenty million Americans are diagnosable with some range of chemical dependency. What is it about the addiction treatment field that we are missing?

Well, the treatment system is not attractive enough for most of those folks. A system that is more harm-reduction oriented, which is what you have in most countries, would pull more people in and hopefully help them make resolution faster. The other piece is that recovery is not ultimately about treatment. It is about something much bigger than treatment. It is about society. The American society is one that breeds addiction rather well. Until some of those changes occur, and keep in mind that I am not expecting that, we’ll always have substantial addiction problems.

In Practical Recovery or Smart Recovery, how is success defined?

We let people define that for themselves, generally speaking.

So relapse is not viewed as failure?

Absolutely not. In fact, that is one the biggest benefits of a Smart Recovery meeting. If we are talking about Smart now, people come back and they talk about their slips and their relapses. Those are some of the most powerful meetings. We do not honor sober time the same way that 12-step groups do with tokens and chips and so forth. Everybody is sad that you just had three months and you relapsed, but let’s hear about what happened so that we can all learn from it.

I’ve always thought the way we diagnose addictive behavior isn’t diversified enough. A heroin addict and a wine-sipping housewife are put in the same form of treatment.

The treatment should be very different.

What do you say to the AA evangelicals who say that there is no other solution?

That is just ridiculous. There is so much scientific evidence that shows there is a wide range of solutions. AA is associated with recovery, but no one has ever demonstrated a cause-and-effect relationship. That often gets left out of the discussion. I am willing to believe that with the proper studies done, we would find that AA causes recovery for some people. I just assume that.

Does AA work?

We really don’t know. I am willing to believe it works. The point is there are half a dozen other things that are rather different than AA, that also work probably about as well. To say to somebody, “AA is the only thing that works,” is the height of unethical behavior in our field. Unfortunately, it is common. It is unethical because it is not factual. There are many roads to recovery. Most people who recover do not get any kind of services. They do not go to support groups or any kind of treatment. They somehow do it via that mysterious process we call “natural recovery.”

That is probably true.

It is absolutely true. There is data, very solid data, that supports it. How many people quit cigarettes by going to rehab? Not many. Most people quit drinking on their own. Most people quit heroin on their own. Treatment is a small part of what actually happens.

Is it dangerous to tell people that they can quit on their own? Isn’t that emphasis on self-reliance—”Oh, this time I really mean it”—one of the things that gets people further into their addiction?

We should be telling people that the fundamental element in change is the decision to change, and that decision, when backed up by sensible action, is what creates recovery. Sensible action may include getting treatment. In many cases it does not. That is the foundation of recovery, not going off to rehab. Rehab has its place—I own and operate two of them, and I’m very proud of them—but I have never told anyone they had to come to our rehab, or any rehab, or they were not going to make it. The facts do not fit that.

Right. So the whole culture of AA, is it the Tea Party of recovery? They are opposed to science. They do not like medication. They are rooted in something that nobody really knows if it works or does not work.

Well, AA is a big organization. It has a lot of different kinds of people in it. My only request is that when people show up at an AA meeting, that they get told this is one way to recover. We sure hope it works for you. You are welcomed back. We have got a lot to offer you. If you do not think this is right place for you, let me tell you about some others. Here is a list of other things you can do.

That is never going to happen.

Not any time soon.

We hear a lot about the idea of moderating drinking and Moderation Management with Smart Recovery. MM started with Audrey Kishline in 1994. She claimed she could moderate her drinking with therapy and other things, and ended up in 2000 killing two people in a drunk driving accident.

Let’s talk about Audrey Kishline. Do you know the group she was a member of when that happened?

Moderation Management.

Absolutely not.

She was in AA?

She was an AA member for the previous two months. This is easily documented. I have been in the field for 27 years and there is a group of us around the country that stay in close connection. I knew Audrey. She posted a whole bunch of places on the Internet in January of that year. The crash was March. She said, “I have decided that moderation is not the best approach for me. It is not working currently. I am joining AA. I wish MM the best. I will no longer be affiliated with it.” Two months later is the collision. That is not AA’s fault. It is sure as hell not MM’s fault.

Right. The popular thing is like when you say to people, and I am curious to know how you would respond, when you say to people “Oh, well maybe Moderation Management.” No, that woman killed a family. That is sort of the response that people give. I think that is the messaging.

I am doing everything I can to change that. A blood-alcohol content of 0.27 or 0.23, whatever she had, is nobody’s definition of moderation.

No. Clearly not. And obviously we have no idea who many members of AA have killed anyone in drunk driving accidents.

Quite a few, I am sure. It is a wide reaching organization.

Do you think that the anonymity is something that can be used to shield against accountability?

For sure. Of course, I am not proposing that people start mentioning their last names at AA meetings. One of the problems, I think, is that because no one speaks for AA, the irony is that then everybody speaks for AA. There is nobody to contradict them. If somebody could stand up in a meeting and say “You know, AA’s policy is that we support other options in recovery and you need to sit down and shut up. You are saying something different and that is not AA policy.” That would go a long way toward changing the field.

I agree. Addictive illness is something that impacts every single American. I do not disagree with anything you are saying. I do not disagree with any approach. I do not think there is any right or wrong way to be sober or get sober.

I have drafted up a mission, purpose, vision and values statement for an organization that I am tentatively calling the Association for Addiction and Recovery. I can see it as this umbrella organization like the American Heart Association or something. It is kind a non-denominational place where everybody could come together and support common sense improvements. The field is pretty divided, though. I do not know if it would work. Right now, I see more fighting that unification. I think the The Fix is part of the solution. I am very impressed with what you guys are doing.

Thank you. And thanks for talking with us today.

Recovery Ride Spin Class 4-1-13

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Laredo –  Band of Horses                                              

Dashboard –  Modest Mouse                                     

Paralyzed –  Bob Mould

Snow (Hey Oh) –  Red Hot Chili Peppers                                                                

(White Man) In Hammersmith Palais –  The Clash                                                              

Keep It Close To Me  –  Superdrag                                                                            

How Beautiful You Are  –   The Cure        

Bigmouth Strikes Again –   The Smiths    

If I Ever Feel Better –   Phoenix                  

Ever Fallen In Love –  Buzzcocks                                                

Lucky Man –  The Verve                

Non Photo-Blue  – Pinback                                                            

Teenage Kick – The Undertones                                                                               

Barely Legal – The Strokes

Teens & Addiction – by Scott Bienenfeld, M.D.

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Teenagers And Addiction:  They Are Not Simply Younger Adults

“Youth are heated by nature as drunken men by wine”  Aristotle (350 B.C.)

“I would that there were no age between 10-23, for there’s nothing in between but getting wenches with child, wronging the ancientry, stealing, fighting…”   Shakespeare “The Winter’s Tale”, Act III (..1594)

As the medical field continues to make strides towards gaining a clearer understanding about the disease of addiction, one of the greatest challenges remains the understanding of how drugs of abuse and addiction affect teenagers.

Far from being simply “younger versions of adults”, teenagers are at a stage of brain development that is, as it turns out, developmentally unique.  That is, as the human brain develops from childhood into adolescence, certain brain regions seem to flourish, and other areas don’t fully develop until adulthood.

Over the past decade, advances in brain imaging have allowed scientists to more fully understand the process of normal adolescent brain development, and this in turn has had a great impact upon our current understanding of how teenage addiction and the impact of substances of abuse affect the developing teenage brain.

During this normal time of developmental “limbo,” teenagers are prone to risk-taking, pleasure-seeking and experiencing intense emotional reactions to seemingly minimal problems; likewise, they often lack the ability to effectively weigh risks vs. rewards, make reasoned judgments about the consequences of their actions or make sound decisions during times of emotional upheaval.  In fact, neuro-imaging studies have shown that when making emotional decisions, teenagers and adults utilize different parts of their brains; teenagers rely on a more primitive brain area called the Amygdala and adults utilize the Prefrontal Cortex, a more mature brain area that is last to fully develop.   (See Figure 1)

To further complicate matters, these developing regions of the teenage brain that are growing rapidly towards the “balanced” adult brain, are the very same regions that are biologically prone to damage from drugs of abuse!  (See Figure 2)

The reason this is so important is not only because developing a clear understanding of the adolescent brain’s vulnerability to drugs and alcohol will likely provide key insights that allow for more effective treatments, but also because parents who bring their teenagers in for evaluation and treatment need to understand that their kids are not yet adults, and therefore require specialized care and treatment that is known to be effective for adolescents.

It is important to realize that while many teenagers manifest signs and exhibit symptoms that indicate a likely problem with substance abuse such as declining grades, behavioral problems, social isolation and irritable or aggressive behaviors, this is not always the case.  That is, a good number of young people with teenage drug addiction issues look absolutely normal in terms of their ability to function, maintain good self-care and even perform well academically!

Another important issue is the fact that many teenagers who experience problems with drugs and alcohol also suffer from co-occurring psychiatric problems such as attention deficit hyperactivity disorder (ADHD), anxiety disorders, mood disorders, and other behavioral health issues, which not only make them more vulnerable to developing serious problems with drugs in the future, but may affect their course of treatment significantly.  Therefore, it is of paramount importance that a qualified addiction specialist be involved early on.

As a parent, or a friend of a teenager who you suspect may have a problem, it is never too late to get help.  The best place to start is with an evaluation by an addiction specialist with expertise in the treatment of teenagers, or a treatment facility that specializes in teenage drug addiction treatment.

Re-Entry – An Exciting and Challenging Time

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Re-entry –

I.  An Exciting and Challenging Time in Recovery

The period of time immediately following one’s stay at a residential treatment facility for addiction is one of the most misunderstood periods of recovery.  Family members, partners, friends, employers and even clients often have the misconception that a person who has just completed a course of treatment is not only healthy, clean and sober, but is also ready to re-enter the community “firing on all cylinders”, ready to return to the way life was before addiction took hold.

Unfortunately, not enough attention is paid to making sure that everyone understands that this is a difficult and challenging time when a large number of clients relapse.

Even among those who do recognize the challenges of re-entry, many do not take the steps necessary to ensure the best chance at sustained recovery.  While many people can tell you that the first 90 days post-treatment is a vulnerable time, few seem to offer sound advice about how to maximize the chance for success.

There are essentially four major reasons why those who successfully complete a course of residential treatment relapse:

  1. Upon return, they do not participate in a continuing program of recovery;
    1. i.e., AA or other 12-step program, continuing relapse prevention treatment, sober living, therapy with an addiction specialist, etc…

 

  1. They try to return to a high level of functioning too quickly;
    1. i.e., work, parenting, dating, or other high-pressured responsibilities.

 

  1. They continue to associate with substance using peers in environments where drugs and other temptations or “triggers” are readily available.
    1. i.e., socializing with substance using peers, hanging around bars, parties, etc…
  2. Support systems expect too much of them upon return, and expectations for sustained sobriety in the context of high functioning are unrealistic.

 

Make no mistake, this is a huge problem.  The fact is that in many cases, identifying an addictive disorder and making a recommendation for residential treatment is the (relatively) easy part.  The challenge is to convince not only the client, but also their entire support system (family, friends, teachers, bosses, etc…) that their problem will be a continual one to be managed and supported, not cured.

As clinicians, I believe that we have a duty not only to our clients, but also to their support systems (relatives, partners, teachers, coaches, bosses, etc…), to educate them about the importance of sustained recovery and the challenges of re-entry, as well as ways in which they can maximize the chance of achieving long-term sobriety.

 

II.      I Just Returned Home From Treatment – Why Is Everything So Difficult?

 

When a car breaks down, the expectation is that the mechanic will diagnose and (hopefully) fix the problem, we receive an invoice, pay the bill, take back the car and life goes on.   Unfortunately, when a person goes away to rehab for treatment of an addictive disorder, many people – including the client – often have a similar expectation.  Nothing could be farther from the truth.  As I discussed in the last section, completion of a stint at a residential treatment facility should really be thought of as more like a starting point rather than the end of a difficult process.   In this section, I will address one of the common challenges that families face when a loved one returns home.

As an example, consider the experience of buying, and moving into a new home.   Anyone who has ever purchased a home is familiar with the issue:  During the first several months after moving in, things begin to break.  The doorknobs fall off, toilets run, door hinges squeak and floorboards come loose.  Many a new owner has experienced a feeling of “buyer’s remorse” left to wonder, “what is the problem?  I just spent all of this money, had the house inspected…why isn’t it perfect?   Is the house possessed by evil spirits?”  Not exactly.   A logical explanation is that the family who previously occupied the home spent years acting and behaving in certain ways (e.g. opening cabinets, turning faucets, walking, flushing toilets, etc…) which the house “got used to”.   When a new family interacts with the home in a different way, the result is that certain “weak” points of the home may malfunction or break.

I   particularly like this example because it addresses many of the same challenges that occur when a loved one — who has been away in treatment for 30, 60, or 90+ days — returns home.  Everyone is excited about the prospect of a new and healthy beginning, but few are prepared to handle the challenges that arise.  Much in the same way that a new home is “used to the old ways” and “breaks” when new behaviors are introduced, family systems often “bend and break” under the stress of the new and healthy behaviors that a returning loved one introduces.  It is pretty much standard issue in my practice that within weeks to months of a person returning home from treatment, family members report increased levels of stress, and concern about the difficulties they are having.  Marriages may suffer, parental relationships can deteriorate and friendships definitely change.  The good news is that while challenges should be expected, they do not have to mean an interminable period of difficulty. Clients, their families, friends and other support systems need to be aware that re-entry will likely mean a need to re-adjust to the new behaviors and expectations that come with sobriety and managing the chronic relapsing-remitting disease of addiction.  With time and the right work on the part of the loved one and the family, (e.g. therapy, al-anon, etc…) these re-adjustments can be useful and hopefully lead not only to more fulfilling relationships, but also to a period of sustained recovery.

Scott Bienenfeld, M.D.

Xanax Article 2012 – By Scott Bienenfeld, M.D.

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 Xanax Article

The article “Listening To Xanax” by Lisa Miller (New York Magazine March 26, 2012) http://nymag.com/news/features/xanax-2012-3/  , stirred up more than a bit of controversy among not only the medical community in general, but also among the recovery community, as well as those who specialize in the treatment of addictive disorders.  Informative for sure, the article in some ways glamorizes the use not only of Xanax, but the entire class of medications known as Benzodiazepines, or “Benzos”.    These drugs are portrayed throughout much of the article as trendy counter-measures to the ubiquitous stress of the last decade, analogous to Prozac, the “game changer” of psychopharmacology which arrived on the scene in the 1980’s.   While Benzodiazepines are well-established as a (for the most part) safe, and effective treatment for a number of psychiatric disorders, their problematic use in patients who present for treatment of substance use disorders cannot be overestimated, and often create complex treatment scenarios.  We see large numbers of adolescents and young adults who are either addicted to, or are severely abusing these drugs.  Withdrawal from a drug like Xanax can be dangerous and even life threatening.  The fact that so many adults use these medications, whether for legitimate reasons or not, means that millions of teenagers and young adults nationwide have access to them via the medicine cabinet at home.  Kids rarely perceive a parent’s medication as being potentially dangerous or life-threatening, let alone addictive, and the issue of legality seems like a non-issue because they are prescribed.    Kids often start by raiding the medicine cabinet at home, and then seek the drug on the street.  Finally, it is important to remember that medications like Xanax and other Benzos regularly turn up in addition to other drugs in post-mortem toxicology reports that are labeled “multiple drug deaths”.   While Benzos alone are probably not a common cause of death per se, the combination of these medications with other powerful drugs like pain killers, cocaine, heroin and even alcohol can be deadly.

 

Scott Bienenfeld, M.D.

The New Trend In Substance Abuse: Synthetic Drugs – By Scott Bienenfeld, M.D.

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K2, Spice, Bath Salts Spice K2

 Parents and Doctors Beware and Be Prepared!

Over the past several years, there has been increased concern about kids using “synthetic” drugs – substances that are developed in a laboratory and intended to mimic more “familiar” drugs such as marijuana and amphetamines.  Two factors make these compounds particularly frightening: 1) They are packaged as “legal” substances in order to avoid DEA scrutiny, and 2) They are quite difficult to test for using routine drug screens.

A synthetic form of marijuana known as “K2” or “Spice” which is usually marketed legally as plant food or incense and is obtainable at head shops, gas stations and via the internet, has been a matter of serious concern in recent years.   Emergency rooms nationwide have reported an increase in the number of kids presenting with an array of bizarre symptoms and negative drug screens.  Symptoms usually consist of agitation, hallucinations, panic-like reactions, suicidal ideation, seizures and strange behavior.   Now technically illegal in The United States (http://www.deadiversion.usdoj.gov/fed_regs/rules/2011/fr0301.htm), these compounds are still relatively easy to get a hold of, especially via the internet.  Certain labs can test for the presence of these synthetic cannabinoids, but routine testing will not detect them.  Brand names of these compounds include: Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury, and Zen.

“Bath Salts” are another example of synthetic substances that mimic more familiar drugs of abuse.  The compounds, which are marketed as bath products, mimic amphetamines, which are powerful stimulants.  As with synthetic marijuana, “Bath Salts” are very hard to detect with routine drug testing, and increasing numbers of cases of kids in emergency rooms are popping up.  Kids high on these drugs often have increased blood pressure, rapid heart-beat and even hallucinations and other psychotic symptoms.  Street names for these compounds include: drone, bubbles, meow-meow, MCAT, Ivory Wave, Vanilla Sky, Cloud 9, Red Dove, and White Rush.

It is important for clinicians and parents to be both aware of and educated about these new types of substances that are becoming widely abused by kids.  The DEA is beginning to crack down on these dangerous products, but as one substance becomes illegal, another one is likely to take it’s place.

 

Scott Bienenfeld, M.D.

Marijuana: A Complex Clinical and Political Picture – Scott Bienenfeld, M.D.

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Marijuana:  A Complex Clinical and Political Picture

As the legalization of marijuana expands throughout The United States, debates about the pros and cons of this policy will continue.  The discussion exists not only among members of the medical community, but also among those who suffer from addictive disorders and the legions of clinicians who treat them.  Regardless of where one stands on this issue, its evaluation requires knowledge about the latest data and information regarding marijuana, particularly as it applies to the risks, benefits and alternatives involved.  It is also important to remember that new information is constantly emerging regarding both the medical benefits of this drug, as well as the potential for clinical risk factors, including both medical and psychiatric complications.

By far the most widely abused illicit drug worldwide, marijuana has a reputation for being perceived as “safer” than other drugs among adults, adolescents and their parents. (A qualitative comparison of parent and adolescent views regarding substance use. Journal of School Nursing. 26(1):53-64, 2010 Feb.)  Many in favor of legalizing marijuana cite the fact that there are no known deaths that can be explained purely by marijuana overdose – a fact that is most definitely not true for many other drugs including: alcohol, cocaine, heroin, painkillers (opiates), crystal-meth, sedatives, sleeping pills and many over-the-counter and prescription medications.

Fatalities aside, studies indicate that marijuana is hardly a benign drug.  In fact, the marijuana produced today is significantly more potent than what was grown during the 1960’s and 1970’s — which may account for recent findings that marijuana can be dangerous for some people.  Most importantly, it has been clearly demonstrated that adolescents who abuse substances early on (including marijuana), are at an increased risk of developing a severe addictive disorder later.  Marijuana is considered to be a “gateway drug” for many adolescents who then go on to use “harder” drugs such as cocaine and heroin.  Neuropsychiatric studies clearly indicate that chronic marijuana smokers suffer from cognitive impairments in the areas of short-term and working memory, visual-spatial processing and abstract thinking.  Recent data link chronic marijuana use starting at an early age with the later onset of psychosis in young adults who may already be at risk.  (Cannabis use in patients with a first psychotic episode and subjects at ultra high risk of psychosis: impact on psychotic- and pre-psychotic symptoms. Australian & New Zealand Journal of Psychiatry. 44(8):721-8, 2010 Aug.) Finally, while many adolescents and adults seem to “self-medicate” with marijuana, it has been clearly demonstrated that chronic marijuana use is associated with, or “co-occurs” with a number of psychiatric disorders such as bipolar disorder, attention deficit disorder, anxiety disorders, and ultimately has a detrimental effect on treatment outcomes for those suffering with these problems.

The point of this discussion is to remind parents and clinicians that marijuana abuse and dependence often presents a complex clinical picture that should be taken seriously, especially in adolescents and young adults who suffer with psychiatric illness and/or have a family history of addiction.  While marijuana use may have potential medical benefits for some, it poses the risk for short and long-term side effects, as well as the potential for abuse and dependence.

 

Scott Bienenfeld, M.D.