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…by Kate Benet…

Marc here: Perhaps the one question I get asked most often is whether it’s possible to go back to safe use (of alcohol or other substances) after being addicted. So, after reading Kate’s story, please reserve half a minute to read my comments at the end. It seems crucial to embed the diversity of people’s experiences in a general framework that can make sense of them all.

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Now, Kate:

Approaching my 25-year anniversary of sobriety in early September 2019, I had thought for weeks, if not months, about whether I could now drink moderately. I had been sober way more years in my life than I had spent drinking (now 57 years old). More importantly, my life in the past 25 years had changed dramatically for the better. I had worked hard for years to create a stable and rewarding life.

I read a lot on the internet about whether moderate drinking was possible after a long abstinence. I read the posts on this blog with great interest. I talked through my thought process with my husband, a normal drinker, and he was supportive of my wish to be able to enjoy a nice glass of wine or good craft beer now and then. This is what I had missed over the years. Those certain occasions when it is so nice to be able to add alcohol to the experience: a fine dinner or a sunny afternoon relaxing on the porch. He was supportive — whether I had a drink or did not, whether I tried it and continued, or tried it and stopped.

Last Saturday night I took the plunge and had one glass of red wine. Waves of fear washed over me. The experience was surreal. Who was I? What was this thing that I was doing? The wine tasted fantastic. I could feel the effect but, amazingly, I did not like it. This was in stark contrast to how I used to experience alcohol, thinking the taste wasn’t too bad and the effect itself was incredibly nice.

One week after this experience I can say this. The unleashing of craving from this one drink after 25 years of absolute sobriety was beyond belief. It   was like the 25 years had never happened. The portal to a horrible, frightening feeling had been opened. I had the sense of a dual persona hovering at the edges of my life, ready to be activated in full.

In the days that followed that one drink I was gripped with craving and mental obsession about when I could reasonably have another.  When I went to work on Monday, to a challenging job that I enjoyed, in my new “maybe a drinker” mindset, the job felt too hard on many subtle but powerful levels.  My feelings towards my husband and my children shifted ever so slightly. I felt annoyance at first, and then a more ominous sense that I would not be willing or able to navigate the nuanced ups and downs that are human relationships.

No one would be the wiser if I continued along this path. Outwardly it would look the same. I could force my life to keep going. But there was something really wrong with how it felt, to me, internally, at a deep and vivid level — that this would be a disastrous path. The degree of effort and struggle that would be introduced into my life would be dreadful. That became obvious — painfully obvious.

One week later the ripples from throwing that stone in the pond are finally settling down and I know I will never do that again. If there are times in the future that trigger my thoughts about the pleasures of drinking, instead of feeling deprived, I’ll think back on this experiment and I will remember how lucky I am.

Not everyone will have this kind of experience. Some people can drink moderately after a long abstinence. Some will have matured out of the problem. I am just not one of those people. I hope this helps anyone else who is facing the big choice. If you are like me, trying to drink again unleashes a unique sort of hell.

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Marc again: When I speak to naive audiences, as I did on Wednesday to a group of college students, I often remark that roughly half of those classed as problem drinkers (those with an “alcohol use disorder” in the current DSM parlance) can return to “social drinking” or “safe” drinking at some point. (There’s plenty of research on this, but perhaps start with James Morris, who specializes in alcohol misuse research and intervention with a harm-reduction focus.) Then, during the Q&A, I often get asked, as I did last week, how to know which side of that 50%-line you (or a loved one) might fall on.

To me, Kate’s tale packs at least two take-home lessons: Lesson 1 is that many people can’t return to controlled/social drinking, so the harm-reduction approach is just wrong for them. And the harm can be insidious. It can start off unconscious and quickly become entrenched. This is of course the nose-dive, we-told-you-so, addiction-doing-push-ups message that AA flaunts unceasingly. And…it just happens to be relevant — for many people. Lesson 2 is that one drink doesn’t usually wreck your life and destroy everything you’ve been working to achieve. In other words, it is possible, and sometimes highly desirable, to examine, to question, and to explore your options — as Kate did. Certainly that is NOT the message we get from AA.

To guide your thinking further on the social issues, psychological issues, and available help associated with Harm Reduction for alcohol, I encourage you to check out HAMS (Harm Reduction, Abstinence, and Moderation Support), founded by Kenneth Anderson, now co-led by April Wilson Smith. Also check out their recent book, a collection of  intimate memoirs introduced with a brief but comprehensive overview: BETTER IS BETTER! Stories of Alcohol Harm Reduction. A guest-post by April is coming up soon.

 

 

 

I just got back from a two-day meeting on animal models of addiction. And here’s what I learned: animals way way down the evolutionary ladder also like opioids and psychostimulants. And flies like alcohol. That should make us feel less lonesome.

I was asked to be the keynote speaker for the meeting, because the organizers thought that animal researchers should learn more about human addiction. Well, it was a nice idea, I got a free trip to Chicago, but my work may just be too distant from what these folks think about. They study “addiction” — or more simply drug seeking — in, for example, crayfish, sea-slugs, something called zebrafish, and the common fruit fly (drosophila). Seriously. They listened to what I said about human addiction. I stressed cognitive-emotional factors like “now appeal” and “ego fatigue”, I stressed how difficult it is to make good decisions in stressful environments, especially when memory serves up powerful associations between getting high and relief. I talked about the symbolic appeal that intensifies addiction for us humans. How we’re addicted to what the drug means to us more than to the physiological change it produces. They listened, but I don’t think they got it. And when it came to my spiel about the internal dialogue, the “addict self” and so on, it’s like we were on different planets.

Regardless, I learned a lot from them. For example, I learned that zebrafish larvae (baby fish that look like seahorses) like opioids. These little guys will swim up near the surface of their tank — which is intrinsically aversive to them — to get Vicodan. Yes, Vicodan…through their feeding tube. And I learned that fruit flies will endure 120 volts of electricity to get a nip of alcohol. Yet they won’t do it for sugar. Crayfish get stoked on cocaine and race around recklessly with their claws outstretched. Like, seriously! I also learned that dopamine is the neurochemical by which lower animals identify and pursue rewards. They may even get a dopamine burst when they acquire drug rewards. I could give you more details, but in sum, it’s pretty simple: opioids and psychostimulants cause physiological changes that we interpret as “good” or “rewarding” — “we” being animals from flies and fish to humans. And we do this using the same neurotransmitters — dopamine and serotonin — across species that evolved hundreds of millions of years apart! It’s no accident that heroin and meth are the most addictive drugs we know of. We’re in good company.

But how do we make sense of the fact that gambling, porn, internet use and sports can also be highly addictive? It seems we somehow have to draw a line from the physiological changes that opioids and stimulants provide, up to the level of “I like this — I want more!” and then back to all kinds of addictive behaviours as well as drugs themselves. Then maybe we can figure out how behavioural addictions — in fact all addictions — really work.

What about the genetics of addiction?

I also learned more about the genetics of addiction. For years I’ve been arguing, much like Maia Szalavitz, that the oft-cited 50% heritability of addiction is mostly due to personality traits. There’s certainly no gene or gene cluster that predicts addiction, though there are genes that can make one more or less sensitive to specific substances, like opioids (the dynorphin receptor gene) and alcohol (which is more complicated). Yet personality traits, which can be genetically shared, predict addiction itself. The most clear-cut example is impulsive personality. More impulsive people are more likely to try drugs, or drink (or drink more) at younger ages, than others. So they and their identical twins (the basis for computing genetic effects) are more likely to become addicted. An introverted or anxious disposition also predicts addiction, for obvious reasons. And, as Maia Szalavitz says about herself, I think I score pretty high on both of these (seemingly opposite) traits. So…my odds started off a little higher than average.

Yet I’ve always emphasized environmental effects. They are so huge and so obvious. From Gabor Maté’s oppressed native populations, to Rat Park, to the ACE studies…yeah, it’s pretty obvious that difficult or stressful or oppressive environments predict addiction. And most of my clients who’ve struggled with addiction have had really shitty times during their childhood or adolescent years. Young people adapt to abuse (physical, emotional, or sexual) or neglect (like rejection by  a parent or step-parent) by trying to make themselves feel better with substances. It’s called “self-medication.” It’s not rocket science.

But here’s what I learned about genetics. Over the history of genetic research, labs could only look at gene-outcome effects one by one. That’s not the way genetics operates. With the huge explosion of computer technology in the last few years, scientists can now look at complex interaction effects. These include, not only genes, but the parts of the DNA that regulate networks of genes. Now things get complicated. I already knew that trauma or early adversity can “set” changes in motion which last a lifetime — called “epigenetic” effects. For example, punitive parenting can set your amygdala on high alert for the rest of your life — i.e., induce trait anxiety. These changes take place at the DNA level, but — and it’s a huge “but” — they are driven by environmental impacts. So, again, environment wins out over inheritance. What I didn’t get until last week is the complexity of the interactions between these environmental impacts and the genes we inherit.

One of the scientists speaking at the conference, Daniel Jacobson, showed us that he can predict fine gradations of autistic behaviour, by data crunching (on the world’s fastest supercomputer!) hundreds of thousands of genetic variables interacting with each other and with thousands of environmental variables. So — once we get better at quantifying environmental impacts (like isolation, abuse, bullying) we may indeed be able to predict addiction, not from genes themselves but from the interplay between gene networks and environmental challenges.

Still, even with all the fancy computing power in the world, I think that environmental challenges will remain impossible to quantify. As I argued with this dedicated scientist at the reception, isolation in Sweden and isolation in New Jersey are entirely different things. The gradations in environmental impact are close to infinite. He disagreed, said it’s a matter of time, but I guess the jury’s still out.

How to conclude? Two things. First, addictive drugs are addictive because of what they do to the nervous system of animals, lots of kinds of animals, not just us. But we humans build all this symbolic stuff — like need fulfillment, warmth, the sense of being in control — on top of that primal impact. Second, we may never be able to accurately compute who becomes addicted, but your chances surely derive from what you were born with (inheritance) interacting in hugely complex ways (development) with the sting of environmental misfortune.

 

Addendum: I realize this post covers two seemingly different topics. Yet they’re deeply connected. Our genes are the basis of our humanity, but we still carry these mechanisms of reward-seeking that go back hundreds of millions of years. After all these aeons of evolution, we still haven’t been able to discard the code for these mechanisms. We still need them. They’re that basic. Think about it.

 

Doctors are taught from year 1 Medicine (if not before): First, do no harm. And yet, in treating addicted individuals, doctors often do more harm than good — by obstructing or totally derailing the recovery process. That should never happen! I want to show you what I mean by telling you part 2 of Sally’s story — the first part of which appeared a few posts ago.

That post was about the value of pharmaceutical opioids for supervised “maintenance” or tapered withdrawal, and about my failure to use a publishing opportunity to educate doctors. In contrast, this post is about quitting, “getting clean” as people still say, without any supervision. Because you can and you want to. A lot of people quit that way.

And yet, incredibly, doctors often advise against it!

Sally (a resident of the UK) wasn’t taken care of properly in her teenage years, became a heroin addict in her mid-teens, became a prostitute soon after, endured physical and sexual violence, including rape, and finally dragged herself off the street by sheer force of will. At that point her soul was flattened. She had little fight left in her. Just enough. She was cared for by a friend for several months; she slept on a spare sofa. She was afraid of noises, afraid of silence, afraid of the night…because the man who had raped her was still out there. Until he killed himself. Good riddance.

Sally struck out on her own, found a stable relationship with a man, had a couple of kids, found a better relationship, had another kid. Life started to settle down — a much as it can with three young kids at home. Now her days are spent soothing, caring, teaching…giving her kids a lot of what she didn’t get enough of. A couple of nights a week she works with elderly people who need help. And if there are hours to spare, house-cleaning and all the rest of it. She and her partner are making it work.

When Sally got in touch with me to start psychotherapy, she was taking eight 30-mg tabs of codeine a day, prescribed by her doc, plus 10-20 tablets of codeine (12.5-mg) mixed with paracetamol (acetaminophen) which she got over the counter. Having survived Hep-C (with successful treatment) it was a wonder her liver hadn’t given up the ghost. But no, she was very much alive: vivacious, generous, funny, smart and pretty. She had made it to 40 and had every intention of staying alive.

I don’t tell my clients they have to stop taking drugs, but if they want to quit, if they want to cut down, let’s see what we can do. Sally wanted to quit. Although the codeine relaxed her and gave her the energy she felt she needed to keep house, images of opiates could hardly be kept apart from images of life on the street. And she tended to obsess about her next dose for too much of her day. She wanted to have done with it. Yet, withdrawing from heroin had been so grueling — it still terrified her. So the solution was obviously to taper gradually.

We talked about tapering in our sessions. I wanted her to reduce her paracetamol intake first, since it put her at great risk. But the rest…we can go slow, I said. With that message from me, she took matters into her own hands. From one week to the next her daily dose went down and down. She was proud and excited about her “detox” (as she put it). She was down to nearly half the amount of codeine she’d been on for years. She was the one pressing me: let’s go down another two tablets this week. I don’t think I need my second morning dose. She started to skip doses…and that meant she had a reservoir of spares, just in case. She was tailoring it, shaping it, doing it. She was the boss.

Until she was assigned a new doctor. Much younger, armed with the latest policies and trends. He knew enough about addiction to help her, and she needed help, he insisted. No, he would not prescribe Valium to carry her through the very end of her taper and possible withdrawal symptoms — not even 15 or 20 tabs. Valium is very addictive, you know. But that was okay: they’d taper together. She’d come to the office every week — not an easy trek for a mother of three small kids, but it was important for him to see her, to monitor her. And she would reduce her intake by one tablet — 30 mg — at a time, he insisted. But she had to agree that every time she reduced her dose, she’d have to maintain the new level. She couldn’t go back up. Not even for a particularly bad day. He knew what was best for her. Did she agree? Did she have a choice? If she didn’t agree he’d stop her prescription, and then she’d be in danger of paracetamol poisoning again, unless she went back to heroin.

I saw Sally next a few days after that visit. Her energy was gone. Her smile was sad and cynical. She’d gone back up to her previous high dose, including the paracetamol torpedoes, because…because it wasn’t her recovery anymore. That’s how she put it. And it was none of his damn business and she didn’t like his rules and she didn’t like him. But the threat of a sudden withdrawal trumped all that. That was the power he wielded, and he knew it.

Sally got a script for Valium from a shady mail-order pharmacy. Valium wasn’t a risk for her. She was saving it for when and if she needed it.

But I don’t think she will need it. She got her old doctor back again, and even though he isn’t knowledgeable about addiction, he’s willing to continue the monthly prescription he’s provided for years. Now it’s Sally’s turn again. She’s tapering. At her own rate. The drawer of unused tablets is filling up again. And she’s smiling again. She figures she’ll be down to zero in another month or two. I occasionally remind her that she can take a few extra if things get particularly rough. People need to know that recovery isn’t a straight line.

Why on earth coerce or scare someone out of their addiction when they want to quit and it’s within their power to do so? Why would you take that away from someone, when it means so much to them?

My brother’s a great doctor — a GP. He’s helped a lot of people. He’s kind and generous and smart. But he doesn’t pretend to be God. And he doesn’t pretend to know his patients better than they know themselves.

 

 

 

 

I haven’t been blogging since last spring, and even then it was pretty sketchy for a couple of months. Why the melt-down? For one thing, I was on drugs. Uh-huh, it’s true. And I was in pain and fairly miserable. So today’s post is about my own drug use, not anyone else’s. No theories to postulate, no models to spin, nothing very abstract at all. Just a field report: what it was like for an old veteran like me to get back on opiates…then off again.

Since moving to the Netherlands nine years ago, this was my third — yes third — spinal surgery. You wouldn’t know it. I’m limber, I can do anything from a 2-hour Tai Chi class to a half-day of zip-lining. But my spine has this uncool tendency to grow too much bone, called stenosis. The bone squeezes my nerves, and then I get pain. For example, leg pain. Sciatica.

The MRI confirmed what my nerves were telling me (about my bones). Not enough room in this town for both of us. So a surgery was planned and I asked my doc for some oxycodone — lots of it — or an equivalent. I’m not fond of pain.

I don’t for a moment think that people who need opiates for bodily pain are more decent, correct, or upstanding than people who need them for psychological pain. (I’ve needed them for both in my life.) It’s a false dichotomy passed down through generations of puritans. Suffering is suffering, and opioids are nature’s first-line defense. (That’s why your nervous system manufactures buckets of them.) But we’d be foolish to overlook the addictive properties of any drug that makes us feel better — and that part is psychological. In the case of opioids it’s physiological too. (See my debate with Maia Szalavitz in the comment section, last post.) Hence the notorious feedback effect: what you take to reduce your suffering leads to more suffering. Super bad planning!

Anyway, there I was, feeling no pain — or at least less pain — in both departments. So a couple of weeks after my operation I was faced with the inevitable quandary: did I still need these drugs to control the physical pain…or was I really just starting to crave their psychological embrace, that caress of warmth, as I have in the past?

This is obviously an important question when it comes to treating former addicts with opiate painkillers. The statistics are clear: those with previous drug problems are far more likely to get addicted to opiates prescribed for pain than those with no such history (who rarely do get addicted). That does NOT mean that opiate painkillers should be withheld from former drug users when they need them. What it means is that patients and doctors need to communicate honestly, in depth, and tread carefully, when patients find themselves in that grey zone — often not really knowing whether they’re asking for a refill to deal with physical pain or to deal with the profusion of psychological issues that former addicts contend with.

Well, I said I wasn’t going to get all abstract and theoretical. I really just wanted to tell you about my own experience and what it taught me. Doctors in the Netherlands don’t see themselves as judge, jury, priest, rabbi, cop and shrink all at once. They’re not being driven by guidelines shaped by profit and reinforced by fears of being disciplined or sued. So…decisions about what to take and how long to take it are shared between doctor and patient. As they should be.

That meant it was largely up to me. Two weeks after the surgery, with my pain considerably reduced, I had to admit that I liked the feeling the drugs provided. Yet it was no longer the grand euphoria itself that I (and almost everyone else I know) tend to get from oxycodone the first few days. That part was getting boring. No, this felt like addiction. Like I don’t want to stop, I’m afraid of being without it, how many do I have left? Will the doctor refill my script when I ask? Would I have to beg?

When that feeling came creeping in, I knew I was approaching a fork in the road. The pain is still there, but it’s not that bad anymore. I could quit now, or quit a month from now. Either way, I’ll have to do some tapering — more if I wait a month. I still need them, “legitimately,” for pain…but I don’t really need them.

Yet the bigger issue (for me as a former addict) was that I was starting to ruminate about the drugs. This was occupying too much of my thoughts. It was anxiety provoking. It was a stupid-ass waste of time. I started ruminating about the rumination, and then I ruminated about that, and…you get the point.

One night I lay in bed for literally three hours trying to decide whether to quit right now or wait for a few more weeks. I mean, why rush it? I still had over 30 tablets. Enough for several days of being pretty high (did I say “high”? I meant pain-free of course) and if I was going to get a refill, I’d better call my doc tomorrow since a holiday was coming up. Better not forget, except that…

Finally there was nothing to do but take the package to the bathroom, grit my teeth, tear each tablet from its bubble wrap (an ancient form of torture still used in Europe) and plunk it in the toilet. One after another. I left myself seven for what I expected to be a mild withdrawal. (It was.) And I went back to bed.

What I didn’t expect, the bonus card I’ve held out to people in addiction — clients, friends, strangers met online — was that I felt fabulous. Just lying there in bed. That’s the only point I wanted to make. This was the thing we call “empowerment” — this was choice, this was a treaty between my “addict self” (yes, he lives on) and the rest of me. This is what I generally hold out for other people with addiction problems. This was me taking care of me.

What I learned from this brief return to the Promised Land was really quite simple: Empowerment and self-care (self-compassion) come together with a thunderclap when you quit. On your own — even if it takes some effort. Because it’s time. Because you want to.

That’s the pot of gold.

…by Nick Jaworski…

After nearly 80 years, addiction treatment in America is slowly warming to the idea of multiple pathways to recovery, after viewing the 12 steps as the only “real” way to recover. MAT (medication-assisted treatment) is among the most promising.

This is a guest-post by Nick Jaworski, owner of Circle Social Inc., a marketing and consulting firm specializing in addiction treatment. (See bio information at bottom)

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Quite recently, MAT has gained recognition as the gold standard for care in treating opioid use disorder (OUD) among researchers, legislators, and even the general populace. But the acceptance of MAT by the professional treatment community has not been nearly as fast.

Many providers I speak with are still very reluctant to accept MAT in their centers or as a viable component of treatment within the field in general. Even if facility leadership is on board, there’s a good chance staff or referral partners won’t be.

Other providers, such as Hazelden, were also reluctant at first but looked at the  research and made their own determination that they had to change their approach (other providers, even today, still look down upon them for it).

Congress and many States have also recognized the efficacy of MAT and so have begun to pump serious money into programs that offer it (like this large grant from SAMHSA). Insurance providers often prefer MAT as well.

Cost is a very significant factor for legislators and insurance providers. MAT protocols can be provided to those struggling with opioid addictions at a fraction of the cost of a residential program ($4,000 or less a year versus $28,000 a month for your average residential program).

Since the majority of those struggling with addiction lack resources or are on Medicaid, MAT also opens the doors for the demographic with the greatest need to access care.

There are two additional drivers of the increase in the use of MAT in the US — Wall Street and parents.

Wall Street has seen great opportunities because the opioid crisis is constantly in the news and the addiction treatment industry has an estimated market cap of at least $35 billion per year. These investors come from outside the field and do not have the same biases. They look at the data and see what’s effective and where trends are going.

And then there are the parents referring their adult children into treatment. Many parents, especially mothers, have become completely disenchanted with the addiction treatment industry as it has existed since the late 1990’s.

Their Children Are Dying from Overdoses, and Parents Aren’t Taking It Lying Down

The bottom-line is that length of care is one of the highest predictors of success for treatment, so any 28- to 90-day program has very slim chances of success for the first round or two of treatment, regardless of what model they are using. To move away from abusive substance use requires extensive development of new neural pathways that drive new habits and patterns of thought.

As outlined in my article on a Brief History of Addiction Treatment Marketing, it was not uncommon for these young adults to go through 10-plus rounds of treatment. My team and I actually just interviewed a client who was currently on his 27th round of treatment!

As you can imagine some parents have become extremely skeptical after 10-plus rounds of failed treatment (not to mention that they’re paying as much as $30,000 a pop). But, more importantly, many parents have lost children to opioid overdose. The 18-26-year-old age demographic has always had the highest prevalence of drug and alcohol abuse. Most of the time, this is alcohol or marijuana, with smaller percentages using meth, cocaine, and other substances.

However, with the rise in availability of opioid-derived prescription pills, more young adults were switching to these painkillers, which have a high potential for overdose when mixed with other drugs. A subset of these users would go on to heroin, especially when prescription regulations reduced the availability of legal drugs. As most readers know, the extremely high overdose rates of the last few years have been driven primarily by fentanyl-laced (or -replaced) heroin. Unlike in the past, when young adults using drugs or alcohol mostly survived to go on and live normal lives (probably like most of those reading this blog), these kids were dying instead.

So parents were sending their children to multiple rounds of rehab, paying tens of thousands of dollars, and then losing their children to overdose anyway. As you can imagine, this created a lot of anger and resentment.

But that was nothing compared to the anger many parents felt when they learned there was this option called MAT that decreased overdose deaths by roughly 40-60% and they had never heard about it! It’s not uncommon for parents who have lost a child to overdose to tell me that the first time they’d heard about MAT was after their child’s death.

Imagine how you would feel if you sent your child to the hospital and you weren’t even told of a readily available and cost-effective method of preventing your child’s death because the doctor personally didn’t care for the treatment.

This is the kind of anger we see from parents such as Gary Mendell, who created Shatterproof, or Justin Phillips, who created Overdose Lifeline. Parents are simply giving up on the traditional rehab industry as a whole because they feel lied to.

American Addiction Treatment Perspectives Are Shifting, But in What Direction?

All of this has started to open the window to different conversations surrounding effective addiction treatment. Programs relying solely on 12-step and abstinence-based models are regularly being called into question.

However, I am not yet seeing an attendant shift in the disease model of addiction. Conferences premised on non-disease models are still small, and advocates of this approach are still few and far between.

I am on the board of Above and Beyond Family Recovery Center in Chicago, one of the most innovative treatment programs in the country. We focus on providing free, high-level outpatient treatment to Chicago’s homeless and disadvantaged, but we have had a hard time gaining the support of other treatment programs in the city because we do not focus solely on 12-step programming or disease models of treatment (although these are offered alongside our other programs).

Americans have a long history of deterministic thinking when it comes to human behavior. Starting with Calvinistic predeterminism in colonial America and then evolving into Eugenics, the American view of genetic influences rarely goes beyond a limited and simplistic notion of Mendel’s pea experiments (perhaps a topic for a future blog post).

With this misconception, most Americans still view addiction as some kind of genetically predetermined disease, one that is chronic, progressive and incurable.

In the context of our conversation here, MAT is seen as some kind of fix for an ingrained defect, one that perhaps rebalances out-of-whack or deficient neurochemicals in the brain. What most Americans have not yet grasped is that MAT, or any other substance that alters the brain’s neurochemicals, simply combats symptoms, which is not so different from how cold medicines alleviate symptoms rather than cure the actual cold. The key difference here is that OUD symptoms induce so much suffering that users are often driven to continue using. Opioids are of course the best (if not only) way to control opioid withdrawal symptoms. In this respect, relieving symptoms, though not a cure, can change behavior patterns that exacerbate the underlying problem.

In order to truly find recovery, you must rewire the neurological pathways in the brain, which will, in turn, drive changes in neurochemical balances. Just as one cannot lose weight or get fit by taking a diet pill, individuals cannot overcome addiction by taking a prescription. The pill can help, but lasting behavioral change requires focused effort over extended periods of time, as Dr. Lewis has often pointed out.

It is only through an accurate understanding of the interplay between genes, environment, and human experience that we can create effective solutions which help individuals and communities. It’s a goal I strive towards every day and I hope others reading this will do the same. For a much more in-depth discussion on how unconscious processes involved in learning and development (rather than genes or choice) drive addictive behaviors, see my article You’re Thinking about Addiction and Choice All  Wrong.

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Nick Jaworski is an internationally recognized executive in the field of behavioral health marketing and operational consulting, with experience building organizations world-wide. As the owner of Circle Social Inc., he has helped healthcare organizations perform turnarounds and accelerate growth. He and his team spend most of their days in and out of treatment programs across the country. They do extensive analysis of trends, observe programs, interview patients and families, and analyze data from marketing campaigns. Nick is an advisor to the board for The Behavioral Health Association of Providers, and is also on the board for one of the most innovative treatment programs in the country – Above and Beyond Recovery.