MENTAL HEALTH VS. SUBSTANCE ABUSE

For the past twenty years professionals have debated whether it is more efficacious to treat mental health and substance abuse together or one at a time. We have tried it both ways. The mental health folks have spent months trying to stabilize clients before turning them over to the addiction specialists. And the substance abuse people have done the same, concentrating on assisting their clents to be clean and sober before dealing with their anxiety or bipolar disorders. The perspective that is most difficult for professionals to understand is why we would not treat the whole person at once. Is this a case of dualing egos or perhaps an unfamiliarity with co-morbidity therapies? In either case, we must look at patient wellness first and foremost. Meeting the patient where he or she is, may mean motivating someone to enter detox, while developing a plan that includes medication for mental health stabilization and individual therapy that addresses both issues. Whatever works, may sound simplistic. And someimes that means abandoning a particular therapy for a more eclectic approach that is comprehensive in areas of mental health, substance abuse, pharmacotherapy, exercise and spirtuality. As non-traditional as this may sound, it may be what works for your particular patient.

BATH SALTS AREN'T FOR BATHING!

Last year at this time I visited a 16-year-old boy in the hospital. He could not speak or walk or control any motor movements. He had been in a coma for three days and was then awake. Blood test results showed no known drugs or alcohol in his sytem. However, after interrogating his close friends, they admitted the boy had snorted bath salts at a party the night he collapsed. The words and the labeling are innocuous enough. Bath salts are meant to be a soothing additive to warm, soaking tub water in an attempt to relax us and lower our blood pressure. But these are not the common relaxing agents of our parents' generation. Today's product being sold in small shops and corner markets, can be purchased legally since they are labelled - 'not for human consumption'. Ingredients in bath salts include three toxic chemicals that were banned by the DEA last year. They are MDPV, methylone and mephedrone. They cause paranoia, psychosis, agitation, a stimulant-like effect and hallucinations. They also have been associated with delayed suicidality. The question becomes, why do young people abuse something with such potentially fatal consequences? The answer is complicated. Some do not have skills to deal with real life. Some blindly follow others. Some want to change the uncontrollable feelings within themselves that prevent their personal happiness. It is time for us to stand up and support an across the board removal of Ivory Wave, Vanilla Sky, Bliss and other bath salt products from all stores. It is too late for the 16-year-old I visited. But it is not too late for others like him.

PHARMACOTHERAPY HAS ITS PLACE

When working on recovery with my patients, I often recommend that they attend AA/NA/GA, go to meetings, join a home group and pick a sponsor. This is very therapeutic, but it is not therapy- it is adjunctive. Yet, I know that the more positive support a patient has, the better off he or she will be in long-term recovery. Whatever works is the prescription I adhere to. The patient's success is paramount. What puzzles me is the negative reception many of my patients receive when they go to AA/NA and members find out that they are on medicines to assist their recovery. Abstinence may work for many people but it is not the only way to enter recovery. Pharmacotherapy, or the use of medication to cut down on urges or cravings, is another method. We often find people who have relapsed numerous times when attempting abstinence. These are the folks who are better off taking medication to help manage their lives, then to chronically feel like a failure. Revia helps with Pathological Gambling. Suboxone works with Opioid Dependence. And both Vivitrol and Campral help with Alcohol Dependence. If folks are suicidal, we recommend their PCP use an anti-depressant. All of these of course should be combined with substance abuse treatment on a weekly basis and frequent contact with the prescriber. Folks in AA/NA/GA adhere to the abstinence model. They learn about acceptance, gratitude and surrender. What they need to learn as well is tolerance and a non-judgemental way of accepting others who struggle with addiction.

FEELING NO PAIN, USING COCAINE

We don't talk much about cocaine anymore. The emphasis these days is on opiates and prescription drug abuse. Yet just as many Americans use cocaine as they do heroin. The difference is that cocaine is 'marginally socially acceptable' in many wealthier circles. For that reason, discussion about it does not peak interest. Cocaine was more or less 'normalized' by high-level executives and celebrities. It is available at parties and bars and folks don't see it as an addictive substance. Even detoxes do not accept clients who only abuse cocaine. The problem however, is cocaine causes serious damage to the brain. Using it with alcohol, even socially, can produce cocaethylene which can be fatal. Smoking cocaine in crack form, causes Dopamine flooding and a slower re-uptake. That means that it is all but impossible to stop smoking until the crack runs out. It goes to the reward center of the brain and produces such a pleasurable effect that people do not want to stop smoking. So the question becomes, why do people smoke cocaine or snort it if it is damaging? Are they addicted? There is no one answer to these questions. People use illicit drugs for many reasons. But they are not addicted to the substance cocaine. They are addicted to the feeling they get when they use this substance. It takes them out of the everyday world that surrounds them and puts them in a different emotional state where no one can demand from them. They do not have to live up to anyone else's expectations. But, damage from cocaine abuse clearly outweighs the good feeling that users get when they are high. It is a negative tool to avoid reality and responsibility. In between use, folks become irritable and anxious. And combined with other drugs it can be fatal. Although not a gateway drug, rarely do we meet clients who only use cocaine. Patients come to us when their life is out of control. When the cocaine/crack use has financially devastated them. And when they have alienated their family and friends in favor of their on-going affair with the drug. Cocaine abuse is a serious problem in America. We should not turn our heads and ignore it when family members use the drug. We should encourage them to get help before they lose everything that is important to them.

NURSE, HEAL THYSELF FIRST

In the past seven years I have treated dozens of nurses. Some have come to us for alcohol dependence. But the majority have been Opioid Dependent. That's correct. These professionals that we depend upon to hold our hands and minister to us when we are sick, are often very ill themselves.

They begin by taking Percocets for stress, then a little Oxycontin for back pain and many of them progress to Dilaudid to get through their shift. The sad part of this behavior is that they more often than not, they take medicine from their places of work - hospitals, nursing homes and even hospice. Some even substitute placebos for the actually pain medications, leaving their patients in distress.

Although this is the minority of people in the nursing profession, it still begs the question, WHY? Is the job too stressful? Do we not provide enough down time for our most valuable caregivers? Are there folks in the profession with no regard for a work ethic and who leave their co-workers to run back to back shifts because they feel like calling in sick? Do some people enter the profession with a predisposition towards drug addiction?

I do not have the answer. What I do know is that this is becoming a problem that we need to address. I also think that support for recovery is a better idea than punishment. We need nurses. They deserve our help, if not for humanitarian reasons, than at the very least because it is good Karma.

CHILDREN DRINKING AT HOME

This morning's special news segment addressed the question about whether or not parents should introduce alcohol in the home, so that children will understand how to drink when they reach majority age. The issue with the question posed, is that there is an assumption made, that parents themselves understand how to drink reasonably.

The problem is that children and teens are not physically capable of handling alcohol. Developmentally, they need pure foods such as fruits, nuts and vegetables, grass-fed beef and poultry, for brain growth. They do not need alcohol at a time when the brain is learning and expanding its knowledge base.

They also do not need to emulate the drinking behaviors of adults around them. Especially when most do not understand that a woman should drink a maximum of 3-4 (one ounce) drinks in an evening at most, and a man about 5 ounces. A standard size glass of wine in America is over the three ounces to begin with. And watching parents who come home and have a beer to relax each night sends a negative message that alcohol is an acceptable tool to use to unwind.

Whether the drinking age is 21 or 18, teaching people how to drink is a great idea. Waiting until the brain and body can handle alcohol is an even better idea!

MARIJUANA PARENTING

Today, I attended a conference that focused on the damage drugs and alcohol can do to the adolescent brain. Most people in the audience were not worried about the effects of marijuana; they were focused on alcohol and 'hard' drugs. In fact, some even defended the position the MA DCF has taken - that removal of children for parental abuse of marijuana is not going to happen.

Yet, these attendees learned today that marijuana may not be a 'gateway' in the traditional sense, but it is harmful nevertheless. It takes approximately 18-24 months for a person to stop depending upon marijuana after discontinuing abuse through harm reduction. And in fact, withdrawal really happens; including mood swings, depression and irritability during protracted withdrawal.

The adolescent brain is not fully formed and smoking marijuana at a young age impedes the user's ability to hold memories and interpret cognitions properly. Smoking causes cognitive distortions.

Developmentally , using drugs and alcohol does not allow the user to progress from adolescence to adulthood emotionally. They get stuck - something we refer to as arrested development.

Most young people begin smoking cannabis around 11 or 12 years old. Research demonstrates that if a 'father figure' is smoking in the home when a child is 6 years old, the child will most likely grow up smoking marijuana as well within 5 or 6years. That makes me wonder whose idea it was at DCF to decide not to consider marijuana as a serious issue.

Smoking marijuana is a serious issue. It is not the cannabis of the 1960's; but cannabis that is ten times stronger. It is not a joke, or a casual source of entertainment. It is a substitute for skills we have not taught our young people. Skills that will help them manage their lives in a more balanced way.

IS MARIJUANA A GATEWAY DRUG?

The question on most folk's minds about addiction is what is wrong with smoking marijuana. It is natural. There is no data on overdose by smoking. And most smokers agree that it is not addictive. While these things may be true, the real question is why do people continue to smoke cannabis on a daily basis. And why is there so much negative press?

The answer is that smoking marijuana changes the way we feel. It numbs us, it clouds our depression, it shifts our focus from everyday stresses to an ethereal experience which takes us out of ourselves. Is the substance itself addictive? NO. Is cannabis a gateway drug leading to more intense addiction and highly volatile drug behaviors? No. So what is the problem?

The problem is that we become attached, dependent and/or addicted to the feeling. To the escape and the method of detachment. Using this method on a daily basis keeps us from doing other things. It does not allow us to develop other coping mechanisms which we need to manage our lives. It prevents us from becoming involved in family and friendships. The loss that we experience is a loss of time. Something we cannot recover.

Marijuana may not be a gateway to other drug use. But it definitely is an obstacle to living life to the fullest.

ADDICTION ELITISM

An elegant looking, well-dressed woman in a designer suit and handbag that cost more than most people's weekly salary, came to see me the other day. She wanted to 'interview' me to see if the treatment my staff and I could provide for her young daughter was up to speed. Her husband had already called and asked about our credentials, years of experience and schools. So this was the in-person visit.

Her daughter was not present. She was at home where she stayed while in the midst of a Percocet-heroin run. Her mother proceeded to tell me that the 17-year old was not like those 'other people' who came to us for treatment. She was not 'that kind of person'; she was from a 'good' home. And could we treat the daughter at home so that she did not have to come in contact with any of the types the mother had seen in our waiting room.

It takes a lot of restraint not to say what is close to the tip of my tongue when folks take such an elitist stance about addiction and treatment. It is an equal opportunity disorder. Addiction knows nothing about socio-economics, or skin color or age. Treatment is not dependent upon the price of a designer bag or the education level of the parents. It is a condition. It can happen to anyone. It is treatable.

As for the therapy most of us in this profession provide, it is not dependent upon the patient's income. It is dependent upon the patient's needs. We work hard regardless of who the patient is or where they come from in an effort to promote wellness - it's that simple.

OVERDOSE PREVENTION

Of course we all know that the best way to prevent drug overdose is not to take any illicit drugs or medications that do not belong to us. Yet each day young people die needlessly by taking large quantities of Opioids such as Percocet, Vicoden, and Heroin. Their friends see that the overdose results in respiratory distress and they become frightened. They either leave the struggling friend or they dump them outside an emergency room door.

But time is crucial when it comes to saving someone who has taken too many drugs or has abused someone's prescription medication. When the respiratory system is depressed by too many opioids the person gasps for air. It does not take too long for death to come.

But there is a substance - Naloxone(Narcan) that average people can be trained to administer that will save lives. Naloxone reverses respiratory failure in seconds. In a study in California where a survey of 48 communities who are trained to use NALOXONE responded, there were 10,171 persons saved with NALOXONE.

Rather than opposing methods of harm reduction in favor of strict abstinence, I encourage communities to seek out hospitals and clinics who are willing to train and give access to Naloxone in an effort to reduce deaths by opioid overdose.

Medication vs. Drugs

I suppose we could pass it off to vernacular speech when we talk about 'drug addiction', but the truth is that using appropriate nomenclature is important when defining the national epidemic in the United States. IT IS PRESCRIPTION ABUSE.

Drugs are illicit substances that people buy on the street or trade. Heroin falls into that category and in most states so does marijuana. The illicit sale of medications such as Oxycontin, Percoset and Opana falls under the same name- with 'illicit' being the major factor.

Medications on the other hand,are prescribed by a physician or nurse practitioner for a medical or psychological condition. The abuse of these medications is the leading cause of concern in this country. Taken as prescribed, medications mitigate pain, lessen anxiety and lift depression. The problem comes when people share their medications or take them as they feel like it to change their emotional state. I understand the pressure that we are all under- never being able to shut down or turn off (computers on IM at work and at home, cell phones and text in the car and when we walk,shop or work out; and the radio competing with TV and the internet for our attention). Yet self-medicating to deal wit these stressors IS NOT THE ANSWER. IT IS THE PROBLEM!

Whitney Tormented by Drugs

Although we do not have the written autopsy report from the death of Whitney Houston, there is a good chance that we will read that drugs and alcohol were contributors to her passing. Once again, we watch a person with a God-given gift and tremendous talent succumb to drug addiction. This begs the question as to why this happens? Did those around her not want to interfere? Were they so star-struck that they could not take her to a facility where she could get help? Did they think this was a boundary issue and that they should mind their own business?

Whatever, the justifications, the bottom line is we lost a magnificent talent far too soon because no one intervened. In the 1970's Time magazine had a cover page with the question: ARE WE OUR BROTHER'S KEEPER? In a world where opioid dependence and prescription drug abuse is an epidemic, the answer is 'we need to be'. We cannot turn our heads or backs when we see drug abuse. We need to intervene when someone gets behind the wheel after smoking marijuana or drinking alcohol.We have to say 'not in our family' when a teen takes pills that are not prescribed. It is time we take our heads out of the sand and step up to stop addiction before we lose another angelic voice. RIP Whitney.

DISEASE VS DISORDER

I am attending a major 'think tank' session today in Texas. The discussion revoles around whether to subscribe to the new definiton of addiction, set out by the American Society of Addiction Medicine. For Physicians and Pharmacists this is an easy sell. They call it a 'brain disease'. It is chronic and can be treated by medication. But the question still lingers as to why it occurs in the first place. If it is a disease than it just appears - we have no participation in it. If it is a disorder then maybe there is the implication that we have a part in the process. No one sits on our chests, puts a funnel in our mouths and pours alcohol down our throats. Likewise no one forces us to ingest or IV opiates. This 'disease' only shows up after we have participated in an action to make it happen. I would like to suggest that we have a disorder or even an illness, and we need help and support to get well. Wellness is our goal. Whether we use pharmacotherapy, or AA, or Mental Health/Substance Abuse Counseling, the goal is the same and we must be involved in the process somehow. Although ASAM decided to redefine addiction in a way that benefits physician practices and pharmaceutical companies, we must consider that stepping up on our own is a critical part of personal wellness.