ALCOHOLISM AND DRUG ADDICTION
My daughter was married for seven years and she had already given birth to three sons when she suddenly started going out at night with friends without her husband and getting totally drunk to the point that the next day, she had no recollection whatsoever of what had happened to her. She actually did take herself to an inpatient facility at one point, but only stayed for one night and then checked out.
Alcohol use is a socially acceptable norm, and many people use alcohol and other substances responsibly. For example, narcotic prescription medications can save lives and marijuana use is increasingly mainstream. Too frequently however, the line between use and misuse is crossed. Substance use disorders are associated with tremendous behavioral difficulties and are a huge problem for families.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), about 17 million adults in the United States abuse or are dependent on alcohol. The National Institute on Drug Abuse (NIDA) has also identified the abuse of and dependence on prescription painkillers as a major problem. An estimated 4.5 million Americans abused or were dependent on marijuana in 2010. Heavy users of marijuana often abuse other substances.
Methamphetamine and cocaine are even more pernicious. In 2011, about 4 million people abused or depended on illicit drugs and about 2 million people abused narcotic pain relievers. Millions are dependent on both drugs and alcohol.
Substance abuse is a scourge that infects millions of American households, and your adult child may be a person with a substance abuse problem. She is one of many. But to you, she is very important.
This chapter provides information on why some people become addicted to alcohol and other drugs and offers information on the types of treatment that can help.
Why Do People Use Drugs?
According to a 2010 report of the National Institute of Drug Abuse (NIDA), most people start abusing substances for four basic reasons:
People who want to “feel good” may select agents like cocaine, which offers a temporary sense of well-being and even euphoria. Pam reports that she snorted cocaine when she was younger because it allowed her to keep pace with her high-energy friends. Others abuse substances to seek a sensation of oblivion from what they perceive as their overwhelming problems. Anxious individuals may use alcohol to lessen their social awkwardness and to ease their hesitation at interacting with others. Students may seek stimulant medications to enhance their focus and concentration in a quest to improve their academic performance. Adolescents may experiment with substances to placate their friends or satiate their innate curiosity. Most people will walk away from their brief substance use without difficulty, but others will find the experience too compelling to forego it again. It is this group that is at increased risk for addiction.
Substance abuse can lead to serious problems. Marijuana can lower normal vigilance, sometimes to problematic levels. The daily marijuana smoker may be so relaxed that he inadvertently neglects his responsibilities, too stoned to notice when his toddler wanders out the front door into the street. Other substances may increase aggression. For example, as he gets high, a methamphetamine abuser may randomly assault a stranger with whom he was peacefully partying moments earlier. Some drinkers quickly transform into “angry drunks” and display their disinhibition in acts of ugly domestic violence.
Opioids are commonly prescribed narcotic painkiller drugs used to treat severe pain. Morphine, derived from the opium poppy, has been around for centuries and still has legitimate medical uses as well as being a drug of abuse. Synthetically derived drugs such as oxycodone, hydrocodone, and OxyContin are now widely available and they pose enormous addictive potential. In certain parts of the country, hospitals and prisons are overrun with young adults, often young mothers and other women, who are either being treated or punished for opiate use.
Defining the Problem
A few definitions will help throughout this chapter. Substance abuse refers to periodic misuse of a substance that leads to an inability to fulfill major obligations at work, school, or home. Substance abusers often are involved in dangerous activities, such as drunk driving, and may encounter legal problems. Their use of substances interferes with interpersonal relationships.
Substance abuse can devolve into dependency, a more extensive problem. While all drugs of abuse can lead to dependency (e.g., marijuana, opioids), it is the easiest to envision the plight of the alcoholic. Alcohol-dependent individuals require ever-increasing amounts of alcohol to achieve intoxication. If they are abruptly cut off from their supply, they have symptoms of withdrawal. Alcoholics who drink for years have difficulty cutting down the amount that they drink, and their usage interferes with their work and recreational activities. Alcohol-dependent individuals suffer many health problems as a result of their chronic exposure, which also makes preexisting problems like diabetes or obesity much worse.
Binge drinking is defined as consuming at least four drinks at a time for women or five drinks for men. During these times of intoxication, binge drinkers put themselves and those around them at great risk.
Signs and Indicators of a Substance Abuse Problem
Experts agree that detecting substance abuse as early as possible helps to limit the subsequent devastation to individuals and families. But how do you know if your adult child may have developed a substance abuse condition? If she lives with you, it may be quite obvious that there is a problem, although you may not initially be able to identify the specific drug of abuse.
If you see your child only occasionally, it may be more difficult to identify the problem unless your child is clearly impaired during your encounters. Many times, adult children spend a lot of energy camouflaging their drug use. Parents are often the last to know that their child abuses marijuana or that she regularly drinks too much on weekends. In contrast, methamphetamine abuse is hard to hide. Abuse of this toxic drug leads to severe skin and dental problems and has a marked aging effect on most users. This section will help you identify possible general signs of a substance abuse issue.
Recommendations for Alcohol Consumption
With regard to drinking alcohol, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that women should drink no more than one drink per day and men should limit their alcohol to no more than two drinks per day. A “drink” is defined as 5 ounces of wine or 12 ounces of beer or 1½ ounces of liquor.
Indicators of Alcohol Abuse and Dependence
Marci described her son Steven’s struggle with alcohol. “When he was fourteen, we found empty beer cans in his bedroom. By the time he was in high school, we realized that he was stealing liquor from the cabinet and watering it down. I think we just did not take it seriously. We thought that he settled down after he left home.”
By age twenty-two, Steve’s alcohol problem was even more severe. By then, he had a devoted girlfriend who absorbed most of the burden. Steve could not hold down a job, and whatever money he made went to buying more alcohol. The girlfriend supported both of them. As Steve’s dependency intensified, the two fought constantly. She insisted that Steve cut down on his drinking. He couldn’t and, says Marci, “She left after staying with him longer than he deserved. Once she was no longer there, I tried to get Steve into treatment but his father could never admit how big the problem was until last year when we found him nearly dead.”
Marci described a time when Steve could not get alcohol for several days. With the sudden cessation of drinking, he experienced physical and psychological withdrawal symptoms. The most severe of these symptoms is delirium tremens (DTs), a condition that includes auditory and visual hallucinations, seizures, confusion, and dangerous changes in blood pressure. “It wasn’t until my husband saw him turn jaundiced [yellowed skin] and have a seizure that he admitted Steve’s problem was very serious. For so many years we were naïve and turned our head away. I still have trouble believing how we missed the signs.”
Indicators of Drug Abuse and Dependency (Addiction)
The signs of drug abuse or dependence are similar to those seen in alcoholism. A drug abuser may use occasionally, but he has not yet developed a physical tolerance to the drug. Conversely, the drug-dependent individual does have a physical tolerance and needs increasing quantities of drugs, even to feel “normal.” He centers his psychic energy on acquiring and using drugs. An otherwise peaceful person may pursue criminal activities to fund their addiction.
The health risks for the drug abuser and drug addict vary with the type of drug that the individual relies upon. Cocaine speeds up the heart rate and can cause heart damage. Depressants have the opposite effect and the user of depressants seeks sedation. This type of self-regulated psychopharmacology can get complicated quickly. For example, a stimulant like cocaine may cause unwanted insomnia and the user sometimes incautiously pairs it with an anti-anxiety barbiturate. Another common combination is oxycodone and alcohol. Mixing drugs can have disastrous effects, including death.
Risk Factors for Alcohol Abuse or Alcoholism
Not all individuals carry the same risk for developing substance use disorders, and well-established research shows that some groups are more vulnerable. They include:
Prescription Drug Abuse
It is not hard to convince young people that illicit drugs like cocaine or heroin are dangerous. These drugs usually originate in other countries and are completely unregulated with regard to their purity, and they may be adulterated with other unreported substances. There is no pretense that illicit drugs are manufactured with the user’s safety in mind. On the other hand, prescription drugs are made in domestic high-tech plants and are under close scrutiny. They are usually prescribed by a physician for a specific medical reason. It is this false sense of security that has contributed to the dramatic rise of prescription drug abuse.
Some young people access anti-anxiety medications like Xanax to feel calm or meditative. ADHD medications like Adderall are used to enhance concentration and to improve academic performance even in individuals who do not have ADHD. In general, neither of these common occurrences is associated with negative or violent behavior. However, the same cannot be said of misused opioid medications. These painkillers offer to some a dreamy euphoria that is highly addictive. Ironically, this pursuit of tranquility is associated with scheming behavior.
The Cycle of Narcotic Abuse Begins
Two major routes lead to opiate abuse. Young people can be exposed to narcotics after a legitimate injury. A small percentage of them will find the unique properties of opioids to be tremendously appealing and will crave the sensation even after the pain episode has resolved.
More commonly, however, young people will plot to obtain opioids. Sometimes it starts by stealing grandpa’s oxycodone. Often the first exposure comes via a friend. The addiction can develop quickly and become all-consuming.
Drug-Seeking Activities
Life for an individual who is dependent on prescription medications is treacherous. Many addicts will seek a doctor for a prescription. They quickly learn that it is not hard to obtain the first painkiller, but most doctors are reluctant to offer easy refills. Unfortunately, every city has a few uninformed or unscrupulous physicians who accede to these requests and their names circulate among addicts.
Some adults go from one emergency room to another with fictitious physical complaints to score a prescription. Most ER doctors are suspicious of nebulous complaints like recurrent headaches. Also, the use of electronic medical records has made this practice less popular. In addition, most states now have prescription monitoring laws that require pharmacists to report prescribed narcotics to a central authority. Thus, if one person convinces multiple doctors to write prescriptions for narcotics, the surveillance system will flag this pattern.
Once exposed to opioids, some patients experience considerable difficulty giving up the perceived benefits of these drugs. Desperate antisocial behaviors emerge. It is not uncommon for the addict to injure himself purposefully to create a pain condition that requires treatment. He may forge prescriptions or resort to stealing from pharmacies. Pain medications are available on the street but they are expensive, the supply is inconsistent, and the criminal penalties are harsh.
Why Some Individuals Are Prone to Addiction and Others Are Not: A Complex Question
It’s often hard to know why some patients can take narcotics after an injury and then never take them again once they recover. In a similar way, some people can take one alcoholic drink and stop, while for others, that first drink is a gateway to alcohol abuse and alcoholism. Some experts believe that the problem is largely driven by a genetic predisposition to addictive behavior, and they cite the fact that addictions tend to run in families. Others see the problem as largely environmental. For example, you can be pressured to use by friends or you can choose friends who use.
If Psychiatric Problems Are Also Present
In many cases of substance abuse and dependence, the individual has an underlying psychiatric disorder. Common conditions include attention-deficit hyperactivity disorder (ADHD), depression, and generalized anxiety disorder. The adult child may also develop a personality disorder, such as borderline personality disorder or antisocial personality disorder. Many times these conditions occur concurrently.
While each psychiatric disorder is unique, with different brain chemical abnormalities that are responsive to different medications, anxiety and depression are common among a wide range of disorders. Those who suffer often find that alcohol and other drugs temporarily neutralize their intense psychological discomfort. Almost always, this method of self-treatment complicates the underlying illness. Understanding substance abuse as a means to self-medicate psychological pain is a medically valid and humane way of viewing addiction.
“My mind raced all the time,” Cheryl recalls. “I could not shut it off. I worried about everything. If there were good things in my life, I could not stop thinking how to keep them good. When bad things happened, I focused everything on how to make things different. I was miserable when I finished top in my law school, I was miserable when my family was young and innocent. I was miserable when my marriage fell apart. The only respite I got was from marijuana. At least with marijuana, I could sleep a few hours.”
Cheryl continues, “As my kids got older, I did not want to smoke in front of them and when my own son got a DUI, I found it harder to continue smoking. As I was trying to get him help, he was diagnosed with panic disorder and obsessive-compulsive disorder. I realized immediately that I had the same conditions. After a few months of treatment, I felt better. My sleep improved on these medications and I no longer felt preoccupied with smoking grass. I hope my son will agree to treatment so that he gets the same benefit.”
Tips for Parents
Don’t Openly Store Your Drugs or Alcohol
It’s far too much temptation for the substance abuser if you leave your own alcohol or drugs openly displayed. Lock up both drugs and alcohol. You should also get rid of all old narcotics. The FDA recommends that you get rid of unused narcotics by participating in programs in which the city or county offers take-back drug days for such drugs to be disposed of by local law enforcement agencies. If this option is not available and there are no disposal directions on the drug packaging, then the drug should be taken from the prescription bottle and put in a container of used kitty litter or coffee grounds, to disguise and also discourage any reuse.
Remove the labels with your name and other information on it from the now-empty drug containers and tear them up so that no one can gain information about your pharmacy account or can gain access to your prescription information.
Don’t Serve Alcohol at Family Functions
Hold off the alcohol at family events when your adult child who is an alcoholic is present. Instead, serve nonalcoholic drinks, juice, water, or soda. Some relatives may object, but they’ll get by.
Don’t Give Up on Treatment
Hopefully the first time your adult child receives treatment will be the last time she needs it. But people with substance abuse often relapse, and this may also happen with your child. It’s disappointing but do not give up.
Treatment of Substance Dependence
Like a noxious vapor in a closed room, alcoholism and substance use permeate every aspect of life. The health risks include damage to the liver and the pancreas and gastrointestinal cancers. The behaviors associated with substance use, depression, and suicide can tear a family apart. Unfortunately, many substance abusers do not acknowledge that they have a problem, let alone that they need to be part of the solution. As a result, trying to convince your adult child to get treatment can be an uphill battle. Sustaining that recovery can be remarkably frustrating for families. Keep in mind that the mere act of agreeing to treatment is a major milestone for a person who is addicted to a substance.
Self-Help Groups for People with Alcoholism and Substance Use Disorders
The good news is that a number of different treatments can work. Self-help groups play a paramount role for all types of substance abuse. In some cases individual psychotherapy is needed. If these efforts fail, residential treatment is required. Medications can also play a supportive role in therapy. Some medications decrease alcohol and opioid cravings, while others are designed to make the person physically ill if they drink alcohol within days of taking the pill. Medications can indirectly combat substance abuse (as seen in Cheryl’s story) by addressing the underlying psychiatric conditions that propel the abuse.
The first lines of treatment are self-help groups, and the best known is Alcoholics Anonymous. Alcoholics Anonymous (AA) stresses a complete avoidance of all alcohol. The abstinence message is reinforced by peer support and with regular attendance at daily meetings. Addicts who are newly in recovery are paired with sober sponsors. AA meetings are free to attend and take place daily in every major city throughout the world. AA subscribes to a twelve-step process of abstinence. The first step is the acknowledgment that the individual has lost control over his use of alcohol. Narcotics Anonymous (NA) and related self-help programs incorporate similar twelve-step principles to aid people who are drug addicted. NA-centered programs are useful for marijuana and stimulant abuse disorders.
Not all adults accept self-help programs. Some object to the apparent spiritual nature of twelve-step programs, although the “higher power” to which the individual surrenders can signify whatever the individual wishes and does not need to be a religious icon. In large cities, twelve-step programs that make no reference to God thrive. Other less well-known self-help groups include Women for Sobriety, an organization for women with alcohol dependency and other forms of addiction (women forsobriety.org); Secular Organizations for Sobriety (cfiwest.org/sos/index.htm), run by founder Jim Christopher; and Smart Recovery (smartrecovery.org).
Outpatient Therapy Treatment
For others, self-help groups or group therapy can feel like an invasion of privacy. In these situations individual psychotherapy may be a helpful alternative. For example, cognitive-behavioral therapy (CBT) is a well-regarded form of individual therapy used with this population. With CBT, the individual is trained to identify and then challenge their irrational and self-defeating thoughts, replacing them with more rational and positive thoughts. Read more about CBT in chapter 9.
Some therapists use motivational interviewing, in which the therapist helps the client find her own personal reasons for staying off alcohol and/or drugs. The theory is that the motivation for change must come from within. If a therapist lectures his young patient on the evils of substances, it is tempting for the patient to refuse or resist these conclusions because he does not own them. The theory behind motivational interviewing is that if the patient generates the reasons for avoiding drugs and alcohol himself, then he is less likely to waste time and energy trying to prove the therapist wrong.
Inpatient Facilities for Treatment
Unfortunately, outpatient treatment does not always yield the desired result of sobriety, and more intensive treatment settings are often needed to treat addiction. Inpatient substance abuse facilities may provide services for weeks and residential units for months or longer. Inpatient substance abuse treatment is costly, and in recent years insurance companies have made it increasingly difficult to secure this form of treatment. But in certain cases nothing else works. Inpatient treatment offers obvious advantages. First, having a physical barrier between the patient and any available substances of abuse serves to decrease the likelihood of a relapse. Secondly, inpatient units allow for regular family meetings and treating staff can arrange an efficient transition to an outpatient treatment plan.
Most importantly, the inpatient treatment team can observe the patient when she is substance-free and this can clarify whether an underlying psychiatric diagnosis exists. For instance, if a patient is suffering from both depression and alcohol dependency, the depression may be overlooked and remain untreated until the substance abuse layer is peeled away. Once identified, the depression can be treated.
Many larger cities have several sophisticated inpatient facilities. It is best to enter a program led by a psychiatrist so that the substance abuse and other underlying psychiatric issues can be identified and treated. Programs that simply focus on abstinence and sobriety are inadequate. If your child does not find success at local treatment facilities, families may consider national centers like the Brighton Hospital in Brighton, Michigan, or Hazelden in ten cities nationwide in Florida, Illinois, Minnesota, New York, and Oregon (hazelden.org). If your child does not find success at local treatment facilities, families may consider national centers like the Brighton, Michigan, or Hazelden in ten cities nationwide in Florida, Illinois, Minnesota, New York, and Oregon (hazelden.org). The cost and getting to these excellent facilities can be obstacles, but they are often worth the investment.
Follow-Up after Discharge Is Important
Once your child has been discharged from an inpatient treatment facility, then outpatient follow-up with a treatment team is necessary to minimize the risk of a relapse. The best program will have an affiliated outpatient unit; in this circumstance the philosophy of the inpatient unit carries over. Unfortunately, relapses are common, even for the most dedicated patients treated in the most advanced programs. As mentioned earlier, twelve-step programs such as Alcoholics Anonymous or Narcotics Anonymous should be a part of the outpatient treatment plan.
Treatment for the Family
Living with active substance abusers can be anxiety provoking, heart wrenching, and infuriating—all at the same time. Parents witness their children making terrible choices and then paying the consequences for these decisions. Many families turn to Al-Anon, a support group for the families of alcoholics. Here families meet regularly and support one another, and it has become a community that lessens the sense of loneliness that each family inevitably has. What has worked for one family may also help another family. Families that are new to the problems are comforted by families that have struggled longer, and both groups find the support process to be therapeutic.
Community resources can be shared during these meetings, including which mental health professionals and facilities in the area may specialize in substance abuse treatment.
Medications for Substance Abuse/Dependency
The best way of becoming clean and sober is to stop drinking (or using drugs). Alas, this is easy to say and very difficult to accomplish for most people who are substance-dependent.
Some medications are designed to minimize the withdrawal symptoms that occur immediately after stopping the offending substance. Others directly curb cravings for drugs or make alcohol use highly unappealing.
Medications Used in Detoxifications
Individuals may abuse drugs ranging from alcohol to cocaine and prescription narcotics. The specific method of treatment for each of these addictions differs but a major obstacle for all substance abusers is the profound discomfort associated with the first few days of abstinence. Detoxification refers to the withdrawal from the addicting drug. Inpatient and outpatient facilities monitor the patient’s health as she detoxifies from drugs and alcohol. Ideally, detoxification is performed under a physician’s care because complications often arise. Benzodiazepines (lorazepam, clonazepam) are commonly used for alcohol withdrawal to reduce the likelihood of seizures and ease the symptoms of agitation, changes in pulse and blood pressure, and altered thought processes. Particular care must accompany the timing of the detoxification medications because the simultaneous use of benzodiazepine medications and alcohol can be dangerous. Some physicians believe that anticonvulsant medications (topiramate, carbamazepine) are superior to benzodiazepines for alcohol detoxification. Clonidine, a medication also used to treat high blood pressure, is commonly used for opioid withdrawal.
An alternative school of thought is that withdrawal should be fully experienced by addicts. Physicians with this viewpoint believe that the promise of a medication-cushioned withdrawal makes the psychological and physical cost of relapse too low and serves to reinforce the underlying drug-abusing behavior. Your adult child has about an even chance of encountering a doctor who subscribes to the philosophy of using medications to ease withdrawal or one who is opposed to such use.
Once detoxification is complete, a number of medications are available to decrease relapses. The medications can be taken over months and years and are most helpful when used with psychosocial therapies. See the chart on page 101 for a summary of medications used to treat alcoholism and opioid dependence.
Medications Used to Treat Substance Dependency
|
Generic Name of Drug (Brand Name) |
For Alcohol Treatment? |
For Treatment of Opioid Dependency? |
Side Effects of Drug |
Key Benefits |
Key Problems |
|
Disulfiram (Antabuse) |
Yes |
No |
Stops the body’s ability to break down alcohol. Causes severe nausea and vomiting even with small amounts of alcohol. May also cause anxiety and fatigue. Patients may experience a metallic taste in the mouth. |
Very effective when taken. |
Can cause rapid heartbeat and sweating if patient drinks alcohol. May also lead to coronary artery disease. Many patients refuse to take the drug unless it is court-ordered. |
|
Methadone |
No |
Yes |
Also used by some doctors for pain management, although some physicians are not aware of potential risks and possible drug interactions. The FDA says that methadone should not be the first drug of choice for those with severe pain. Is potentially an addictive drug. |
Effective and helps to prevent opioid addicts from seeking injected drugs on the street. |
Can be addicting if patient takes more than the prescribed dosage. It is also an opioid and should not be combined with other opioids. |
|
Acamprosate (Campral) |
Yes |
No |
May cause sleepiness and diarrhea. |
Increases number of alcohol-free days. |
Rarely, may lead to thoughts of suicide and should be avoided in those with past suicidal attempts or with depression. |
|
Naltrexone (Depade, ReVia); injectable naltrexone (Vivitrol) |
Yes |
Yes |
Reduces craving for alcohol or opioids. |
May help with alcoholism or opioid addiction. |
Should not be used if person has liver or kidney disease or needs to take other opioids. |
|
Buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone) |
No |
Yes |
Headaches, nausea, mood swings, difficulty sleeping and sweating. Can be addictive if misused. |
May decrease the craving for opioids. |
May cause insomnia, headache, sweating, and nausea. These drugs are sometimes abused. |
Medications Used in Treatment
After detoxification occurs (with or without the help of medications), medications such as disulfiram, naltrexone, methadone, and other medications help people to get off and stay off alcohol and the drugs to which they were addicted.
Disulfiram
Disulfiram, which is usually known by the trade name Antabuse, inactivates an enzyme needed to break down alcohol and it is used to treat alcoholics. As a result, even small quantities of ingested alcohol are transformed into a chemical that causes severe nausea and vomiting. If your child drinks within forty-eight hours of taking Antabuse, he will pay an uncomfortable toll.
This aversive method is most helpful for impulsive drinking. Disulfiram needs to be taken daily and under most circumstances has no effect. But if alcohol is consumed, the effects are profoundly unpleasant, so many people are fearful of taking the medication or do not stick with it for long periods.
Disulfiram treatment may be ordered by a court as a part of a comprehensive compulsory treatment plan that includes individual and group therapy. The medication can be taken at AA meetings and compliance can be recorded for the court. It also allows parents to watch their child take the medication in the morning to ensure that they will not drink at night.
Disulfiram is not indicated in individuals with heart disease and should be used only with caution in people with a history of diabetes or kidney disease. Disulfiram reacts with some drugs, particularly warfarin (Coumadin), phenytoin (Dilantin), and over-the-counter drugs that contain alcohol. If disulfiram is being considered for treatment, the person should have a blood test of their liver function beforehand to ensure that no liver disease is currently present.
Naltrexone and Vivitrol
For many years, doctors have used naltrexone and naloxone. Both are opiate blockers that decrease the action of the pleasure centers of the brain. As a result, the physiological “high” associated with substances of abuse is less intensely registered. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) reports that oral naltrexone (Depade, ReVia) decreases the risk for relapse by about a third when a patient is in the first three months of treatment. An injectable extended-release form of naltrexone can be administered monthly. Vivitrol has been shown specifically to decrease the number of serious drinking days. Insurance companies are increasingly offering coverage for this monthly injectable medication.
Campral
Acamprosate (Campral) is another medication shown in clinical trials to promote sobriety. The medication decreases craving for alcohol and thus helps to end drinking, but it needs to be taken three times daily. Even when patients are regularly reminded that sobriety is an hour-to-hour proposition, the demands of this schedule are hard to maintain, and the early promise of this drug has not been realized. Campral comes in an oral tablet form. Kidney function should be assessed before starting the medication and throughout treatment.
Methadone
Methadone maintenance therapy has been used since the 1960s to treat heroin and prescription opioid addiction. Methadone, like heroin, is an opioid, but it is long-acting and it is administered by mouth rather than by needle. A primary advantage of methadone maintenance is that heroin addicts are able to avoid sharing contaminated needles. As a result they are much less likely to transmit bloodborne diseases such as the human immunodeficiency virus (HIV) or hepatitis.
In recent years, methadone clinics have become less popular. Voices in the substance abuse treatment community argue that although methadone is safer than heroin, it remains an addictive drug. Some politicians and the Food and Drug Administration (FDA) have become disenchanted with methadone, because methadone clinics are expensive to operate, tend to maintain rather than halt opioid use, and methadone clinics may also have an interest in extending the length of treatment. Another problem is that for some drug-dependent patients, the long-acting effects of methadone are preferred over the use of heroin and the easy access via a maintenance clinic gives them little incentive to quit opioids altogether. Furthermore, methadone patients may continue to use alcohol, and the combination of both substances can be fatal.
Methadone is still used by pain management doctors for chronic noncancerous pain, such as severe back pain or frequent headaches. The Centers for Disease Control and Prevention (CDC) reports that more than 4 million prescriptions of methadone for pain management were written in 2009. Recent CDC reports suggest that methadone may not be very helpful for these health problems and that long-term use may be dangerous. Although methadone represented only about 5 percent of all prescribed opioids in 2009, about 30 percent of opioid-related deaths that year were associated with methadone. The fact that methadone is frequently diverted to other addicts may contribute to this alarming number of deaths.
Bupenorphine
The current standard medication therapy for treating opioid dependency is buprenorphine (Subutex) or buprenorphine combined with naloxone (Suboxone). Buprenorphine carries a lower risk for addiction than other opioids such as oxycodone. When combined with an opiate receptor blocker, the patient receives a muted high. When this dosage is slowly reduced, the transition to becoming free of opioids is much easier to tolerate.
Suboxone has been approved by the FDA for office-based treatment of opioid addiction by physicians with specialized training. Subutex may be given in the early stages of detoxification while Suboxone is used during the maintenance phase of the treatment.
The successful plan demands that the physician and patient determine a titration schedule (tapering down the medication) and stick to it, acknowledging in advance that each dose reduction will be temporarily distressing to the patient. Making the transition from pure opioid to Suboxone represents progress, but complete cessation of opiates and opiate treatment agents is the intended goal.
These drugs can be given by prescription and they are less tightly controlled than with other opiate dependency treatments. Suboxone comes in the form of a thin film that dissolves rapidly in the mouth. Side effects may include headaches, sweating, nausea, mood swings, and insomnia. Like other opiates, Suboxone may cause a person to have trouble breathing if the medication is taken with alcohol or other depressant medications.
What You Can and Cannot Do about Your Child’s Substance Abuse Problem
As a parent of an adult child with a substance abuse or dependence issue, of course you want to help your child if you can. It’s important to know that there are some things you can do to help and others that are not so helpful. The chart on page 105 offers you some suggestions.
Convincing Your Adult Child to Get Help
You want to help your adult child become clean and sober. Sometimes this goal is achieved quickly, but more often, several attempts are needed to get it right. Frequently your child is an unwilling participant or is reluctant because of her past treatment failures. A solid strategy is to schedule a family meeting with your child’s permission. Ideally this occurs at a counselor’s office, although the family may need to stage the discussion alone if a counselor is not in the picture. At such a meeting, family members express their concern at the ongoing substance use and encourage their loved one to pursue the next level of treatment. “This is the time to consider a medication, or you need to sign yourself into a treatment center,” are common refrains heard at these meetings.
Sometimes a more dramatic effort is required. “Interventions” have become grist for the reality show mill, and many television viewers have seen several memorable examples. Effective interventions are highly orchestrated meetings where family and friends confront the adult child (or other person) about the negative impact of their substance abuse. The goal is for the ill person to agree to enter treatment directly after the intervention. A mental health professional trusted by your child should lead the intervention. It’s important to remember that interventions are a high-stakes tactic that can backfire.
What You Can and Cannot Do to Help Your Child with Substance Abuse Issues
|
What You Can Do |
What You Cannot Do |
|
Recommend your adult child go to meetings of Alcoholics Anonymous, Narcotics Anonymous, or other self-help groups. |
Force your child to attend a self-help group. (You can, however, make it a condition of living in your home.) |
|
Recommend your child seek medical treatment for substance issues. |
Compel your child to seek treatment. (Unless it is a condition of living at your home.) |
|
Learn about your child’s problem. |
Cure your child. |
|
Stage an intervention to encourage inpatient treatment. |
Compel your child to go to treatment after an intervention |
Steps in an Intervention
The Mayo Clinic outlines key steps for an intervention. First, the intervention should be planned with a mental health professional who is both trained and experienced in interventions. An appropriate inpatient treatment facility with specific expertise with your child’s type of addiction (i.e., prescription drugs, alcohol, cross-addiction) should be chosen with input from the therapist.
Next, the team members must be identified and recruited. Team members generally include family members and friends, hopefully all united in their commitment to treatment. They must be willing to speak candidly to your child about the emotional pain that the addict has caused them. For example, Linda recalls that in a meeting prior to an intervention for her older brother Robert, she decided to tell him how much she resented that he was intoxicated at her wedding ceremony. Robert’s mother seethed that he did not show up for his grandfather’s funeral because he was drunk, and she realized that she needed to let him know of her resentment. Interventions become the forum to convey these feelings.
At these pre-intervention meetings, team members need to identify what consequences they are willing to enforce should your child refuse the overture for treatment. For leverage, families can plan to withhold money or lodging or refuse to allow their adult child to see certain family members. Linda recalls making the decision that Robert could not see her year-old daughter until he got clean. “I am not used to making threats, but I had to protect him and protect my family,” said Linda.
Individual members should write down ahead of time what they plan to say when the intervention occurs, so they don’t forget in the heat of the moment.
Intervention Day
On the day of the intervention, your child is asked by a member to go to the site. She often will guess the agenda when she sees key people in her life glumly sitting together. Don’t be surprised if she asks to leave before the meeting starts, but usually the force of so many familiar faces keeps her there.
The intervention starts with the leader expressing their love and the group’s desire that more extensive treatment take place. Each member will then get a chance to speak. The consequences of not acting will be clearly outlined.
Does Intervention Work?
According to Copello and colleagues there is “robust evidence” that family interventions work for alcohol or drug dependence. However, it is important to understand that interventions can go either way. In the best case, the person will agree to seek treatment immediately.
Another possible outcome is that the person will become angry, continue to deny her addiction, and walk out. Even if this occurs, the seed has been planted and your child may become more amenable to treatment down the line. In the worst case, the adult child refuses help, the family’s actions are enacted without impact, and a permanent break occurs in the family. Your child continues to abuse substances, but now without family contact.
Key Points in This Chapter
The next chapter describes psychiatric problems that often contribute to serious behavioral issues.