Medication Assisted Treatment for Opioid Addiction

Just got done reading an interesting piece on the headline topic on NPR website:

Apparently the makers of Vivitrol are lobbying hard to get states to use their product at the expense of other products. This is just a heads-up on the subject. These issues are, of course, controversial, but for the first thing to know is when laws are being made, who benefits and who doesn’t? I find it troubling, however, that a maker of a drug being promoted to treat addiction is trying to get ahead by stigmatizing addiction and stigmatizing competing methods of treating addiction that have been shown by research to be effective.

Thoughts on medication assisted treatment for substance use disorders– I have worked in substance abuse treatment and mental health for about thirty years now. I remember back when there were two possibilities– antabuse (disulfiram) for alcohol, and methadone for opiates. Taking disulfiram was sort of like blackmailing yourself. “If I drink, I’m going to make myself really sick.” The thing was, some people didn’t even get sick if they drank on it, and other people could get sick if a vinaigrette salad dressing had any alcohol content. So at it’s best, it was not a great tool. But thing about was that every day you either took it, or you didn’t. If you took it, that meant you were planning on staying sober. If you didn’t take it, that meant you were planning on drinking. So it was a daily gut check.

Methadone, on the other hand, was still pretty highly stigmatized– and still slammed (as the article above points out, still today) as trading one addiction for another. And you still had to structure your day around it, getting to the clinic in a relatively small window and dosing, and in some cases, dealing with the fact that the dose wasn’t properly adjusted & you might end up too sedated to even use public transit, much less drive safely, or you might start to get dope sick later in the day. And you had to be a little angel for a long time to get take home doses. And don’t even try to get methadone for high levels of chronic pain.

I’m not closely in touch with the part of treatment that’s doing methadone these days, but I’ll bet it’s still a big hassle. I do know some people who have done office-based suboxone treatment and have had great success. And, just like people on antidepressant medication, some people have a long term goal of being off it, others don’t. Personally, I don’t see the fuss, but I’ve been in the treatment world for a long time. Isn’t it about having your life work?

Now let’s talk for a second about my clinical experience with people doing Vivitrol. What the article didn’t mention is that there are doctors doing it for people with alcohol use disorders.  There’s a certain amount of literature about people using it to deal with alcohol cravings. My clinical experience is that this application is pretty hit-or-miss. There are people who’ve done it with a goal of becoming casual or controlled alcohol users.  I haven’t seen that work out. Also, if you look at the substance use treatment literature, no reputable providers think that medication-only strategies really do the job. There has to be some kind of psychosocial component (read: counseling). Granted, that’s what I do, so I’m biased. Without a psychosocial component, though, it’s not uncommon for people do drug switching to something that naltrexone doesn’t affect, like cocaine or methamphetamine.

Now let’s take a sec to talk about the abstinence-only people. Unfortunately, there are a lot of them, including what I have sometimes called the Christian Science wing of AA. They don’t want people taking psych meds, they don’t want people doing medication assisted treatment, they want you to refuse opiates for a broken leg, and maybe will grudgingly allow you anesthesia for open heart surgery. Fortunately, the genius of the Twelve Traditions & the Twelve Concepts (the latter extremely little known) which structure the larger movement, it’s essentially impossible for one group to hijack the movement and impose a monolithic party line.

Fortunately, times are changing. I remember taking an adolescent client with a substance use disorder to an AA meeting where one of the members got up and gave a rambling, disjointed monologue. The person next to me leaned over and whispered, “He’s bipolar but doesn’t want to take the medication.” However, it was said with a tolerant smile, and the person was a regular. Another time, at the same meeting, a member apologized for coming late because they were at a psychiatry appointment getting a medication adjustment.  That person, too, was fully accepted by the group.

My greater concern is that across the nation there are many places which bill themselves as substance abuse treatment, some of them very expensive,  which do little more than take people to 12-step meetings and do structured step-working groups.  Some of them are contractors to local governments. (Just as an aside, the 9th U.S Circuit Court of Appeals ruled some years ago that people convicted of DUI can’t be forced to go to AA meetings by the courts because a Higher Power looks too much like God) As a taxpayer, I don’t like the idea of my tax dollars going to pay for people working 12 steps when they can do that for free.

Don’t get me wrong– I support 12 step groups. There is a body of research that shows people who connect with AA (the 400 pound gorilla of 12 step groups; others are much smaller) are more likely to have better treatment outcomes.  I just don’t feel comfortable with it as a treatment modality that people have to pay money for. the AA literature itself emphasizes that it should be voluntary and that AA should be independent of other institutions to work.

This post is becoming rather rambling, and I don’t have a clear destination. But I guess the main thing that moved me to write after having seen the article quoted at the top is that after all these years, it’s still so hard to get treatment, and that stigma is not only hanging on, but being used as a tool to make money by a manufacturer of what is represented as a treatment tool. The tool itself is not that great, in my clinical experience, but if they want greater sales, they should encourage more treatment of all kinds for all kinds of substance use disorders, not disparage other providers of other tools. After all, the disease has overtaken car crashes as a cause of death. If you’re really trying to help, don’t be so greedy.

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Turning the Mind, Fighting Worries

Sometimes I forget to put things here because they seem very basic to me, but then I go over them with a client and I realize that while they may be very basic and simple to learn, they are not inherently obvious to people.  So if you have, for example, been taught all about turning the mind through DBT (Dialectical Behavior Therapy) or other channels, you already know all about this. It is a skill that we all have, fortunately, and can also be key in dealing with anxiety or worries.

The most obvious way to explain turning the mind would be, for example, to look at something, then to turn your head and look at something else. You are turning, in this case, your eyes from one physical thing to another. If you don’t feel this qualifies as turning the mind, do it this way: look at something closely, as though you will be asked to describe it. Then look at another object or scene in the same way. Now, close your eyes and recall the first scene, then replace it by the memory of the second. You have the ability to turn  your mind from one thought to another thought. It’s essentially that. When I choose to think about something like the salad I just had for lunch, then remember the doughnut I ate after lunch (happy National Doughnut Day), that is also turning the mind.

Now, about dealing with worries or anxiety. Here’s a basic procedure:

  1. Ask yourself, “What am I worried/anxious about? Be specific.
  2. Look at the specific worry and identify an action step that you can take, right now, to deal with the worry.
  3. Do the action step.
  4. Turn the mind to something else.

Example: I feel anxious. when I think about it I realize, I’m worried that my phone might get turned off.  I check my account status right now and realize that I missed paying the bill last week. I check my checking account right now and find that I have the money. I authorize payment right now. Then I turn my mind to something else.

Suppose, on turning the mind, that I now start worrying that I will be killed by an asteroid hitting the Earth.  I then go to to see if there are any asteroids scheduled to hit the Earth. When I discover that there are none, I have no action item, so I turn the mind to something else.

There can be more to this, of course, but I’ve known folks facing complex medical issues with life-threatening consequences to maintain happiness in the moment by acknowledging that they’ve done every action item they can, up to and including estate planning, and now have no more action items. Note that I’ve used words like simple and basic but not the word easy. It may or may not be easy for you, but it certainly can be done.

Alfred E. Neuman from


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When Happiness Is Bad For You


I’m still short on time for original content creation, but couldn’t pass up this item from the Center for Greater Good. It reminds me of a folk story I read in a collection once upon a time, long ago & far away. In it, a boy catches a magic fish who promises him one wish in return for freedom. The boy wishes to always be happy. The fish, being a wise magic fish, asks him, “Do you REALLY want to always be happy?” The boy can’t see anything wrong with it & goes with the wish, and is immediately happy. Happily going home, he finds his family standing around crying because their house has just burned down. But he’s completely happy– and everyone thinks he’s insensitive, weird, and a little slow. Soon thereafter, he finds himself chased through the jungle by a lion, but even when running for his life, he’s feeling nothing but happiness. After a couple more experiences of inappropriate happiness, he finds the fish & wishes to always feel the right feeling for whatever’s going on.

“You, yourself, as much as anyone in the universe, deserve your love and affection.”


Image from–Emotions-Chart-114055

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Not New Content– But..

Perhaps a clue as to how to be content…

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Love After Love

Ran across a poem from one of my favorite poets:

Love After Love

The time will come
when, with elation
you will greet yourself arriving
at your own door, in your own mirror
and each will smile at the other’s welcome,

and say, sit here. Eat.
You will love again the stranger who was your self.
Give wine. Give bread. Give back your heart
to itself, to the stranger who has loved you

all your life, whom you ignored
for another, who knows you by heart.
Take down the love letters from the bookshelf,

the photographs, the desperate notes,
peel your own image from the mirror.
Sit. Feast on your life.

Derek Walcott


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Fake News, Creativity, Fact Checking, Happiness

Three people thinkingIf I am someone with depression, I may go to a cognitive therapist. The cognitive therapist will then coach me on identifying my cognitive distortions, like all/nothing thinking, fortune-telling, discounting, labeling, over-generalization, and so on. The handbook for this is David Burns, The Feeling Good Handbook. If it had been published by another publisher in another time, it might have been called Cognitive Therapy for Dummies, except when you’re already depressed you don’t want to be called a dummy.

So here’s the thing, for me, about cognitive therapy. If I’m already depressed and wouldn’t like to get my treatment from a book like Cognitive Therapy for Dummies, I might also be a little sensitive about being told that a lot of my thinking consisted of cognitive distortions, either. So how to use the fearsome weapons of cognitive therapy to get on the right track without having to give my thinking a negative label, in effect kicking myself while I’m down? And how do I use the techniques without buying into the negative labels?

Here’s my suggestion: I see myself as a creative story-teller. As I go through life, I interact with people & the world, and I get a few facts, which I then use as the basis for making up stories. I’m a creative person and I like to make up stories. So, for example, someone invites me to a party. I start to make up a story– “I’ll go to the party, I won’t know anyone, I’ll feel shy and alone, will get even more depressed watching people have fun, will spend all my time eating junk food, maybe drink too much & make a fool of myself, and will have a terrible time.” My cognitive therapist tells me that I’m engaged in the cognitive distortion of fortune-telling and also all/nothing thinking. “I won’t know anyone” is obviously false– I got invited, so I know the host. Also, I’m making up a (sad) story about a future that hasn’t happened– fortune-telling.

So, bummer. I’m invited to this horrible party and now I’m thinking bad thoughts on top of it. Or, I could just think of myself as a journalist, or the editor of my own script. What are the facts? The fact is, I got invited to a party. That’s nice. All the rest is made up. I’m not a bad person, I’m just someone making up a story, and I fell in love with my own story so much that I forgot I made it up. Wow, I’m a great story-teller. But my story is a sad story. I’ve just been victimized by fake news– that I made up myself. So after I fact check myself, I make up a different story. In this story, I go to the party, decide I’m not having a good time, and leave early. So I don’t pig out on junk food, get drunk and disgrace myself. Or I make up another story– I go to the party, get the host to introduce me to some people, and make new friends, or reconnect with old ones. In actuality, given that my only real fact is being invited to a party, I can make up many stories, and they can all be more positive than the original bummer story. In fact, I have the ability to make up stories where I have some control– I decide to bring healthy snacks and non-alcoholic beverages to the party.

You get the idea.

image from :

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Mixed Feelings

On one hand, it would be nice if we could get away from stigmatizing people with mental illness.

On the other hand,

gun suicides outnumber gun homicides two to one.

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