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We Now Take Medicare, Blue Cross Blue Shield Coming Soon

Medicare Accepted at Triangle Wellness & Recovery

We now take Medicare, and look forward to working with new and existing patients with Medicare.

Blue Cross Blue Shield Acceptance Is in Progress

As of April 5, 2020, we will be in network with Blue Cross, Blue Shield (BCBS).

In the meantime, we are offering significantly reduced rates for patients with BCBS, and we continue to extend a same-day payment discount to all other clients. Contact our office for more details.

patient-talking-with-doctor-via-pad-telemedicine

What Triangle Wellness and Recovery is doing in response to the Coronavirus

Slowing Coronavirus-COVID-19

At Triangle Wellness & Recovery, we are committed to protecting the health of our clients and staff. While the people most at risk of serious complications from the Coronavirus are the elderly and those with pre-existing medical conditions, all of us can take actions to help to keep our families and communities safe by slowing down the spread of this virus. By doing our part to slow the spread of this virus, we make it more likely that our healthcare system(s) will be able to meet these needs of those who become severely ill. In this way, each of us has the power to actively protect the most vulnerable among us.

Protect Yourself from Sudden Withdrawal

If you abruptly stop drinking alcohol or benzodiazepines (Xanax, Klonopin, etc) you may be at risk of life-threatening complications, including seizures an delirium.

Dr. K can work with you to reduce the risk of complications and evaluate if a home-based detox with telemedicine monitoring is appropriate.

We remain open to accept new patients.

Please contact us today if you or your loved one is struggling with addiction, depression, anxiety or other mental health concerns.

Effective immediately:

  • All individual or family therapy visits will be held using secure videoconferencing (teletherapy) or, when web camera access is not available, sessions may be conducted by phone.
  • All in-office groups are suspended at this time.
  • Medical visits which may be conducted through telemedicine will be converted to telemedicine visits.
  • Our office continues to remain open for medical procedures such as Vivitrol or Sublocade injections as well as other in-office procedures.
  • New and existing clients receiving suboxone or other controlled substances will be evaluated by telemedicine whenever clinically appropriate.
  • Any medical client who has a fever, sore throat, cough or other possible symptoms of Coronavirus should stay home and contact our office to arrange for telemedicine services.
  • Cancellation fees will be waived up until the scheduled time of your appointment. No show/no call fees will still apply.

More about our telemedicine/teletherapy services:

We use a simple and secure application which allows us to send you a link for your appointment by text or email.

You can then click on the link which automatically takes you to our “virtual waiting room”.

There is no requirement to register or enroll with doxy.me, the HIPHA compliant platform that we use.

We do not have the capability to have group visits by videoconferencing at this point in time.

physician typing hands doctor addiction medicine

Who can provide medical addiction treatment? Not just psychiatrists.

I’M NOT A PSYCHIATRIST

When I tell therapists or my patients that I am an Addiction Medicine physician, not a psychiatrist, they frequently respond with a quizzical look. Patients may ask themselves, am I in the right place?

 

WHAT KIND OF DOCTOR TREATS ADDICTION?

The confusion about addiction medicine versus psychiatry is understandable, especially when people are used to the idea of seeing a psychiatrist for addiction treatment, or if they are fortunate, an addiction psychiatrist.

 

Over the past decade the opioid epidemic has highlighted the role of pain, especially chronic pain, in addiction. Yet, most medical physicians and psychiatrists don’t treat addiction (or chronic pain) in their practice.

 

Why is that?

 

WHAT KIND OF TRAINING IN ADDICTION TREATMENT DO DOCTORS GET?

Until recently, medical education has largely ignored addiction.

Most practicing doctors received no training on addiction treatment in medical school.

 

I graduated from a top-tier medical school in 2006. I was taught how to recognize and treat many of the medical complications of substance use such as:

 

      • Liver disease
      • Hepatitis C
      • HIV
      • Blood infection
      • Vascular disease

 

I did not receive any training on how to assess and treat addiction itself.

 

THE WRONG MESSAGE ABOUT DRUG ADDICTION 

Compulsive and dangerous drug use was considered self-destructive behavior that made patients frustratingly sick and more expensive to treat.

 

The message relayed to my generation of doctors was that these patients just didn’t want to get better, and they didn’t deserve the health care resources the way that people with other diseases did.

 

ADDICTION PSYCHIATRY

Until I started working in the field of addiction, I assumed that psychiatrists treated substance use disorders, but I was wrong. At least most got exposure to addiction treatment as part of their training, even if they never treated a patient for addiction once they went into practice.

 

Addiction Psychiatry became an official subspecialty of psychiatry in 1993. This is shockingly late given how much sickness and premature death were caused in the 20th century by alcohol, tobacco, opioid and cocaine use.

 

Few psychiatrists pursued specific training in addiction. At the time it was not as in-demand as other specialties, and as now, there was tremendous stigma around “those patients”.

 

So for over 20 years the only pathway to board certification in the field of addiction required completion of 3-5 years of psychiatry training and after that additional in-depth training in addiction. Physicians who were not psychiatrists were excluded from this training and certification.

 

 

EXPANDING OPTIONS FOR ADDICTION TREATMENT: THE BIRTH OF ADDICTION MEDICINE

In recent years, Addiction Medicine has become its own officially recognized specialty with board certification provided by the American Board of Preventative Medicine.

 

Addiction medicine is open as a subspecialty to psychiatrists as well as to medical doctors from other specialties including internal medicine, family medicine, emergency medicine, and even transfusion medicine (my former specialty) among others.

 

WHY SHOULD I LOOK FOR A BOARD CERTIFIED DOCTOR?

Physicians aren’t actually required to be board certified to practice, but board certification is an important signifier that your doctor has completed a rigorous process of training, clinical experience and examination in their field of certification. To maintain certification, physicians must demonstrate that they are staying up to date within their specialty and many must take additional exams throughout their career.

 

Board Certification in Addiction Medicine is offered through the American Board of Preventive Medicine (ABPM)

 

To be eligible to take the board exam for Addiction Medicine physicians must:

 

      • complete an addiction medicine fellowship

 

                      OR

 

      • have extensive clinical experience in the assessment and treatment of substance use disorders

 

A small number of individuals, including me, qualified by clinical experience AND also pursued advanced training through an addiction medicine fellowship.

 

WHAT ARE THE DIFFERENCES BETWEEN ADDICTION MEDICINE AND ADDICTION PSYCHIATRY?

While the scopes of addiction psychiatry and addiction medicine overlap considerably there are some general differences between the two fields.

 

ADDICTION MEDICINE

      • Explicitly includes the assessment and treatment of chronic pain conditions
      • There is more comfort with the medical complications and disorders in people struggling with addiction such as chronic heart, lung or liver disease or infection.

 

ADDICTION PSYCHIATRY

      • Psychiatrists have more skill in the diagnosis and treatment of conditions such as schizophrenia, dementia, severe personality disorders, autism and other developmental disorders

 

BOTH ADDICTION MEDICINE AND ADDICTION PSYCHIATRY

      • Includes training to recognize and treat the psychiatric disorders that commonly occur in patients with addiction such as mood disorders, anxiety, trauma-related disorders, and sleep disturbances.
      • Emphasize the understanding of the biological, psychological, social and environmental factors that contribute to the development of addiction, its clinical course, and response to treatment
      • Must know how to manage and treat intoxication, withdrawal and long term effects of substances of abuse and be able diagnosis and treat behavioral addictions in addition to drug and alcohol use disorders.
      • Physicians of both specialties must be familiar with the various individual and group therapies effective in recovery treatment as well as the clinical levels of care and treatment settings for substance use disorders.

 

HOW TO CHOSE A DOCTOR

The choice of who to see for your addiction treatment, chronic pain or mental health conditions should be based on a number of factors.

 

Certification is a marker of clinical knowledge, but consider also using these questions to help you chose:

      • Does your doctor make you feel safe and respected or do they increase your feelings of fear and shame?
      • Does your doctor listen to you and ask questions in a non-judgmental way?
      • Does your doctor take the time to educate you about your conditions and treatment options?
      • Do you feel like a partner in making treatment decisions or do you feel that decisions are made without you?

 

There are more questions to consider, but these are the most important.

 

A right fit can be had to find, but you deserve no less.

willpower tree

Willpower Is Not Enough

“They just need to be more committed.”

 

“They don’t have enough willpower.”

 

“They don’t really want to get better.“

 

 

I’ve heard all of these and more from the family and friends of clients.  I’ve heard them from strangers I meet who offer me their assessment of why people struggle with addiction, as if I have not been working in this field for years. Worse yet, I have hear variations of this from sponsors who have overcome addiction themselves and strenuously pass along this belief to those that they are trying to help.  Not everyone in recovery believes this – in fact, it is my hope that it is the minority, but this message is misguided at best, and fatal at worse.

 

Willpower is about the future,
but our brains are designed to make decisions based on the here and now

 

We think of willpower as a fixed feature of someone’s personality, “he has a lot of willpower; look at what he’s accomplished”.  But willpower is a not a stable characteristic; it is always context dependent. Willpower is the ability to chose freely in a situation, given one’s (long term) values and goals. Humans are already at a disadvantage here. Our brains are much more sensitive to the short term consequences of our actions than long term ramifications. We are simply not designed to value the future as much as we value today. This has provided a survival advantage, after all, it is foolish to prioritize collecting enough wood to last through the winter when an angry black bear is charging at you. The first instinct is always survival in the moment.

 

When our brains do not perceive an immediate threat to survival, we are capable of remarkable things.  We raise children for nearly two decades, tending to their physical and emotional needs often at the expense of a good night’s sleep. We plan for the future by putting money in retirement accounts. We buy Halloween candy the week before trick-or-treaters arrive and we (usually) don’t eat all of it before then.

 

Your mood has a huge impact on how much willpower you have in any given situation

 

Willpower is heavily mood-dependent. How, much more likely are you to resist a pint of Ben and Jerry’s when you’ve just been laid off from your job? How likely is it that you will go the gym when you’ve feeling depressed and hopeless? How much more successful will you be when you wake up confident and excited to start on your New Years resolution? When you find yourself anxious and self-conscious at a social event are you more or less likely to drink alcohol?

 

Telling someone that their problem is that they lack willpower (and that is why they haven’t conquered their addiction) comes with two assumptions which directly contradict what we know from decades of addiction research. The first is that free choice is a reasonable expectation for someone who has addiction, that they can and should be able to stop themselves from using their drug(s) of choice. The lack of willpower to stop using despite serious negative consequences is a defining characteristic of addiction.  This is like telling someone that it raining because clouds are dropping water from the sky. Duh.

 

The second assumption is that willpower alone is enough to recover from addiction. If willpower alone was enough to overcome other challenges then we wouldn’t have more than 30% of adults in our state classified as obese. We wouldn’t spend so much time on social media instead of spending time with our kids and we wouldn’t buy things with a credit card that we can’t pay off in full each month.  Willpower is not a reliable companion. It is more like a flaky friend who rarely shows up on time and has a poor excuse for forgetting they promised to drive you home from your colonoscopy (again). It’s great when they come through for you, but you would be foolish to trust them with your life.

 

So how do we help ourselves make good decisions in the moment?  How do we safeguard ourselves from our own destructive behaviors?

 

Instead of depending on willpower,
we can change the decision we make or change the choice we face

 

We can change the decision we make by boosting factors that enhance our mood, sense of safety and self-image. We can get enough sleep and practice exercises that decrease anxiety and strengthen our focus.  We can learn how to recognize when we are emotionally vulnerable and give ourself extra self-care.  We can accept treatment for psychiatric or medical conditions which interfere with our ability to enjoy time spent with loved ones or perform the necessary daily activities of living.  We can lay the foundation for a meaningful and joyful life in recovery.

 

We can change the choice we face by avoiding situations in which we have access to drugs, alcohol or the means to engage in our behavioral addiction. We can change the choice by identifying other immediate options to using drugs, like engaging in a hobby or listening to our favorite music. We can decrease the chance that we will be offered drugs or alcohol by communicating our intentions ahead of time to friends and family and asking for their support. We can remove all illicit substances from our home, and take a route to work that bypasses the specific locations that trigger cravings.

 

Think like an engineer:
problem solving instead of self-punishment

 

These are practical, strategic changes that can be implemented regardless of where someone is in their struggle with addiction.  Instead of treating addiction from a place of moral superiority, we can approach addiction from the perspective of an engineer. This is effective problem-solving, this is something within reach.

 

Moving away from addiction and into recovery is not easy, but neither was many other things you’ve overcome in your life.  Needing help doesn’t mean you’re weak; it means you don’t yet have all the pieces in place to succeed. That is why we’re here for you.

asparagus analogy detox intoxification addiction

What are the Differences Between Intoxication, Detox and Addiction Treatment?

Many people confuse detox or medically supervised withdrawal (when a patient is admitted to a detox unit) with treatment for alcohol or drug addiction. This can create unrealistic expectations for the client and their family and can make it difficult for them to make informed decisions about care. Furthermore, because the criteria for detox are different from the criteria for treatment, I have seen clients discouraged and disheartened by being turned away from a detox facility after finally gathering the courage to seek help. An easy way to think about the difference between detox and treatment is to use what I call the asparagus analogy.

 

The Asparagus Analogy

 

Imagine that you really like asparagus (I hope you do; it is a delicious and healthy vegetable). You especially love to eat it grilled or roasted with olive oil and a bit of Parmesan cheese or toasted nuts. When asparagus is in season you eat it nearly daily. You read the vegetable section of every library cookbook searching for more ways to prepare this delicacy, your friends who are not asparagus eaters are annoyed with this, but you don’t really need them anyway. More asparagus for you.

 

Anyone who has eaten asparagus is reminded the next day (and sometimes the day after that) that they did in fact recently eat asparagus. This happens when they go to the bathroom, specifically when they urinate. Even though the taste of asparagus is no longer in their mouth and the actual asparagus they ate has moved from their stomach to journey through the rest of their digestive system, their body is still processing asparagus and the evidence of that is the distinctive smell of “asparagus pee”.

 

Now asparagus was sold out at all the local grocery stores the other day, and you haven’t even been able to find any in the frozen food section. There is such a shortage of asparagus that you haven’t eaten any for weeks, maybe months. Do you still crave asparagus? Do you still enjoy eating it?  If you went to a restaurant and asparagus cooked your favorite way was on the menu, would you hesitate to order it?

 

This may be a silly analogy, but asparagus conveniently  illustrates the distinction between intoxication, detox(ification) and addiction.

 

Intoxication

 

Intoxication is the pleasurable experience of eating the asparagus itself.  It is the taste of it and the feeling of contentment after a delicious meal.

 

Detox

 

Detox is the process that occurs over the next few days after eating asparagus.  You are no longer experiencing the pleasure of eating asparagus, but your body is still directly dealing with the consequences of your recent meal. This is the period of asparagus pee.

 

Addiction

 

Addiction, in this analogy, is represented by the degree to which you can resist the opportunity to eat your absolutely favorite food (in this scenario, asparagus) when it is available to you.

 

Detox does not change the underlying disease of addiction.

 

Detox is the biological process of substances exiting the body.  Unlike our asparagus example, detoxification from drugs or alcohol can cause severe symptoms of discomfort and abnormalities in the function of the brain and body that in some cases can even be fatal. The medical risk of detox is frequently the determining factor in whether  insurance will cover the cost of stay in a detox facility, or even if the facility will agree to admit the patient. Yet detox is often necessary in order for the patient to get “clear headed” and physically comfortable enough to participate in the work of recovery.  It is hard to learn new skills when someone is experiencing the acute pain of withdrawal, and even harder when someone is intoxicated. While detox is often a critical step to prepare someone for effective treatment, it does not “fix” the underlying addiction itself.

 

Effective addiction treatment actually does change the underlying biology of addiction.

 

Whether through counseling, medication treatment, lifestyle interventions or other processes, effective addiction treatment actually changes the underlying biology of the addicted brain. With treatment, the brain is able to return to what we consider more “normal” biological functioning. This is a gradual process in which the activity of areas of the brain which drive emotion and memory are essentially “re-balanced” with the activity in areas in the brain responsible for thinking and planning.

 

When addiction treatment is effective, instead of being driven by an overwhelming compulsion to use drugs or alcohol despite the client’s best intentions and knowledge of the painful consequences of use,  the client is able to regain the choice of NOT using drugs or alcohol.

 

This is much harder than it may seem, and it requires effort, attention, and patience. For many people, the shift away from the immediate gratification or relief from drugs or alcohol causes new difficulties or uncovers problems that were hidden by substance use. In addition, newly sober clients commonly struggle with shame and regret for their actions when they were in the active cycle of addiction.

 

Effective addiction treatment should include attention to the physical, mental and emotional aspects of recovery. Detox prepares someone to start that journey – it gets them to the door, but the client still needs to open that door and walk through it.

 

If only overcoming an addiction was as easy as giving up asparagus, right?

Picture of hopeful person

What does recovery mean in addiction treatment?

When we talk about recovery, what does that mean, really? Is it the absence of alcohol or drug use? Is it measured by reliably “clean” urine tests?  Is recovery a return to a prior stage, an effort to turn back time to happier days, or is it more like the concept of healing from an injury, like rehabilitation after breaking a bone? Is recovery a destination or a process?

 

The definition of recovery that most resonates with us at Triangle Wellness & Recovery
is from the Substance Abuse and Mental Health Services Administration (SAMHSA):

 

“Recovery is the process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.”

 

Recovery is an active, not passive, process. It takes effort and courage because change itself, even when it is “good” change, is something that we naturally recoil from. Change can be frightening.  For most of our clients, drugs or alcohol started to become a problem when they began to be routinely used as imperfect solution(s) to very real problems. This may take the form of self-medication, such as when a person uses alcohol to manage their anxiety, or opiates to distract them from emotional pain. In other contexts, drug or alcohol use seems to offer solutions to more practical problems. For some couples, drug use is such a core part of how they spend time together that they have a hard time imaging their relationship without drugs taking center stage.  In many jobs, such as sales, alcohol use is embedded into the business culture and people believe that in order to be successful they must fit completely into the expectations of their role.

 

Even before our brains start biologically adapting to the frequent presence of drugs or alcohol, our minds find ways to justifying NOT changing our behavior:

 

“If I don’t smoke marijuana, I won’t sleep.”

“If I don’t take my hydrocodone I won’t be able to get through the morning.”

“If I stop drinking, I won’t be able to wind down after a long day.”

 

In these situations, clients may feel threatened by the idea of giving up their drug and alcohol use, despite significant harms they have already experienced such as getting arrested for driving while intoxicated, or losing custody of their children. Drug use may have become such a core part of their self-image that clients are at a loss to imagine who they would be without their drug or alcohol use.

 

The litmus test for recovery cannot be based on substance use alone.
Recovery without joy, meaning or hope is just another form of suffering.

 

To be successful, addiction treatment cannot just focus on what our clients should stop doing, it must also provide a compelling vision of what their lives can be without drug or alcohol use and help them “lean into” the things that give them joy, purpose, satisfaction and security.

 

We believe that a recovery focused on health and wellness
enables people to reach their full potential.

 

Yet, many clients don’t believe that they “deserve” to reach their full potential. Shame and self-hatred overwhelm them, and even loved ones may believe that punishment must be prioritized over healing in order to prevent a return to drug use.  Punishment and restitution address the consequences of past harmful behavior, but they do not profoundly shape today or the future the way that recovery does. For those clients that believe their potential recovery to be a gift they are not worth receiving, I remind them of the hope and healing they can offer to those around them as they work through their recovery. Being a more loving and reliable parent, son or daughter, spouse or community member is a path to “pay forward” the gift of recovery.

 

You don’t need to prove that you are worthy for recovery.
You just need to take the first step towards hope.
Benzodiazepines xanax klonopin anxiety addiction

Xanax, Klonopin and other Benzodiazepines: How to treat Anxiety and Addiction

Benzodiazepines such as Xanax, Klonopin, Ativan and prescribed at alarming rate in this country, and  these prescriptions are disproportionally written for women, a trend that has remained constant since these sedatives first made it onto the scene in 1960.  The Rolling Stones memorialized Valium with their song “Mother’s Little Helper” in 1966. Like prescription opioids, benzodiazepines are  often less stigmatized than other drugs of abuse because they are prescribed by doctors, however the risks of benzodiazepines are  severe and like prescription opioids, many benzodiazepines purchased illicitly are actually counterfeit pills containing other ingredients, even including fentanyl.

 

Benzodiazepines are dangerously over-prescribed

 

Like prescription opioids, benzodiazepine can be clinically appropriate in specific situations including panic attacks and and short-term treatment of overwhelming anxiety or insomnia.  But also like prescription opioids, many people have been prescribed benzodiazepines for long-term use, often for years which led to a dramatic rise in benzodiazepine use and illicit misuse as pills are diverted and sold on the street. Benzodiazepines can be deadly form some when combined with prescription opioids, alcohol or other sedatives. While most people prescribed benzodiazepines do not become addicted to them, a significant minority do. For those fortunate enough to avoid addiction there are still lasting negative effects of chronic benzodiazepine use including problems with cognition and memory. For geriatric patients, benzodiazepines use is associated with increased incidence of falls, dementia, and an overall increase in mortality.

 

Similar to many other substances of abuse, benzodiazepines offer the false promise of an easy way out of anxiety, stress and emotional suffering. But for many people tolerance develops rapidly and safer and more effective treatments for chronic anxiety are ignored in favor of the immediate onset of action of Xanax or Klonopin. Once physical dependence develops, withdrawal from benzodiazepines can be especially brutal.  Instead of experiencing a return to pre-treatment levels of anxiety, people commonly experience both rebound anxiety and prolonged  symptoms of withdrawal which can last months. This is incredibly discouraging for individuals, who will often return to using benzodiazepines out of desperation. To make matters worse, rapid discontinuation of benzodiazepine can result in seizures and is even potentially fatal. Chronic, high dose benzodiazepine use should never be stopped abruptly without the close medical supervision that is available in a detox facility or hospital setting.

 

Detox is not treatment

 

Just as with other substance use disorders, it is the drug related adaptations in the brain  rather than the actual presence of drugs in the body that is the most challenging to treat.  Detoxification (or medically supervised withdrawal) is not an actual  treatment for addiction. During detox, drugs are essentially flushed from the body and because it is a closely supervised environment, this can provide window of sobriety and lay the groundwork for continuing treatment. Addiction is a result of changes in the structure and function of specific brain regions in response to repeated substance use – and these adaptations are slow to change.  This is what people who don’t understand the biology of addiction miss when they say things like “well, you just need to have more willpower” or “why don’t you just stop?”.

 

Treating addiction requires looking beyond the immediate effects of intoxication to the changes in the brain itself especially in the areas responsible for motivation and reward, emotion and memory. There is no quick-fix here. The process of changing the brain back to “normal” takes months, not days. This is work that can’t be “front-loaded”, which is why 28 day programs have such disappointing long term outcomes.  People need to practice recovery – live it daily so that new habits and thought patterns can begin to replace the destructing cycle of  compulsive drug use.

 

Keeping people in early recovery when they are addicted to Xanax or other benzodiazepines is hard

 

Treating persistent symptoms of withdrawal is a critical way to help  someone invest the time in recovery which is needed to actually heal the parts of the brain that drive addiction.  Because benzodiazepine withdrawal can cause  such long lasting symptoms of anxiety, insomnia, tremor and gastrointestinal upset, a significant part of treatment should be directed at reducing or eliminating these symptoms  in order for the patient to be able to fully participate in and benefit from therapy and other recovery activities. There are multiple ways to do this, including use of other medications, biofeedback, acupuncture, and therapy focused on distress tolerance and emotional regulation.  For people who have been taking high doses of benzodiazepines on a chronic basis, it may be actually be preferable to place them on a carefully designed taper which stabilizes then gradually reduces their benzodiazepine use over several weeks to months.  This can enable  the patient to stop using benzodiazepines while avoiding spikes in anxiety or insomnia. During this time, even though the brain is still exposed to some level of benzodiazepines, the cycle of addiction is able to be broken and replaced as long acting benzodiazepines gradually replace short-acting ones, distracting the brain from the constant need to maintain the quickly-fading effects of benzodiazepines like Xanax. As the total level of benzodiazepine use decreases, patients think more clearly, sleep better and are able to focus on building the foundation of successful life-long recovery.

 

 

There is no quick fix for benzodiazepine addiction, but there is effective treatment

 

Effective and long-lasting treatment of benzodiazepine addiction is possible. Find a doctor who understands the risks and benefits of different treatment approaches and who takes the time to explore the underlying reasons why you started taking benzodiazepines and how your use has changed over time. Most importantly, be candid and honest about which prescribed and non-prescribed medications you are taking and how much you are taking. This information is critical to developing a personalized taper plan that leads to long-term recovery.

 

At Triangle Wellness & Recovery PLLC,  we work with clients addicted to Xanax, Klonopin or other benzodiazepines. We specialize in treating clients who are struggling with more than one substance use disorder or addiction, as well as those also be living with mood, anxiety or trauma-related disorders,  and/or chronic pain.  We also help clients without addiction transition from chronic benzodiazepine or opioid use to safer treatment alternatives for anxiety, insomnia or pain. We customize a plan for each client and support them and their families throughout their journey. We love what we do, and it shows.

 

References:

Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies Markota, Matej et al. Mayo Clinic Proceedings, Volume 91, Issue 11, 1632 – 1639 https://www.mayoclinicproceedings.org/article/S0025-6196(16)30509-2/fulltext

 

Agarwal SD, Landon BE. Patterns in Outpatient Benzodiazepine Prescribing in the United States [published correction appears in JAMA Netw Open. 2019 Mar 1;2(3):e191203]. JAMA Netw Open. 2019;2(1):e187399. Published 2019 Jan 4. doi:10.1001/jamanetworkopen.2018.7399

 

A Fluyau D, Revadigar N, Manobianco BE. Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation. Ther Adv Psychopharmacol. 2018;8(5):147–168. doi:10.1177/2045125317753340

addiction learned behavior disease

Is Addiction a Brain Disease or Something that is Learned?

 

There is a debate in the addiction world about the whether or not addiction is an actual brain disease, or instead behavior that is learned (and therefor “un-learned”). The debate is more than academic – it significantly impacts how the public views and responds to people with addiction, how healthcare dollars are distributed and how people who are struggling with addiction view themselves. Until we had some of the advanced imaging technology that we have now, and especially before we had medications that effectively treated addiction, it was easier to argue that addiction is merely a result of behaviors and bad choices, poor coping skills that someone could replace with healthier ones using willpower alone.

 

Addiction as a disease

 

For some, the concept of addiction as a disease is profoundly demoralizing. It violates our belief that we are in control our lives, that our drive for self improvement can overcome any challenge we face, and that our minds and bodies are “normal”, not broken. Some say that calling addiction a disease is allowing “addicts” to avoid any personal responsibility. That it is a moral “get out of jail” card for people who have caused so much pain and suffering to those around them. It goes against the understandable urge to punish people who have hurt you or others.

 

For others calling addiction a disease implies that the only path to recovery is through medical care, which is especially infuriating in light of doctor’s responsibility for the current opioid epidemic. “Medication is what got us into this mess – medication sure as hell isn’t going to get us out of it”. I share their anger and frustration. I see patients everyday whose opioid (or benzodiazepine) addiction started with a doctor’s prescription. I understand the reluctance to trust the medical establishment and pharmaceutical companies to treat the very conditions they helped to cause. Their cynicism is well justified.

 

Addiction as a behavior

 

Then there are compelling factors that seem to support addiction as a behavior, something that one can chose not to do. Most of GIs who had been using heroin during the Vietnam war stopped using after returning home (though many did not). And there are no shortage of people in AA who assert that they stopped drinking only when they finally made up their mind to commit to sobriety, or that it was the spiritual act of turning their addiction over to a higher power that set them free. I have no doubt that both these acts played a role in overcoming their addiction(s).

 

Through advanced imaging technology, especially with the use of function MRI, we can now specifically identify how the addiction changes the structure and function of several areas of the brain. We can see in real time how the addicted brain over-responds to cues of drug use and under-responds to normally pleasurable stimuli.  We can actually see the decreased “braking power” of the part of the brain where planning, rational thinking and judgement reside. We can also see these changes reverse, slowly, with time and abstinence, or more rapidly in some cases in response to effective pharmacologic treatment.

 

Do changes in brain structure and function cause addiction, or are they merely the down-stream effects of repeated learned behaviors? 

 

This is like asking which came first, the chicken or the egg? The answer to this is both. The brain shapes behavior, and behavior shapes the brain.

 

 

The biology of the brain – determined by genetics, fetal development, early childhood, toxins and physical injury – determines how we respond to the world around us.  Someone who was born with an extra chromosome resulting in downs syndrome will have less cognitive ability than peers their age.  Someone who suffered a traumatic brain injury may show increased aggression or impulsivity. The brains of adults who suffered extreme childhood abuse or neglect show structural and functional changes in areas of the brain related to memory, emotion and attention. In people with severe addiction, the biological response to repeated substance use is no less significant. The brain can be injured by being deprived of oxygen during an overdose or stroke, or from the direct toxic effects of alcohol or inhalants. But addiction itself is a condition different from toxic effects on the organ of the brain.

 

Addiction as mis-learning

 

 

It is the changes in the function of specific pathways that drive maladaptive and self-destructive behaviors of people with addiction. This superhighway system of the brain connects decision making with motivation, reward and memory.  And in fact, this path is also critically important for a specific type of learning we call “reward-based learning”.  But for people who develop addiction, substance use doesn’t just use this superhighway to “learn” to use substances to improve mood or treat discomfort, it CHANGES the superhighway itself.  It is as if drugs or alcohol block off 5 lanes of a 6 lane highway for their own use.  Like racing sport cars, signals fire and are received rapidly, and through this process the brain is “learning” really well that substance use = positive reward. But what about the other signals that need to get through? What about the delivery trucks and school buses and station wagons? These signals represent reward-based learning that takes place normally through the course of our lives: how holding our children close releases feelings of pleasure and connectedness, how sweet desserts delight our senses, how after a run we feel somehow more confident and more alert and how when we hear that one song we feel as though the music is touching our soul. These vehicles are now stuck in single-lane bumper-to-bumper traffic. Compared to the guys in the sports cars (the drugs in this analogy), the other drivers and passengers (things that are naturally rewarding) aren’t going anywhere anytime soon.

 

So addiction develops when the brain’s “normal” biological pathways for learning are effectively hijacked by substances that are able to deliver a much, much more intense reward than the things that we normally learn through this pathway. The catch is that in addition to just using these pathways for “learning” drug or alcohol use, it becomes MUCH harder to learn or re-learn the healthy activities that bring us pleasure. As discussed above, people have different brain biologies, and some of the variations can make it much more likely for someone to become addicted. This is especially true in cases of adults with history of childhood trauma, or people with a strong family history of addiction. Stopping the use of an addictive substance or behavior is not as simple as just replacing it with another coping device. The brain is frustratingly resistant to this “unlearning”, not because the person doesn’t want to stop drinking or taking drugs, but because they have “learned” that behavior so well that it is now essentially automatic. What was voluntary substance use is now a compulsive cycle of cravings, using and recovering from drug or alcohol use compounded by shame and grief.

 

Can someone “unlearn” Addiction?

 

 

There are non-medical treatments that can help people to achieve and sustain their recovery. Various types of individual and group counseling, peer support groups, mindfulness training, acupuncture and other interventions have been shown to be effective to varying degrees based on the population and addiction(s) studied. The question here is really whether people can change the function of their brain without requiring medical treatment such as medication.

 

The answer is “yes…but…”

 

… for some people it will be much harder, more painful and take longer than for others

… the ability of the brain to re-model itself is extremely reduced in the presence of chronic stress, malnutrition, poor sleep, depression and other factors

…while someone is still fighting addiction they can (continue) to cause severe harm to themselves or others (car accidents, overdoses, emotional pain, etc.)

 

We treat other biological conditions with medicine that reduces the symptoms of disease or reverses the course of an illness without hesitation, why wouldn’t we extend the same compassion and concern to those struggling with a brain disorder? Most people now accept that antidepressants are a valuable tool for many to recover from depression and lead full lives, why do we not treat medication for addiction the same way?

 

For many addictions there are no pharmacologic treatments that have been shown to be safe and effective and approved by the FDA. Most of the prescriptions that I write in my own practice are to treat co-occuring disorders like depression, anxiety, or chronic pain that when left untreated worsen the chances of recovery from substance use or addictive behaviors.  But in cases where there is safe and effective treatment, I stress to my client that taking medication does not in anyway mean that they are “less than” someone who is in recovery without the benefit of medication. Recovery is about building a healthy life that has joy and meaning and purpose. It is just as precious whether you get there with or without medication.

 

Back to the question: do we call addiction a disease?

 

 

From my perspective, whether to call addiction a disease or learned behavior is much less important than working individually with each client to support them on their journey to recovery. I take my cue from my client. Classifying addiction as a disease can reduce shame and open the doors to effective treatment.  Calling addiction something that is “learned” gives people hope and motivation to change things in their own life to support recovery. Either way, we must insist on treating people with compassion and respect, cultivating hope and helping them let go of feelings of shame and worthlessness.  We should generously share our knowledge and expertise and support them on their chosen path to wellness. As doctors we owe this to them, and to ourselves.

 

 

References:

Fowler JS, Volkow ND, Kassed CA, Chang L. Imaging the addicted human brain. Sci Pract Perspect. 2007;3(2):4–16. doi:10.1151/spp07324

 

Noël X, Brevers D, Bechara A. A neurocognitive approach to understanding the neurobiology of addiction. Curr Opin Neurobiol. 2013;23(4):632–638. doi:10.1016/j.conb.2013.01.018

 

Dikmen Sureyya, Machamer Joan, Fann Jesser, Temkin Nancyr. Rates of symptom reporting following traumatic brain injury. Journal of the International Neuropsychological Society. 2010;16(3):401-411. doi:10.1017/S1355617710000196

 

Teicher, M., Samson, J., Anderson, C. et al. The effects of childhood maltreatment on brain structure, function and connectivity. Nat Rev Neurosci. 2016;17:652–666 doi:10.1038/nrn.2016.111

 

Lewis, Marc. Brain Change in Addiction as Learning, not Disease. The New England journal of medicine 2018; 379(16):1551-1560. 10.1056/NEJMra1602872

x-ray-of-woman-with-pain-in-upper-back

Chronic Pain and Opioid Addiction Treatment

It is estimated that around 30% of people who are addicted to opioids also struggle with chronic pain. Many of these individuals became addicted when they were prescribed opioids for their pain. When I was in medical school, we were taught that if the opioids were prescribed for “legitimate” pain then the patient wouldn’t become addicted to them. That message was wrong; it led to wide-spread over-prescribing of opioids across the country, and led us into the opioid epidemic that we face now. Nearly 70 thousand people died from opioid overdoses last year, 2018, which was actually an improvement from the year before, when the number of opioid deaths in the United States was equivalent to the deaths on 9/11 every three weeks.

 

Patients with chronic pain and opioid addiction are shuffled from doctor to doctor

 

Opioid prescribing practices have changed, dramatically in some areas of the country. That has resulted in fewer prescription opioids available on the street. It has also led to a frightening increase is counterfeit prescription opioids and heroin use. 

 

Many people with living with chronic pain are facing dramatic reductions in their pain management treatment. While there is an increase in awareness and identification of opioid addiction in patients being treated for chronic pain, many doctors are unsure how to treat these patients. They discharge or transfer patients to other providers who may have a better understanding of addiction, though they may not know how to effectively treat chronic pain. Patients can end up seeing multiple different providers without finding a doctor with the skills, compassion and commitment to treat these complex issues.

 

Many people living with pain are being under-treated or not treated at all

 

Doctors in pain management and primary care now often use screening questionaires to attempt to identify which patients are at higher risk for developing opioid addiction. While this is  well-intentioned, it leads to a false sense of security when prescribing opioids to people who do not provide certain answers to the screening questions; and it can also result in critical opioid treatment being denied to patients with severe acute pain. In fact, a recent review in the Journal for the American Medical Association (JAMA) concluded that all of the currently used screening tools showed poor accuracy in identifying patients as having a high- or low-risk for opioid addiction.

 

Chronic pain, addiction and emotional suffering must be treated at the same time to provide the best chances of healing and recovery

 

Research is clear that for best patient outcomes, chronic pain and addiction must both be addressed in treatment. Just because someone has  an opioid addiction does not mean that they don’t have chronic pain. These two conditions co-exist quite frequently and each worsens the treatment outcome of the other. There are even shared biological circuits in the brain between physical pain, withdrawal,  and emotional suffering. So sometimes the boundaries between these conditions become difficult to identify – for the patient AND the doctor.

 

So how do patients find help?  How can patients get treatment for  both addiction and chronic pain at the same time? Finding a doctor who takes the time to listen and understand the whole picture is difficult. Finding a treatment center that offers treatment beyond medication and injections can be difficult as well. Patients can wait months for a new client appointment, only to leave feeling frustrated, hurt and hopeless.

 

Treatment should be about more than just medication

 

There is no one-size-fits-all solution, but there are best practices in the evaluation and treatment for chronic pain that both patients and doctors should be aware of.  Pain management doctors should be knowledgeable about non-opioid and non-pharmacologic treatments for pain and offer or know where to refer patients to access these treatments. These treatments do not interfere with addiction treatment and can even reduce the symptoms of addiction and decrease the risk of relapse. In addition to physical therapy, these should include other evidence-based treatments.

 

Evidence-Based Treatments

 

– Cognitive behavioral therapy (CBT), Acceptance and Commitment Therapy (ACT)  or other behavioral therapies with strong evidence for effectiveness in treating chronic pain

– Mindfulness training and gentle movement found in some forms of yoga and Ti Chi

– Biofeedback training that can be learned in the office and practiced at home between visits

– Nutritional therapy to focus on foods, vitamins and supplements especially for pain due to inflammatory conditions such as auto-immune arthritis or ulcerative colitis

– Weight loss programs for patients with obesity to decrease strain on painful joints or other parts of the body

– Acupuncture for muscle pain, arthritis or migraines

– Peer support and group visit formats focusing on lifestyle interventions and coping mechanisms for living with chronic pain

 

There are effective medications that treat both pain and opioid addiction

 

Many patients with chronic pain and opioid addiction are terrified to give up their pain pills because they fear their pain will get worse. Others may have been taking opioids for so long that changes in the brain make it nearly impossible for them to resist cravings for opioids, especially in times of increased pain or stress.  While my practice emphasizes non-opioid and non-pharmacologic treatment of chronic pain for the majority of patients, for several patients, treatment with buprenorphine, which is the active ingredient in medications that are FDA approved for chronic pain as well as medications FDA approved for treatment of opioid addiction. 

 

Buprenorphine is classified as an opioid but it works differently than other “full strength” opioids. Buprenorphine blocks the effects of these other opioids while at the same time treating symptoms of physical withdrawal, craving and pain. It is one of the medications that are considered the “gold standard” for opioid addiction, but unlike methadone patients get in as a prescription and take it at home just like other medications, and unlike naltrexone (Vivitrol) it provides pain control. Buprenorphine is marketed to pain patients and providers in certain forms that cannot be legally prescribed to treat co-exisiting opioid addiction and it is marketed to treat opioid addiction in a different form that can be legally prescribed to treat both pain and addiction (Suboxone or Subutex). This situation creates some confusion among both doctors and patients and increases the stigma of taking a medication which contains buprenorphine.

 

Find a doctor who looks beyond the quick-fixes and takes the time to listen and understand

 

Treating patients with chronic pain and addiction is challenging, but also intensely rewarding. It takes time to understand all of the different factors that impact a person’s pain and opioid use. Maybe more importantly, it takes time for a new patient to trust that the doctor they see won’t reject them or dismiss their concerns. 

 

At Triangle Wellness & Recovery PLLC we are passionate about providing the highest quality personalized care to people living with chronic pain. This includes both prevention, and treatment of opioid addiction or other substance use disorders. We understand how pain and addiction can create a frightening cycle that it is hard to escape from. We’re here to help you reclaim your life.

 

Sources:

CDC – Opioid Overdose

NIH NIDA – North Carolina

NC DHHS

What Is Integrated Care vs. Integrative Care

Integrated vs Integrative – What’s the difference and why it matters in treatment for addiction, chronic pain, and mental health.

 

At Triangle Wellness & Recovery PLLC we provide both integrated and integrative care to individuals struggling with addiction, chronic pain or other mental health conditions, but what does that mean exactly?  Based on my observations, most people, including individuals who work in the healthcare field, use the two terms interchangeably. But they are actually two distinct approaches to care, which can be combined to deliver an extraordinary level of person-centered care.

 

Integrated care is collaborative, team-based care with two or more specialties working together.

 

Integrated care refers to having clinical staff with different areas of expertise working together to coordinate patient care and, in the best cases, collaborate on treatment plane.  An example of this is a pediatrician’s office that has a psychologist on staff who performs assessments for ADD/ADHD and sees patients within the same practice. Another example is an orthopedic surgical practice that employs physical therapists to help patients regain their strength and mobility after surgery. In practices which operate with an integrated care model, there is greater communication between providers and less chance that important aspects of your treatment or monitoring will “fall through the cracks”. 

 

Integrative care doesn’t limit itself to conventional medical treatment options.

 

Integrative care refers to incorporation of evidence-based recommendations and treatments that (currently) fall outside of the scope of the main-stream western medical approach.  These types of treatments are collectively referred to as “complementary medicine”. The boundary between main-stream medical care and complementary are is a moving boundary as the culture of medicine and the training of doctors adapts to reflect current clinical research.  One of the leading indicators of inclusion of a treatment modality into the western medical world is when a service starts being covered as an “in-network” benefit or eligible for reimbursement as a health care expense. A good example of this is acupuncture for chronic tension or migraine headaches or massage therapy for fibromyalgia. Many clinicians now routinely recommend supplements such as omega-3 fatty acids for vascular health or mindfulness practice for anxiety. 

 

assembly of wild healing herbs representing alternative treatments

 

Integrative physicians help you understand and choose from complementary or alternative treatment options in addition to main-stream western medical options.

 

Integrative health care is NOT the same as alternative health care. This distinction is crucial to understand when searching for a treatment provider.  An integrative physician combines or substitutes evidence-based (but non-mainstream) recommendations and treatments with conventional medical practice. In many cases, natural alternatives to medications are safer and as effective as conventional medicines. In contrast, an alternative practitioner exclusively provides care that falls outside of the mainstream of medical practice. There are several areas of alternative health care, some of which have significant clinical research backing their safety and efficacy, and some which do not. Nearly all alternative health care practitioners lack medical training and therefore do not have the expertise or licensure to practice medicine and cannot compare the risks and benefits of alternative treatments to conventional medical approaches.

 

At Triangle Wellness & Recovery PLLC, we partner with you to create your personalized treatment plan for recovery and wellness

 

How does this apply to Triangle Wellness & Recovery? We are integrated; our team is composed of both medical and behavioral specialists who work together to develop treatment plans and provide clinical services.  We are also integrative; in addition to providing high quality western medical and psychiatric treatment approaches to care, we also use evidence-based complementary treatments such as biofeedback, nutritional and supplement counseling and mindfulness. We offer more than just one perspective on health, recovery and wellness. We empower you to ask questions and choose options that speak to your values and preferences. There is no single “right way” to recovery from addiction, chronic pain or mental illness, and as we say in our practice, we have no plug-n-play solutions.  We build treatment plans for each client from the ground up, working with you each step of the way, because we believe that is how to provide care that is truly transformative.