The David Sheff Solution - Page 2

By John Lavitt 10/24/14

Author David Sheff on the stigma of addiction, the concept of rock bottom, the rise of video game addiction, and how to help the most vulnerable among us, in The Fix Q&A.


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In your Yale Department of Psychiatry Grand Rounds Lecture, you made two powerful statements that seem intimately related. The two statements are as follows: First, “People in pain are desperate for relief,” and, second, “Stress is related to addiction on the most primal level.” Given the overwhelming prevalence of stress and the pressures of a consumer society that manipulates people to consume beyond their needs, isn’t drug abuse a given? Is there any way to avoid addictive uprisings like the recent plague of prescription painkiller abuse in such a society?

What you just described explains the reason behind the prevalence of the disease in the United States. Twenty-three million people addicted is the official number they give, but the actual number could be much higher. Life is really, really hard, and the stresses are enormous. People are overwhelmed, and it starts at a very young age. Kids are overwhelmed so it makes sense that they go out and want to get high. If you get high, the stress evaporates, at least for a little while. Drugs can provide a temporary escape from depression and anxiety; they're a temporary solution to real problems for many people. But that solution ends up leading to greater stress and ultimately addiction. Stress and addiction are related on the most primal level.

The disease of addiction is hard enough to deal with for people who do have resources. There are good community programs in some places and there are 12 step groups everywhere, but the chances are very bleak for people without quality health care. 

The reason that everyone isn’t addicted is because everyone’s different. Some people are more resilient and protected against addiction just like they are against other diseases. There’s no specific recipe that causes any one individual to become addicted. Some people can become addicted with only a single or even without an apparent risk factor. Others have multiple risk factors and never become addicted. But risk factors increase the likelihood that an individual will become addicted. Stress is just one. There is often a genetic component. Beyond that, people with mental illness or psychological or neurological disorders are at higher risk. Those with learning disabilities are subject to a heightened risk. Stress can come from something obvious, like physical or sexual abuse, or something subtler, like divorce and families where there’s constant discord. It’s no surprise that poverty is a risk factor. 

The manner in which our neurological systems respond to chemicals explains why not everybody gets addicted. At the same time, addiction is not the only negative reaction to stress. There are people who don’t become addicted, but are suicidal. Twice as many people are killing themselves now than did only ten years ago. What’s that all about? The levels of binge-drinking and sexual assaults on college campuses have greatly increased. Is that related to the level of stress that is being generated by our present culture or are there other factors that we haven’t identified? 

In a recent article for Time Magazine, "If You Want to See Inequality in the U.S. at Its Worst, Visit an Impound Lot," you wrote: “We must also acknowledge and condemn the daily injustices born of a system that slowly grinds down the people who can least afford it, and, in too many cases to count, leads to their early death.” How can the battle for addiction be won in a country where such inequality seems to be the name of the game?

First of all, it’s why the challenge is so formidable. There are so many people from a socioeconomic perspective that are so vulnerable. I got a glimpse of the impact of socioeconomics recently when my car was towed in San Francisco. I went to the impound lot and gave the clerk my credit card. I was charged an outrageous fee—about $475—and went on my way. But the office was filled with people without credit cards or the ability to get that much cash. 

People were weeping and pleading and were completely distraught because they couldn’t get their cars. These people needed their cars to get to work or to pick up their kids from childcare or daycare. Many of them would never be able to get their cars. The frustration people feel. The constant wearing down by an injustice of the system toward the people who can least afford it. Sometimes, I’m amazed that there isn’t more addiction and other results of stress.

The question is how do we help people who are vulnerable? Yes, we want them to have access to schools and doctors who can detect problems early and intervene, but that’s not enough. We have to help kids and help families, and that involves a whole array of social services that either do not exist now or are hanging on by a thread and are threatened because of budget cuts. All of the organizations that potentially could help these people are being forced to operate on shoestrings. It’s a great challenge. It’s part of what underlies addiction and other specific disease.

People are desperate to get treatment for their own addiction or a child’s addiction. They constantly contact me, but they don’t have money or decent insurance or any insurance at all. The disease of addiction is hard enough to deal with for people who do have resources. There are good community programs in some places and there are 12 step groups everywhere, but the chances are very bleak for people without quality health care. As a culture, it’s unconscionable that we let so many people fall off the grid and enter into a spiral that makes everything worse in their lives. The suffering is incalculable.

With the Affordable Care Act now in place and in full swing, do you think it is hurting or helping addiction treatment options? It appears that many of the insurance offerings under the Affordable Care Act are trying to opt out of extensive addiction treatment coverage. You recently said, “The Affordable Care Act should help on the treatment end, but people have to hold the government accountable for making sure the law does what it's supposed to do.”

What is the Affordable Care Act supposed to do in terms of treatment options for addicts and alcoholics? Given your past hope that the ACA might change the landscape of addiction treatment in the United States, what’s your present perspective and what do you believe should come next? 

I think the Affordable Care Act is a profound, almost miraculous step forward. Suddenly insurance plans have to cover addiction treatment and other mental illness treatment at the same rates--in parity-- as treatment for any other disease. In theory, it’s great, and we have never had that before. If addiction was covered at all, it was always covered inadequately. Always. 

Now, insurance companies are supposed to pay for comprehensive addiction care, but I have heard two different things about what is happening. First, in some places, I’ve heard that the Affordable Care Act has actually hurt programs, because plans are paying at lower rates than they’ve paid for in the past. We have to hold our legislators’ feet to the fire and have them fix the law where there are problems and enforce regulations. On the other hand, I’ve visited community-based treatment centers that provide a vast array of services that have told me that they now get a much larger reimbursement than ever before; much higher rates per person per day that they are actively treating for addiction. It’s a huge step forward because that means they’ll be able to offer better services to more patients with a better-trained staff. 

As importantly, with more people covered, more people will have access to treatment for themselves and for their loved ones. At the same time, insurance companies will demand that programs provide evidence-based treatment, not a haphazard collection of treatments that have little or no efficacy. Programs will adapt and provide evidence-based care or they’ll go out of business. 

I recently interviewed some of the top addiction researchers in the country: Professors Richard Rawson, M. Douglas Anglin and Michael Prendergast of the UCLA Drug Abuse Research Center. In talking to them and learning about their findings, it baffled me how their cutting edge work on addiction treatment and ways to improve recovery outcomes is largely ignored by the treatment industry. 

Why are the majority of providers in the addiction treatment industry so resistant to the expertise of these top researchers? If you were given the power to change the addiction treatment industry, what would you do beyond licensing and basic regulation? What other improvements need to be made? 

The resistance is there because people are threatened and people are uneducated. Traditional programs are almost all based on the 12 steps. The people running those programs are often devoted to helping others, but only know a single treatment paradigm -- often the one that helped them, which is most often the 12 steps. They don’t want to change because they simply do not accept that there are other options beyond the 12 steps. They mistakenly believe that other treatments threaten the 12 steps, whereas they can co-exist. If they offer behavioral treatments and psychopharmacology when it’s appropriate, particularly when it comes to opiate addiction, they are going to realize that they’ll be able to save more lives. 

A positive example of change can be seen at Hazelden under the direction of Dr. Marvin Seppala, its chief medical officer. Hazelden is ground zero for the 12 step treatment approach, and the Minnesota Model, which is based on 12 steps, is the most prevalent treatment model around the country. I have a lot of personal experience with their approach. Nic was in 2 Hazelden programs. 

As Hazelden's medical director, Dr. Seppala was frustrated that people would do well in treatment, but relapse soon after they were discharged. Many of those with opiate addiction would leave, relapse, and in too many cases, die. Acknowledging that they were losing too many people, Dr. Seppala investigated other options. Hazelden, like many similar programs around the country, had rejected the use of medications, like Suboxone. But the research showed that the medication was extremely effective. Since Hazelden is a major influence in the addiction-treatment field, Dr. Seppala’s decision has far-reaching implications. Other programs will follow suit. As a result, lives will be saved. 

From a traditional 12 step perspective, you don’t treat drug problems with drugs. But in some cases, you do. 

You recently did a podcast interview with Dr. Drew Pinsky where you discussed your latest work. Despite his powerful presence in the popular culture, Pinsky is a divisive figure in the addiction field because of his popularization of the treatment industry through the reality series Celebrity Rehab with Dr. Drew, Sex Rehab with Dr. Drew, and Sober Living with Dr. Drew. How do you find a balance between interacting with this popular culture side of the treatment industry and your criticism of the treatment model for addiction in the United States?

Anything that exploits addiction - makes it funny and fun and light-hearted – is beyond counter-productive. It’s dangerous. Sensationalizing a disease is harmful. On the other hand, portraying addicts for what they are, people with a serious illness—mostly, people—is useful. When--whether on television or interviews or elsewhere--people come out and speak about their recovery in public, it’s truly helpful. People know they aren’t alone. They know they can get help. They may seek treatment. For instance, Mackenzie Phillips works with the Pasadena Recovery Center, and she’s been a powerful advocate because she’s very open about her own recovery. I’ve heard from people in recovery who were inspired to go into treatment after hearing her speak. 

My only criticism of Dr. Drew himself is specific. His thinking on this may have changed, but I’ve heard him tell people that they shouldn’t take drugs, like Suboxone. He’s a firm believer in the 12 steps, but suggests that addiction medications are anathema to being sober and staying sober, but they aren’t. Thank God for the 12 steps -- they have saved countless lives, but they are no longer the only treatment method. Everyone is different.

The problem is that whenever anyone, including myself, is given a public platform, desperate people tend to believe. We should all be called to task if we espouse treatments that aren’t effective, discount ones that are, or suggest that there’s only one way to treat a given person.

When you wrote “Game Over: How Nintendo Conquered The World,” you described how the Japanese company came to earn more money than the big three computer giants or all Hollywood movie studios combined at the time. Given that more American children recognize Super Mario than Mickey Mouse in addition to the rise of the new consoles like PlayStation and Xbox 360, do you think video game addiction is a serious problem that needs to be addressed? Does it place young people at significant risk and can it be compared to drug addiction? 

There’s no doubt that video game addiction is real. The rush of dopamine that goes along with the kind of neurological stimulation produced by video games can become addictive to some people. There is a compulsion to use despite dire consequences to a person’s life. People who get into that destructive spiral need help, and there are programs that address video game addiction and other forms of addiction as well. 

Still, there is a big difference between behavioral addictions and drug addiction. Drugs are toxic chemicals that change the way the brain functions. As opposed to the external stimulation of video games, drugs directly alter neurological function. That damage can’t be underestimated. I don’t want to minimize video-game addiction--the pain experienced by a person – but there isn’t the physical withdrawal and detoxification required in regards to drug addiction. It also takes a long time to recover from some drug addictions because the damage is severe. A doctor explained to me that it can take up to two years of continuous sobriety for the brain of a methamphetamine addict to return to so-called normal. 

The good news is the brain almost always will repair itself - it’s incredible how resilient the human brain is. Too many people are being lost to this disease, and too many lives are in jeopardy because they’re unable to access the help they need. It’s changing, but way too slowly. At least after decades of ignoring addiction, the country is waking up to a disease that’s crippling us. It’s a time when addicts and their families have a reason to be hopeful.

John Lavitt is a regular contributor to The Fix. He last interviewed Professors Doug Anglin and Michael Prendergast.

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Growing up in Manhattan as a stutterer, John Lavitt discovered that writing was the best way to express himself when the words would not come. After graduating with honors from Brown University, he lived on the Greek island of Patmos, studying with his mentor, the late American poet Robert Lax. As a writer, John’s published work includes three articles in Chicken Soup For The Soul volumes and poems in multiple poetry journals and compilations. Active in recovery, John has been the Treatment Professional News Editor for The Fix. Since 2015, he has published over 500 articles on the addiction and recovery news website. Today, he lives in Los Angeles, trying his best to be happy and creative. Find John on Facebook, Twitter, and LinkedIn.