Medication-Assisted Treatment is Not Enough

By Dr. Richard Juman 12/22/16

A double-board certified addiction medicine physician believes that 12-step programs are a critical part of recovery.

Medication-Assisted Treatment is Not Enough
A little support helps the medicine go down.

Russell Surasky, MD, who is board-certified in Neurology as well as in Addiction Medicine, is certainly well-versed in the pharmacologic treatment of addiction. And yet he is also a passionate believer in 12-step programs for his patients, calling them the “gold standard” when it comes to achieving stable recovery. For more on his treatment approach and philosophy, see below.

Richard Juman: It's interesting that a double-board-certified addiction medicine physician, who is obviously well-versed in the role that Medication-Assisted Treatment now plays in many treatment episodes, is also passionate about the role of 12-step programs in a recovery plan. Can you describe your general theory about the development of addiction and your philosophy of treatment? 

Russell Surasky, MD: Individuals often seek drugs to escape from their underlying psychological and emotional conflicts. When this behavior occurs enough times, then significant neurological changes occur in key regions in the brain, causing addiction to set in. Once addiction begins, the brain prioritizes the importance of using drugs at the same level as survival behaviors including eating food and drinking water. This is why those suffering from addiction will often keep using drugs despite the continuous and horrendous consequences that they face. Left untreated, many will use drugs until death.

These brain changes are not permanent but rather can be reversed with the proper treatment. The ability for the brain to reorganize itself by forming new neural connections is called neuro-plasticity. A person’s genetics determines how much exposure to the drug needs to occur before addiction takes hold. 

RJ: What would you say are the most significant recent pharmacologic and medical advances for treating the brain changes in addiction, and how do you incorporate them into your practice?

RS: The biggest changes have come in the treatment of opioids, as we respond to the opioid epidemic. After as little as a few weeks of use, opiates "hijack" the limbic system of the brain to the point that it needs the drug for survival, and the compulsion to continue taking the drug becomes overwhelming. Withdrawal and counseling aren't enough. Unless the neurological changes to the brain can be reversed, those cravings may persist for a lifetime. One of the newer and most effective treatments is Vivitrol, an extended-release medication that is injected once a month and immediately stops cravings.

Vivitrol is a safe medication that helps the brain to heal from the changes that have occurred during the drug use. Vivitrol itself is not an opioid, is not addictive and does not cause dependence. Vivitrol is an “opioid antagonist,” meaning it binds to the receptors in the brain and prevents opioids from acting on the receptors. By blocking that attachment, Vivitrol prevents the pleasurable opioid effect and reduces cravings for the drug. A patient on Vivitrol who does take opioids does not get high, does not get sick, and does not crave drugs. Treatment is individualized for each patient to ensure that the psychological and behavioral aspects of the disease have been adequately addressed and the individual has developed the life skills needed to remain drug free. Drug addiction destroys lives and families. Medication-assisted treatment can heal the brain by undoing the neurological damage opioids have inflicted, and along with ongoing behavioral therapy offers patients a lifeline and the hope of a permanent recovery. I believe that Vivitrol represents a giant leap forward in helping those suffering with addiction. By any measure by which you could measure recovery, the results that I have seen in practice have been incredible. However, medication by itself without counseling, is very often a failure.

RJ: Given your view of addiction as a brain disease, how does your view of the importance of 12-step programs for your patients fit within that paradigm? 

RS: Simply being abstinent from drugs is not recovery. In most cases, patients who were dependent on drugs have learned the behavior of "escaping" chemically from every stressor or uncomfortable feeling. If those who were addicted to drugs don't learn to live life in a healthier manner, the chance of relapse is significantly higher. Completing the 12 steps includes a tremendous amount of self reflection and growth. Learning to avoid triggers, establishing a sober network of friends and companions, and developing healthy coping mechanisms are critical to maintaining sobriety. 

RJ: What do you think are the mechanisms that make 12-step groups so powerful?

RS: The foundation of its model is that through regular meetings and sharing experiences, people can help each other achieve and maintain abstinence from the drugs to which they are addicted. Twelve-step programs provide structure and support, both critically important for people who are recovering from addiction. The opportunity to connect with others facing a similar challenge and the bonds that develop as a result of sharing common experiences are a vital aspect of the recovery process and have lasting benefits. One of the most important bonds forged in a 12-step program is with a sponsor, a recovering addict who becomes a key support, helping the new member navigate the steps, and offering friendship and advice in difficult moments.

These programs work. The challenge of recovery and establishing a drug-free life can feel overwhelming. A 12-step program is a tried-and-true therapy that helps people accept responsibility for their behavior and accountability for their lives going forward.

RJ: Given that 12-step programs emphasize abstinence as the route to recovery, is it also your view that abstinence (as opposed to moderation) is the only path to recovery? 

RS: Abstinence is a critical part of true recovery. Mood-altering substances of any kind must be avoided. My experience, as well as a large number of clinical studies, shows that patients are far more likely to relapse back into their addiction if they continue to use any mood-altering substances. These drugs disinhibit and distort our brain's ability to properly assess situations and make good choices. It is often the case that patients in early recovery believe that they can use drugs other than their "drug of choice." For example, I have seen many patients who believe that they can continue to drink alcohol because their main addiction is opioid drugs. In the vast majority of cases, these patients, when inebriated, will ultimately seek out and use their drug of choice.

RJ: How do you see the role of psychotherapy, both group and individual, as part of addiction treatment, and do you offer them as part of your treatment? 

RS: Of course there are many different forms of psychotherapy. I believe very strongly that specifically psychoanalytic psychotherapy is detrimental to a patient who is recovering from addiction. At its best, this mode of therapy suppresses the analytical strength of the cortical brain. The thinking, planning, rational, reasoning part of the brain (cortex) is the strongest protection an addict has for reining in the cravings of the addicted limbic system. 

Psychotherapy in general, however, can be very helpful. The CDC has the Childhood Adverse Events Study posted which shows that a score of 4 or higher (adverse childhood events) correlates with the onset of addiction. Many patients with addiction have traumatic histories and are in need of emotional healing. Other patients are prone to anxiety, depressive and/or mood disorders. Counseling, often in conjunction with medication, can be very helpful for these patients.

RJ: I'm curious about the idea that psychoanalytic psychotherapy is detrimental to recovery. You point out that adverse childhood experiences are one of the core elements of addiction, and wouldn't psychodynamic therapy be a good technique for understanding their impact? Or would you say that psychoanalytic work is not helpful in early recovery but that it might play a role later on, when a stable recovery has been established?

RS: It is likely that adverse childhood experiences become etched into the amygdala indelibly. Additionally, this is where the circuitry of addiction takes hold. The best weapon against addiction is strengthening the rational capabilities of the prefrontal cortex to calm the emotional centers of the amygdala. It is my understanding that one of the possible effects of psychoanalysis is that it can reduce the analytical activity of the cortex. Much of the ideas behind how this mode of therapy works are hypothetical, which makes this a difficult hypothesis to study. I am not an expert on psychoanalysis and so I am certainly open to hearing critiques of this concept.

RJ: Thank you very much for your time, Dr. Surasky.

RS: You’re very welcome, thank you for allowing me to participate in this interview.

Dr. Russell Surasky, FAAN, ABAM, is a Board Certified Neurologist as well as a Board Certified Addiction Medicine Physician. He operates the Surasky Neurological Center for Addiction in Great Neck, New York. Utilizing unique medication protocols individualized to each patient, he provides specialized treatment for opiate, benzodiazepine, and alcohol addiction.

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.