Wednesday, November 11, 2009

Private Outpatient for Opiates, Done Right

Prescription drug abuse, especially by young people, is on the rise, and opiates like Vicodin and Oxycontin rank high on the list.  People with chronic pain all too often end up addicted to their medications.  People who got into  heroin or other opiates for recreational use or to self-medicate some psychic hurt frequently find themselves in deeper waters than they ever intended.  We meet all these people, among others, in LifeRing meetings, and one of the big concerns for them is anti-addiction medications.  In the past, the most common medication to treat opiate addiction was methadone.  Methadone continues in use, but buprenorphine (byou-pruh-NOR-feen) is the new kid on the block, and both physicians and patients are picking up on it because it's easier to administer, has fewer side effects, and less potential for abuse than methadone.  Buprenorphine is being used both to detox the person addicted to opiates and in some instances as a maintenance regime.

It isn't easy for the person who wants to address an opiate addiction to find proper care.  Apart from a few outstanding practitioners like Dr. Howard Kornfeld in Mill Valley, the patient who is without Kaiser coverage may not find any place to go.

That's slowly changing, as both physicians and patients become educated about new addiction pharmacology.  One of the bright signs of change in the field is the opening of Reliance Center in San Francisco.  Located on the third floor of the beautiful old 450 Sutter Street building, a block north of Union Square, this new outpatient clinic brings together a very high powered medical and counseling staff in a comfortable, almost living room atmosphere.

Putting physician and counselor on the same team tells me that these folks really "get it."  You need both the medical doctor and the empathetic psychological advisor to deal with an addiction.  I had the opportunity to meet and to look up the resumes of the key staff.  Dr. Carrie Schuman, Medical Director, has treated people with opiate dependence for more than 25 years.  She's a leading member of the California Society of Addiction Medicine and a member of the national addiction medicine group.  This physician knows what she's talking about when it comes to opiate addiction, and she also projects a warm, caring, nonjudgmental attitude.  On the counseling side, there's Lubov Smith, a Licensed Marriage and Family Therapist, who comes to the Reliance Center from years as Executive Director of the Henry Ohloff Centers, one of the oldest addiction treatment programs in the area.  She's bright, funny, and very knowing.  If I had an opiate addiction issue, I'd put myself into the hands of this team without hesitation.  Check them out at

Professionals who include pharmacological tools in their recovery approach are often pleasantly surprised to learn that abstinence support groups exist that are open to patients who are taking these medications.  More than ten years ago, the medical director of a local treatment facility complained to me about the "G**damn 12-step sponsors who interfere with my treatment plans."  Although AA co-founder Bill W. was personally very positive about anti-addiction medications, the organization he founded contains a strong streak of anti-medication Luddites, who in many instances tell the recovering person to throw away their anti-depressants and other prescription drugs, or they're not really considered "sober."  That hasn't changed in the past ten years, judging by recent stories I've heard.  And so, when a support group like LifeRing comes along, with a more evidence-based approach, physicians' interest perks up.

In the past few years, LifeRing has mounted exhibit tables at conferences of addiction counselor groups such as NAADAC and CAADAC and at APA events (American Psychological Association).  If we can raise the money -- it costs at least $1000 to exhibit at one of these events -- we hope to exhibit next year also at ASAM and CSAM -- the American and California Societies of Addiction Medicine.  With our evidence-based supportive approach to anti-addiction pharmacology, LifeRing should get a positive reception from these professional groupings.

Saturday, November 07, 2009

Goodbye Genetics, Hello Epigenetics

For the first time in history, science now has tools that can definitively answer long-standing questions about the role of genetics as the cause of diseases.  So far, the results have been devastating for believers in genetic causality.  The better we can see, the less genetic causality we find.

I've previously summarized the minimalist findings of modern genetics research for a number of psychiatric disorders, including addiction, here and here in this blog, and in my book, Empowering Your Sober Self.

Now comes another blockbuster study, this time of schizophrenia, a disease commonly believed to have a strong genetic component.  According to the November issue of Scientific American, summarizing a recent report in Nature, "three crack teams of investigators pooled genomic data from 8,000 schizophrenics of European ancestry but could lay claim to only a handful of weak genetic risk markers."

By contrast, says the same article, epidemiologists have been able to find significant correlations between schizophrenia and environmental and cultural conditions.  Growing up as an immigrant or as a racial minority in a big city, particularly in densely populated and troubled neighborhoods, is a significant risk factor for the disease.

These studies have given a boost to the field of epigenetics -- the study of how environmental conditions evoke or overwrite genetic predispositions.  The primitive notion that our DNA is our destiny is giving way to the understanding that our genes do nothing until they are activated.  Environmental conditions (including not only the chemicals that enter our body but also the decisions we make, the people we hang with, and the stress we undergo) determine whether a gene gets turned on or off.  Our genetic array is like a keyboard, and our interaction with the world governs what melody gets played on it.

By coincidence, a recent issue of Counselor, the magazine for addiction professionals, features an article, "Epigenetics Has Come to the Addiction Field," by Mike Taleff, Ph.D.  Taleff's main point is that it's not genetics that makes a person an alcoholic or other addict.  It is the repeated consumption of alcohol and other drugs that programs a person's genetic material to crave the drug and prioritize its consumption.

This epigenetic understanding, says Taleff, can help a recovering person shed some common myths, such as the belief that "they are somehow morally, bad, defective, or otherwise flawed.  Often, this kind of thinking gets in the way of recovery."  Epigenetics teaches, by contrast, that becoming addicted "has little to do with your moral character."  Addiction is a result of the programming that addictive substances perform on your brain.

Many questions remain to be settled before science can claim that we have a comprehensive understanding of the causes of addiction.  But progress is being made.  For decades, addictionology was stuck in the belief that the alcoholic/addict's disorder was genetically programmed. Thanks to the enormous strides made by genetic science in the past decades, with the deciphering of the human genome and the subsequent advances, we can now say with considerable certainty that genetics supplies only a weak explanation at best. Now we need to turn our eyes toward the epigenetic factors:  environment, culture, and above all the neurochemical properties of the addictive substances themselves.

Cover story

The cover of my new book -- Empowering Your Sober Self -- is going to appear as a prop in the forthcoming made-for-TV movie "Sins of the Mother."  According to the synopsis, the heroine, Kim, postpones writing her Ph.D. thesis to go live with her mother, a recovering alcoholic.  To establish the mother's character, the camera scans the books on her coffee table, and lingers on "Empowering Your Sober Self."

Just so you know, this is not a paid product placement.  A member of the film staff ran across the book in a bookstore and asked my publisher for permission to feature it as a prop.  The movie will air on Lifetime Television. Date not yet known.  The producer is Mother Road Productions Ltd in Vancouver BC.

Oh, and a review of my book, by William L. White, will appear in the next issue of Alcoholism Treatment Quarterly.  White also wrote the preface for my book, and it is expected that the review will closely track the preface.  It will not mention the cover.