Walk Away from Temptation

The singer Paul Simon's composition, "There Must be Fifty Ways to Leave Your Lover," also holds true for leaving your addictive substances. If you ask a group of people who've gotten free of the monkey on their back what they do when they feel a craving coming on, you'll wish you knew shorthand to write down all the different solutions that work for somebody. "Take a deep breath!" "Count to 100." "Call a sober friend." "Go to a meeting." "Drink a glass of cold water." "Touch your sober talisman." "Do a meditation." And so on.

Now comes a roundup of studies in the New York Times -- thanks, Dr. Joe Mott for pointing me to it -- highlighting evidence in favor of one of the simplest ways to leave your demon: walk away. A series of studies completed in the past five years demonstrates the empowering effect of locomotion. A brisk but not strenuous walk of as little as 15 minutes enabled study subjects to turn their backs on substances they craved.

Why does walking work? The Times' science writer doesn't try to answer. Three hypotheses come to mind immediately: endorphins, distraction, and Aristotle.

Exercise, as is well known, causes the body's glands to manufacture and release endorphins. Endorphins are often called the body's own morphine; they are native opioids that take away pain and make you feel good. If you've seen the smile on the face of a bicyclist or a runner, you've seen a natural endorphin high.

So, taking a brisk walk as a device for rejecting an external drug makes sense on the theory of substitution. You allow the soft hand of your inborn neurochemistry to scratch your itch instead of the bloody claws that some liquor company, tobacco cartel, or other drug syndicate has cooked up to ensnare you. Substitution of a harmless, wholesome gratification for an addictive fix is a basic recovery strategy with a very wide range of applications.

But endorphin substitution may not be the whole story, or may not be the story at all. People vary in their rate of endorphin production, and the studies in the current report don't include blood samples that measure endorphin levels. Daniel Goleman, the brilliant popularizer of the Emotional Intelligence concept, highlights the famous marshmallow experiment, destined to take its place alongside Pavlov's dog as one of the foundational studies in psychology.

The experimenter puts a marshmallow on a dish in front of a child and says that he, the experimenter, must leave the room for a few minutes. The child is free to eat the marshmallow; but if the child waits until the experimenter returns, the experimenter will add a second marshmallow, and the child can have both.

In the original study, the children who ate the one marshmallow ended up, years later, dropping out of school, stuck in low-wage jobs, in trouble with the law, divorced, etc., while the children who resisted and waited for the double reward became valedictorians, chief executives, senators, etc. (I exaggerate wildly, of course, but that was the general drift of the results.)

Goleman's follow-up studies tried to find out how the children who waited for the two marshmallows were able to resist the marshmallow sitting in front of them. His results threw out various genetic and characterological hypotheses. Resisting the lure of the sugary treat, he found, is a teachable skill. The children who succeeded did so by distracting themselves. They took their eyes off the item and played some game or walked around the room. In short, they derailed the train of craving by setting their minds busy with some other concern. Goleman concluded that any child could learn to do this, vastly increasing their chances of success later in life.

So, the effectiveness of walking may be due partly or even wholly to the distraction effect. We set our minds to working our legs, keeping our balance, choosing a path, managing our breath, and all the other efforts required for effective ambulation, and in the process the craving fades away in the rear view mirror.

Then also, there's Aristotle, one of the ancient founders of the scientific method. Aristotle, not being an Athenian, could not own property there, and therefore taught his followers on a public walkway. His philosophical school came to be known as the Peripatetics -- the walkers. Ever since, walking has become linked in legend with stimulation of the inquisitive, analytical mind.

Why this should be so, if it is so, remains hazy, but we know that the mind and the body are a unity, and no one should be deeply surprised that ambulation might stimulate cogitation. And rational thinking certainly would lead one to avoid putting addictive substances into the body.

Does walking help avoid cravings because of substition? Or because of distraction? Or via the Aristotle effect? Or all the above? We don't have the answers yet. But we don't need to know why something works in order to benefit. For decades, doctors didn't know why Aspirin or acupuncture worked to relieve pain, yet both helped millions. Perhaps you can cogitate on the reasons as you amble.

Next time you feel a craving coming on, walk away from it. It works!

[Originally published in hellowellness.in]

Pain Relief Without Addiction: Walking the Tightrope

[Originally published on hellowellness.in on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

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 http://reliancecenter.com.

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.