Parity Bill Becomes Law

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

On Friday, October 3, 2008, President Bush signed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Bill. The passage of this bill into law is the culmination of years of effort to end discrimination against those with mental health and substance use disorders. In response to the passage of the bill Pete Domenici (R.-N.M.) said, “We are ushering in a new era of health care for those with mental illnesses. No longer will we allow mental health to be treated as a stepchild in the health care system. If you have insurance, then your mental health care must be equal to benefits you get for any other disease.” People with mental health and addictive disorders will now have access to the same type of insurance benefits they receive for physical illness.

The bill requires health insurance plans that offer mental health coverage to provide the same financial and treatment coverage offered for physical illnesses. It expands parity by including deductibles, co-payments, out of pocket expenses, coinsurance, covered hospital days, and covered outpatient visits. It also requires that medical necessity determinations and the reason for denials of coverage are made available to the public. It does not mandate that group health care plans provide mental health coverage and there is a small business exemption for companies of fewer than 50 employees. The effective date the requirements will go into effect, for most health plans, is January 1, 2010.

This bill is a solid start in ending the discrimination and stigma associated with addiction and mental health issues. It will make it much easier for people to obtain the treatment and care they need for these disorders. This bill will end the loophole in Oregon’s parity bill as those insurance companies with headquarters outside the state will no longer be exempt from providing this type of coverage.

I want to thank everyone who contacted their Senators and Representatives to support passage of this historic bill.

A summary of the bill can be found at Thomas.gov by searching the name of the bill. It was part of the financial rescue package.

Buprenorphine Maintenance

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

Our experience with buprenorphine maintenance has revealed this medication to be a very helpful tool in the treatment of opioid addiction. We have used a somewhat unique maintenance program, so it has been exciting to see people use it during outpatient addiction treatment and have successful transitions into recovery.

Maintenance treatment of opioid addiction is used around the world. It is primarily done with methadone, which is often prescribed for years if not for life. Maintenance treatment with methadone helps to eliminate use of the opioids, reduces psychosocial problems, reduces the risk of medical problems associated with IV drug use (HIV, Hepatitis C) and results in less illegal activity and increased employment. It appears that maintenance treatment with buprenorphine provides similar benefits. Unfortunately, many methadone programs provide limited addiction treatment and people are left entirely relying on the medication. Recovery from addiction using a 12 Step model is seldom emphasized.

We have taken a different approach, combining the standard use of buprenorphine with our outpatient addiction treatment program. As a result, people receive medication that allows for resolution of craving and prevention of relapse, while they are advancing their lives and learning to live without drugs and alcohol. We use the buprenorphine to help people transition into recovery. They are involved in the outpatient program, and attend 12 Step meetings. As a result they establish personal recovery programs and the confidence needed to remain abstinent. We also treat co-existing mental health problems during the maintenance treatment period, so psychological stabilization occurs as well.

After 6 – 8 months on buprenorphine, once good recovery has been established, we taper people off of the buprenorphine. This is always scary for the individual who has been using opioids, but has worked out remarkably well. They are tapered while attending treatment once a week so we can provide support and help them through the transition to a medication free state.

We have gone through this with several people who have had great success. They often request the taper before we bring it up. They tolerate the taper with minor withdrawal symptoms. They remain involved in addiction treatment and 12 Step programs. And they have remained abstinent from opioids without buprenorphine. This exciting use of a pharmacological intervention for addiction has resulted in more people staying in treatment and getting sober.

Recovery Month

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

Working in the addiction field provides ample opportunity to witness both the miracles of recovery and the stark reality of active addiction. Addiction can destroy lives, and our culture tends to be indifferent unless it affects someone close, or is an interesting, newsworthy story. Most people only give thought to addiction when it affects someone in their family or the story becomes a voyeuristic pursuit. Those of us who treat addiction recognize it for what it is: a devastating, chronic illness that fools people into thinking the alcohol or drugs are not the problem.

I get queried regularly by friends about someone they know with a problem. It is such a common illness that people tend to forget how awful it can be to experience it or to be in a family with active addiction. Everyone starts to feel crazy. To the causal observer it just seems like they should take care of it, as if it’s as simple as placing a cast on a broken leg. Why can’t that starlet just quit using drugs and get on with her life? Addiction is remarkably different. It affects the parts of the brain that normally function to prevent risk to our lives, resulting in continued use of drugs or alcohol that promotes repeated risk. It’s a perverse cycle, at a subconscious level, that is not fully recognized by the individual. They don’t know what is happening.

We see people who’ve lost jobs, family and all their favorite activities, but cannot stop doing the very thing causing the problem. And they don’t even enjoy it anymore. A common reason people do nothing about a friend or family member is the myth that they have to want help. Most people in the midst of addiction want help at some level, but the drug or alcohol supersedes their concerns and fools them into thinking they are doing fine, that the only relief they get from their real problem (spouse, work, stress…) is the drug. We can’t wait for them to seek help. The history of addiction treatment in this country is one of raising the bottom, helping people identify addiction earlier in the course of the disease and getting treatment before it becomes severe or tragic. Good treatment helps those people who can’t see it to open their eyes to the whole problem. We can make a difference early and save people the next worse consequence. Why should we wait for a job loss, a car accident or worse before we act to help those we love?

September is Recovery Month in the USA. Don’t let another friend or family member continue down the path of destruction without offering help. Don’t wait for them to recognize the problem, or to ask, for it may not happen. Bring attention to this vast problem. Learn more about it and determine resources that can be used to help others. Talk about your experience with addiction and shed some light on the misconceptions that keep so many people stuck in this cycle of self defeat.

Fun in Early Recovery

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

Early recovery is fraught with problems and difficulties. Most people get focused on the seriousness of recovery, and the daily disciplines necessary to prevent relapse become paramount. It’s not easy to stay sober after a life of addiction and it is necessary to prioritize the activities associated with recovery and devote oneself to them. Without this level of attention, abstinence can be tenuous. However, we still need to enjoy our lives.

In the midst of addiction people quit having fun. Daily use of a drug loses its excitement quickly, and it becomes a daily grind complicated by ongoing consequences, shame and guilt. The individual’s whole world revolves around obtaining and using drugs and alcohol, as a result those activities that we used to enjoy get left behind. Almost every interview I have with people entering treatment reveals the loss of interests, hobbies and the fun activities that brought them so much joy in the past. I recently met a guy who was a professional snowboarder and gave it up entirely due to his alcohol use. When I ask new people what they do for fun they often describe all of the things they used to do, in the past tense, because they are no longer participating in the fun and joy that life has to offer. Their lives have been narrowed by the power of the addiction and they usually have not recognized this tremendous loss.

Unfortunately, we tend to be slow to re-establish fun activities. We get sober and we get serious. Sobriety and the working of a recovery program become serious business. It’s as if there’s no time for fun, I have to stay sober. This is a mistake. We need to become re-involved in those activities that provided joy in the past, and develop new ones. The ability to experience joy is not lost, but can seem that way, until we pursue it again. A common misperception is that one can’t dance sober. Other people have never skied without smoking pot, and others have never had sex without drugs and alcohol. What a remarkable feeling to fully experience these wonderful activities in sobriety!

Early recovery is about change, so how about committing to something new and fun? It can be as simple as going to the beach, or as complicated as a new sport that requires lessons, like golf. What about taking dancing lessons? Samba anyone? There are so many things to choose from, the possibilities are endless. Grab some recovering friends and commit to enjoying your life. Get out and try something new or re-engage in a lost hobby, but don’t think that recovery is entirely about seriousness and discipline. Have some fun!

Limitation and Acceptance

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

In our last newsletter I initiated a discussion of spirituality and I would like to continue to address this important issue. Spirituality is not defined in the AA literature, yet is a paramount aspect of all 12 Step programs. The AA text states, “The spiritual life is not a theory. We have to live it.” In spite of its essence to a 12 Step recovery program, spirituality is left up to the individual to define. By design, 12 Step programs are as open as possible to various spiritual beliefs and interpretations which was done in an attempt to prevent religious bias from limiting participation. The absence of a definition of spirituality leaves some confused, but most find that it provides a more acceptable path to belief in something outside themselves.

In Not God - A History of Alcoholics Anonymous Ernest Kurtz wrote: “Because the alcoholic is not God, not absolute, not infinite, he or she is essentially limited. Yet this very limitation – from the alcoholic’s acceptance of personal limitation – arises the beginning of healing and wholeness.” This profound principle was established in 12 Step programs as spiritual. One must accept limitation, the disease state of alcoholism and addiction, and look outside oneself to begin the process of healing.

At 12 Step meetings one regularly hears the statement “my best thinking got me here.” This reveals the necessity of another way of thinking and being, accepting of limitation, and in effect it is a statement of recognition that the answer lies outside oneself. It is also a concept which is supported by neurobiological research that reveals the remarkable power that addiction has over the individual. 12 Step programs suggest that those with addiction accept that they have this disease and look outside themselves for the solution. Acceptance of this limitation, the inevitable human act of acceptance of imperfection, opens the door to recovery.

Hope and the possibility of change are recognized in this limitation as well. 12 Step programs are verbal traditions and the telling of one’s story is an essential act of healing, but not just for the individual story teller. Hope and healing are expressed for the newcomer by those who have accepted their limitations and have already addressed them in a successful manner. Hope is found in the powerful stories of those who have already sought a spiritual solution in 12 Step programs and are leading remarkably different lives as a result. And it is this hope that uplifts the individual when facing the truth of their own limitations.

These remarkable examples of success allow people to begin to safely look at themselves and outside themselves to consider the possibility of a spiritual solution. “Working the Steps” is synonymous with daily attention to one’s spiritual condition. The AA text states, “We are not cured of alcoholism. What we really have is a daily reprieve contingent on the maintenance of our spiritual condition.”

Recovery through Surgery

When I had 5 years clean and sober I faced my biggest fear in recovery—needing another surgery. Prior to my sobriety, I spent more than 15 years in and out of the hospital for many surgeries and prescribed narcotics. Eventually I found I was well into my disease of addiction and the fall was hard. I spent 90 days in residential treatment. By the Grace of My Higher Power I have maintained my Sobriety by my willingness to adhere to a Recovery Program that included AA, a Sponsor, and a strong 12 step program.

Recently, it was determined that I would have to under go three very complex surgeries in 4 months. I turned to my program of Recovery to overcome my fear of facing surgery, pain, narcotics and months of possible complications.

The first thing I did was increase my attendance at AA meetings. I spoke up, shared and let other recovering people help me work through it. I involved my sponsor and discussed a plan to keep me safe.

The second thing, I involved a medical team, including my surgeon, some nursing friends, my friend an Addictionologist, and my husband. As a recovering alcoholic and addict, it was very important that I have nothing to do with managing or dispensing my pain medications.

I learned so much from this experience. I learned that when narcotics are taken as ordered, they help the pain! I was so afraid that they would awaken the beast lying in wait for me. I was taught the difference between addiction and dependence. I also came to believe that I didn’t have to suffer because I was an addict. I learned to be honest about my pain needs. In the past my pain was maximized, now I had more challenges in being honest about my pain.

During these long trying months I did have several complications. There were times I became discouraged, I pressed in closer to my program and the counseling that I had in place. Until I was able to get out to meetings, some wonderful AA women brought AA meetings to my bedside.

Now the time came that I had one last mountain to climb. I had been on monitored pain medications and, as was inevitable, my body was dependent. My surgeon turned over my care to a wonderful clinic called Beyond Addictions that helped me detox from the opiates. Make no mistake it was tough! How did I do it? By NEVER, NEVER forgetting or doubting how much my sobriety means to me; by NEVER, NEVER forgetting my desire to stay present for me first, for my husband and my children. I never want to lose the connection recovery gave me to my Higher Power, whom I call God.

Today I am back to work, living life, and healing more every day. Today I am drug free; therefore truly free to be me!

A Spiritual Path

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

A quote from Herbert Spencer found in the Alcoholics Anonymous text helps to introduce this discussion about the use of spirituality in the treatment of those with addiction. “There is a principle which is a bar against all information, which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance—that principle is contempt prior to investigation.” Twelve Step programs are based on spiritual principles of healing executed by working the Steps in the context of the fellowship of AA meetings.

The spiritual activities inherent in 12 Step programs and the spiritual emphasis of the written documents used by these programs leave many attendees confused and some frankly resistant. The same can be said for those mental health professionals working with people involved in such programs. Survey research reveals that those involved in AA rate spirituality as the most important aspect of the program. However, most mental health professionals are not trained in the spiritual and some reject it. Many recovering alcoholics and addicts need psychotherapy to address problems associated with addiction or to treat other mental health issues. If the therapist has little knowledge of addiction and recovery using the 12 Steps or if they are negatively biased about spirituality, the potential exists for confusing the attendee, undermining the gains the individual has made in recovery from addiction and even contributing to relapse. Thus, it is essential for mental health professionals to not only have a thorough understanding of addiction but also to have a working knowledge of the 12 Steps.

When therapists include the spiritual, they are enlisting a powerful means of healing. New schools of psychology have recognized this and incorporate the spiritual as essential to understanding the human condition and healing our ills. Even western medicine has begun to use the spiritual in the healing of chronic illness. The addiction field has done so from the onset as a result of the popularity, success and influence of 12 Step programs.

Working in addiction allows me to use my training and experience in psychiatry, neuroscience, psychotherapy, spirituality and the 12 Steps. Using these diverse disciplines I am able to provide care in an effective, eclectic manner to those who seek my help in addressing their addiction and other mental health issues. Knowledge of the 12 Steps allows me to engage people in a holistic examination of their recovery. It also assures them that I understand what they are going through; the crushing despair of addiction, the depth of pain associated with self examination, and the joys of recovery. When someone is struggling with the 4th Step (“Made a searching and fearless moral inventory of ourselves.”) because of their resistance to admitting to an act of great shame, something they vowed never to tell anyone, it can be remarkably helpful to offer a perspective based on intimate knowledge of their plight that helps them move past the resistance and complete the task. We can share in the healing process, with full recognition that we are together on a spiritual path.

Healing

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

I recently gave a lecture to our outpatient program clients on the neurobiology of addiction. It was interesting, thought provoking and helped to explain, in scientific terms, why we do the crazy things we do during active addiction. Later that night several clients were graduating so I attended the celebration.

I heard people describe their struggle with addiction, their apprehension about treatment and their gratitude about staying sober. I heard them thank their peers and our staff, and they described the dramatic and wonderful changes taking place in their lives. I also heard family members describe their own journey into recovery, as well as the tempered excitement of having their loved ones abstinent and involved in their lives once again. They all spoke of the pain of addiction, the losses, as well as renewal and hope. They were beginning to experience the benefits of abstinence and were engaging in early recovery.

People expressed the raw emotions of addiction; both the tragedies of the disease and the gifts found in early recovery. Several new clients were there, still in the fog of detox, but buoyed up by the hope of change expressed by their predecessors.

As I took all this in I was struck by the juxtaposition exposed that evening. Neurobiology is essential to our fundamental understanding of this disease, and will lead to new medications and treatments that could make abstinence easier to attain. However, this is both a disease of the brain and a disease of the soul. Not one of the participants spoke of their neurotransmitters, or described the benefits of the brain sciences to their recovery. They spoke of the caring and love they have for each other, essential when one can no longer provide this for oneself. They exalted in hope and in the potential for change found in recovery from addiction. They expressed the joy of openly sharing themselves with other human beings. Their deep gratitude was exposed and readily expressed to one another. They were actively engaged in the process of emotional and psychological healing, perhaps even spiritual healing. Their strength was found in each other, and revealed to me once again how real healing takes place.

Opioids and Addiction

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

The use of oral opioids, pain medications, is escalating dramatically throughout the U.S. and we are seeing the end result in our treatment program. This class of drugs includes morphine, Vicodin, Oxycontin, methadone and heroin. These medications are extremely easy to obtain, whether from physicians, dealers or the internet. Prescriptions for oral opioids have increased since 1995 when it became apparent that pain was not being adequately treated, and when Oxycontin was released for use. Emergency room admissions for problems secondary to use of these drugs have escalated, in fact they doubled between 1997 and 2002. Treatment center admissions for opioid addiction doubled during the same period and continue to rise. With increased access to these drugs we have seen increased problems.

Often people start with legitimate use, but find that they like the effects for more than pain relief. Opioids provide a euphoric experience and numb psychological pain as well as physical pain. Oddly enough the opioids provide energy to most people who become addicted to them so when they run out or stop they not only experience terrible withdrawal symptoms, they have very little energy. The opioids are known for extreme withdrawal, and although it is miserable, it is not life threatening.

We have seen many young people seduced by the high associated with these drugs. Recently we met a 22-year-old who began to use these drugs during his days as a high school football player in one of Portland’s suburbs. He was given Vicodin for an injury. It was legitimate use of the medication, but he was already experimenting with other drugs and found he liked this one. He overused it and became very adept at convincing doctors that he needed more for various pains. Some of his friends on the team began to do the same thing and now several of them are in the midst of opioid addiction. The price of these drugs is high; Oxycontin costs between 50 cents and a dollar a milligram and comes in 40, 80 and 160 milligram tablets. Many of these people use as much as 240 milligrams per day, requiring either a good job or regular illegal activity. Unfortunately the cost is so high that heroin is less expensive, which results in many people switching over to save money. This can result in intravenous use adding to the danger.

Beyond Addictions provides outpatient detoxification and treatment for opioid addiction. We attempt to discern who could benefit from abstinence based treatment versus who would be better served by using buprenorphine for maintenance treatment of opioid addiction. We have equal numbers in our outpatient program. We require that those on maintenance buprenorphine enter into the outpatient addiction treatment program so that they are establishing recovery with multiple tools, not just relying on a medication.

Incredible Outcomes

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

12 Step programs are universally ignored and even derided by many mental health professionals who, like physicians, have little if any training in addiction. This lack of knowledge undermines the appropriate evaluation, treatment and referral of those people that come to them seeking their care. The professionals are left to their opinion, rather than their education, training and expertise, which is never a solid foundation for decision making. This sorry state of affairs brings us to an examination of the research about AA.

The federal government no longer funds studies examining whether AA works, it has been repeatedly proven to be effective in numerous studies. This is not a sexy research topic and doesn’t get a lot of attention because they are not examining new therapies developed by brilliant academics, nor can one make money by promoting 12 Step programs, as could occur with a newly defined therapy. So the dedicated researchers who take on the study of 12 Step programs are not highly honored or lining their pocketbooks, they are just proving that a program developed by a group of alcoholics in the 1930’s actually works better than anything else available for the treatment of addiction.

Approximately 20% of the US population will deal with addictive disease during their lifetime and more alcoholics will use AA than any other resource. Naturalistic studies have proven the effectiveness of AA, not just for abstinence from alcohol, but also in reduction of psychiatric symptoms and improved functioning. (1) AA attendance after formal addiction treatment doubled the rates of abstinence at one year and three years compared to those who did treatment alone. (2) Multiple studies have shown that involvement in AA, actually participating in specific aspects of a 12 Step program, result in better outcomes than merely attending and that those who attend more often per week have a higher likelihood of abstinence. Abstinence rates of close to 90% were shown at 8 years for those attending AA for more than 49 months. (3)

I tell people they will be twice as likely to be abstinent by attending AA after addiction treatment, and they often don’t believe me. The 90% abstinent rate data is often discarded because it is so remarkable. However, as a psychiatrist, this is the only disease I treat with the potential for such successful outcomes.

The research overwhelmingly supports the use of 12 Step programs for those with addiction. Unfortunately most mental health and medical professionals, as well as the public, are unaware of this information. As a result, they rely on their biases, and cannot make good decisions. Those of us that realize this data are responsible for letting others know and training our peers so that more people will be able to gain the benefits of an essentially free, incredibly successful, long term means for addressing alcohol and drug addiction. 1) Ouimette, Finney, Moos 1998 (2) Timko, Moos, Finney, Lesar 2000 (3) Moos & Moos 2006

Take Another Look at Relapse

Dr. Marvin D. Seppala, Medical Director, CEO
Beyond Addictions

I attended Beyond Addiction’s graduation ceremony over the Holidays and witnessed the beauty, gratitude and hope of new-found recovery from addiction. What struck me was that the graduates had each relapsed during their involvement in treatment, but continued to finish. They all spoke of the relapses and how they were afraid to discuss them, but found that our staff accepted their situation, developed new treatment plans, and helped them to move forward with more structure. The graduates repeated that they were ashamed and feared being kicked out of treatment, but found acceptance and caring, allowing them to quickly come to understand their addiction better and continue down the path of recovery.

Relapse happens with all chronic illness, not just addiction, and the rate of relapse is basically the same whether one has addiction, hypertension, asthma or diabetes; at least
40-60% in the first year. Most relapses occur in the first 12 to 18 months of initiation of abstinence from alcohol and drugs. If we take this information seriously and work to limit relapse while accepting it as inevitable in up to half of our clients, we can greatly inhibit the negative consequences of a return to drug or alcohol use.

People relapse for a lot of reasons, but addiction research tells us the three most common reasons are: increased stress, triggers of past drug or alcohol use, and use of a small amount of a drug or alcohol (the first drink). Many people will describe their relapses as related to a lack of recognition of the seriousness of addiction, basically related to denial of the power this disease has over them. 12 Step wisdom reveals that people relapse when they quit working a program and isolate themselves. People often think that their addiction is not that bad or they are somehow different and readily able to remain abstinent, only to find out it really is as difficult as they were told.

We know from research that completion of treatment, longer treatment and follow-through with treatment recommendations results in less relapse. Addressing other problematic life stresses and issues, like a failing marriage or an anxiety disorder, helps to eliminate relapse. The research on 12 Step programs also reveals that attending meetings regularly and getting involved in recovery activities eliminates relapse. There are new medications that can be used as pharmacological interventions and help improve the percent of people who stay sober and do not relapse.

Although we always treat people with the goal of abstinence, we must accept relapse as an integral aspect of any chronic illness and inherent to recovery from addiction. We cannot shame and berate people into recovery; they need our love, our support and our best efforts using every treatment approach available to them. Relapse goes with the territory, and we need to approach it as just another feature of addictive disease and its treatment.