Addiction: Treatment, Recovery, and the Role of Family & Friends
A conversation with Petros Levounis, M.D., M.A., APA president-elect, and Monica Taylor-Desir, M.D., M.P.H., a member of the board of the APA Foundation, on what addiction looks like, what treatment looks like, and how family and friends can help a person in recovery.
Dr. Taylor-Desir: Great, thanks for being here. As we are in September, which is national recovery month, we are going to talk today a little bit about what recovery looks like, and what addiction treatment looks like. A common question we see on social media and from the public is, what does addiction treatment really look like? In my practice, I explain to patients that it can be different; we look at addiction treatment from all angles. There are some folks that are interested in medication-assisted treatment, and that is not only for opiate addictions, but we also have medication-assisted treatment for alcohol addiction and sometimes we forget about the common substance use disorders of tobacco use disorder, or smoking cigarettes, we also have medications to help with that and sometimes we as physicians forget to offer those options. But there are also some folks that would just need more intense addiction treatment and they may look at an inpatient or residential treatment. What about your practice?
Dr. Levounis: Very similar to yours Monica. I would say that the three major blocks for addiction treatment in 2022 are meditations, as you mentioned, psychotherapy and counseling, either in a group setting or in an individual setting, in an inpatient setting or an outpatient setting, but these are the things that really get people better, and of course mutual help. Mutual help groups like Alcoholics Anonymous and a number of other mutual help programs that help our patients tremendously. Now when you mention medications, I would really emphasize opioids and tobacco. These are really the success stories of medications for addiction treatment. The medications that we have for opioid use disorder or for tobacco use disorder, things like the patch and the gum, and varenicline and for opioids buprenorphine and methadone - these are the medications that really have a major impact in our patients lives. I like the medications for alcohol as well and I prescribe them, and I do use them, and I think we should be using them, but really for the opioids and tobacco is where we've done our best work.
Dr. Taylor-Desir: I’m glad you brought up mutual help, but we also don't want to forget that in that whole or holistic treatment many people will look towards having participation with their spiritual communities, or in Native American communities with traditional ceremonies, and I think that's really important not to forget that it's not just biological but there are so many other effects of addiction. So, we know that family and friends, and their support, is so important.
Dr. Levounis: Absolutely. I was going to say here that we get in trouble when people feel that these are mutually exclusive treatments and they say “either I'm going to go for medication, or I'm going to go for a spiritual approach” and truly, there are not in in combat with one another. They really work very very well synergistically, and we have so many patients who do extremely well on medication, in psychotherapy, also going to their AA meetings or other mutual help meetings.
Dr. Taylor-Desir: Great, so how might you inform a patient family or friends on how they can best support a loved one going through addiction treatment?
Dr. Levounis: It's a little tougher than it sounds. Let me just take a step back and say that it used to be that I would say to a patient, “Come see me when you're ready! I've got nothing to offer to you unless you are ready to change!” and thankfully we have put that aside and nowadays we can work with patients who have very little interest in changing anything in their lives. Motivational interviewing, a particular form of psychotherapy, really helps patients who are highly ambivalent about whether they want to change anything in their lives. But recently we we’ve gone a step further and we can help patients who not only have very little interest in changing anything in their lives, but also do not want to come see us. We can help patients who refuse to come see the doctor. And the way that we do that is we bring in the family, and we say “You are here to really help your loved one, it is not that you have to see a psychiatrist yourself, but you do need someone to help you navigate this very difficult terrain of recovery for your son, or your daughter, for your spouse, for your parent, or whoever it is who's struggling with addiction.” And that works pretty well, in fact, what we do is we teach the family members motivational interviewing techniques so they can grow and do that kind of work at home until the patient is ready to come and see us directly.
Dr. Taylor-Desir: Those are very good techniques. I think the other things that I've found important in working with families - they really want their loved one to heal and be in recovery is to help families to understand the chronic nature of substance use disorders. Because, a lot of times people will think it's a “one and done” you know, they go to treatment, they'll be better, there will never be any relapses or any other challenges, and you know I think it's hard sometimes for families to grasp, but sometimes the addiction and the substance use disorders have been there for a long time, and it's going to take time to heal and it's not a straight course - sometimes it's up and down.
Dr. Levounis: Very, very true. The majority of people at some point in their lives that met criteria for substance use disorders will end up beating the disorder. So, that part is true, that actually there is good news - treatment works, and people end up doing well. However, the vulnerability to go back to using stays with you for a long, long time, if not for the rest of your life. Once the addiction, once the substance or the addictive behavior - like gambling, and the internet, and sex, and things of that sort - take hold of parts of our brain, even if we manage to do well — and a lot of people do well actually, the majority of people do well — there's always a danger of rolling back to where you were, at the significantly higher risk than, let's say, the general public. So that's something that people need to be aware of, and it’s exactly as you said, it’s a chronic relapsing illness and people need to appreciate that part.
Dr. Taylor-Desir: Right, right. I think, you know, it’s also important to remind families that, you know, if you can help your loved one get back on track, relapse is a part of the illness, it's not a failure in their character. It's also, you know, we compare it to diabetes; we know that sometimes we can do well with diabetes and our sugar levels are good, and then sometimes people have a hard time at managing their sugar - but we don't really blame them.
Dr. Levounis: Imagine you have somebody who suffers from diabetes, comes to see the doctor, or let's say high blood pressure or any other disorders, and the doctor says “OK, from tomorrow, you're going to exercise three times a week, you're going to eat healthy, no concentrated sweets, no stress in your life…” all these kind of laundry list of things that you must do, and if you do all these things then you'll be fine. I mean, that's what kind of thing we expect with our patients with substance use disorders. We say, “alright if by tomorrow, you came to see me today, by tomorrow I want you not to use, I want you to fix your life, and all these things” and this is just too much, and patients do need help.
Dr. Taylor-Desir: Absolutely. And since it is National Recovery Month, it's important to talk about what recovery looks like. Another common question I hear is - what is recovery? Or how do I know if someone is in recovery? Petros, I’m curious to know how about, how you might answer this question from a patient.
Dr. Levounis: Yeah, in the past we used to think that recovery was all about abstinence. As long as you don't use the substances, as long as you refrain from the addictive behavior, you'll be fine no matter what. And, we have shifted our thinking in recent years, and we define recovery more in terms of rebuilding your life - in terms of connecting with your loved ones, giving meaning to your life, having fulfillment, being happy. This matters, you know, getting at home, if you're homeless, are finishing school, if you are a student, getting meaningful employment - these things that really matter to people - have a romantic relationship, have a family if you so choose in life. So, that's how we see the covering of a much more holistic fashion. Abstinence is quite often part of recovery, but we do see it in a much broader sense.
Dr. Taylor-Desir: Definitely. And, I think recovery in my daily work with assertive community treatment for patients who have severe mental illness and also have substance use disorders, you know, recovery is definitely a process, it’s the journey, it's not the endpoint, like “Oh I'm in recovery, I'm done!” But people again are working towards all those goals that you mentioned, and recovery can mean abstinence, but it also can mean “I am in recovery, and also utilizing harm reduction.” And they're starting to decrease their use, and they're starting to look at “how can I safely move towards a healthier existence?”
Dr. Levounis: Yes, absolutely. Everything that we recommend to our patients does have repercussions. Patients look up to us, it's an incredible privilege that we have, and we better be very serious about that privilege that society has given us. So, these days we certainly think about harm reduction, but we also think about harm escalation - what kind of things do we do that may actually escalate harm? By not giving buprenorphine to a patient who suffers from severe opioid use disorder, we’re most likely doing some harm escalation in that person's life. So, it's a let's be careful about the things that we do, but also the things that we don't do that may have detrimental effects for our patients.
Dr. Taylor-Desir: Petros, thank you so much for joining the conversation. There was something you mentioned about the privilege of working with our patients and I definitely agree. It is a privilege to walk on this journey with them and to move toward recovery, to move toward help.
Dr. Levounis: And thank you so much for joining us! If you want to learn more about addiction and addiction treatment, please visit us at the American Psychiatric Association's website psychiatry.org. Thank you so much, bye-bye now!
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