Expert Q & A: Addiction and Substance Use Disorder

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Expert Q and A: Addiction

What can you do to prevent relapse?

Preventing relapse to substance use is mainly a matter of becoming aware of the triggers to relapse and either finding ways to avoid or cope with them. Triggers can be external, for example being in places where substances are being used. Stress of any kind (job stress, financial stress, arguments with important people) can also be an external trigger. Triggers can also be internal such as craving, depressed mood, anxiety, hunger or fatigue. The key is to anticipate triggers ahead of time so they don’t come as a surprise and use a plan or coping strategy to deal with the triggers. Usually professional help is needed to gain awareness of and plans to deal with triggers to relapse. There are also very good medications for alcohol, opioid and tobacco use disorders that effectively reduce craving and can help prevent relapse.

I live with pain and I want help, but I’m worried about becoming addicted to pain medication. What can I do?

Opioid type medications that have potential to lead to addiction are only one way, and probably not the best way, to help manage chronic pain. So the best plan is to try all the alternatives first.

Non-medication interventions such as graded exercise programs, physical therapy, mindfulness meditation, yoga, tai-chi and a form of psychotherapy called cognitive-behavioral therapy (CBT) all take some effort but often work very well. Acupuncture may benefit some people living with pain. Many medications that do not have addiction potential can also be helpful for chronic pain. These include anti-inflammatory medications like aspirin, ibuprofen or naproxen; antidepressants like nortriptyline or duoloxetine; or medications often used for seizures like gabapentin or pregabalin.

If you or someone you know does require opioid pain medications to help manage chronic pain, it is reassuring to know that the majority of people who take these medications for chronic pain do not become addicted to them, although anyone who takes these type of medications for more than a few weeks is likely to have some tolerance (less effect of the medication over time) and withdrawal symptoms if the medications are stopped abruptly.

What resources are available for family members of an individual with addiction?

Al-Anon and Alateen are widely available and free resources for family members. These organizations offer mutual help groups. Members do not give direction or advice to other members. Instead, they share their personal experiences and stories, and invite other members to “take what they like and leave the rest” — that is, to determine for themselves what lesson they could apply to their own lives. The best place to learn how Al-Anon and Alateen work is at a meeting in your local community. Most professional treatment programs also offer family groups to help families support their loved ones struggling with addiction.

Do men and women differ in terms of their risk of addiction?

Yes. Overall, men are about two times more likely to have a substance use disorder (SUD) than women. Data from the National Survey on Drug Use and Health indicate that in 2010, approximately 11.6% of males 12 years of age and older and 5.9% of females met criteria for an SUD in the prior year. It is important to note, however, that when children 12 to 17 were examined apart from adults, the rates for boys and girls were much closer and even slightly higher for girls (7.7%) than for boys (6.9%).

Similarly, epidemiological research has found that among younger women and men in the U.S., the gender differences in rates of binge and heavy drinking are smaller than are seen for older adults. This suggests that women are essentially catching up to men in unsafe use of alcohol and this has significant implications for their health and safety and that of their children, both unborn and born.

There are a lot of people in my family with addictions. What should I be telling my children about addiction and their risk?

Children in families with a lot of drug or alcohol addiction among the members are at high risk. It is very clear from studies of twins that 50% of the risk for developing addiction is determined by genetics. Among identical twins who share all their genes, if one twin has addiction, the other twin has a 50% chance of having it as well. Among fraternal twins who, just like any other siblings share about half their genes, if one twin has addiction, the other twin has about 25% chance of having the disorder. The good news here is that half the risk for developing addiction is environmental so that effective interventions can probably prevent it in many genetically susceptible individuals.

We also know that, regardless of genetics, the earlier a child starts using substances, the higher the risk of later developing addiction. Children at high risk should be told of their risk at the earliest age when they can begin to understand the meaning, generally between ages 10 and 12 depending upon the child’s maturity.

I’m really worried about my son’s heroin use. I fear I might one day find him dead because of his use. What can you tell me about heroin overdose and how to prevent it?

If your son is using heroin, you are absolutely correct that he is in a life-threatening situation. The very best way to address this problem is to get him into medication-assisted treatment with one of the three medications that are approved by the FDA for treatment of opioid use disorder (buprenorphine, methadone or naltrexone). Treatment without medications does not work for most people. If you can contact a local addiction psychiatrist, that physician would know how to help you. If there is no doctor with that specialty in your area, at least take your son to his or your regular physician and ask for help arranging medication-assisted treatment with one of those medications.

In addition, there is an available antidote to heroin overdose, a medication called naloxone. It is used in emergency rooms to reverse an overdose and is increasingly being prescribed to patients with opioid use disorder and their family members. The naloxone doesn’t work if swallowed so it must be given either in the nostrils or by injection. Since someone who has overdosed on heroin cannot give himself or herself the naloxone, family members need to be trained to respond to an overdose and give the naloxone. The most important thing to do even before giving the naloxone is to call 911.

I know my husband drinks too much and needs help, but isn’t treatment going to be very expensive? I don’t think we can afford it.

The cost will obviously depend upon the severity of your husband’s problem and what components of treatment your health insurance covers. Many of the costs mentioned below should be covered by insurance. A very important piece of information is whether your husband has alcohol withdrawal symptoms if he stops alcohol use for 12 to 24 hours. The symptoms could include sweating, rapid heartbeat, tremor and difficulty sleeping. If these types of symptoms are present, your husband will most likely need at least some medical attention to help him reduce or stop his alcohol use. If he does not have such symptoms, it is very likely that he could get the help he needs at no cost by attending Alcoholics Anonymous meetings (AA), getting an AA sponsor, and engaging seriously in the AA 12-step program (called “working the steps.”)

If he does have alcohol withdrawal symptoms, it is still worth attending AA, but he should also seek medical attention to deal with the withdrawal symptoms. Such medical attention should not cost any more than a routine doctor’s appointment. Many people can have withdrawal treated on an outpatient basis with three or four brief doctor’s appointments. If outpatient treatment for withdrawal does not work or if alcohol withdrawal is severe with a risk of seizures or delirium (extreme mental confusion), inpatient treatment would be needed. Inpatient withdrawal treatment usually lasts five to seven days and, depending upon how much is covered by insurance, might cost several thousand dollars. Many communities do have public “detox” programs which can provide a similar service for much less cost. After the withdrawal is completed follow-up with AA attendance at no cost may be sufficient.

I struggle with mental illness and think I might have a drinking problem. A counselor told me I need to quit alcohol completely for at least 90 days before getting help for my mental illness. Is this the only way?

It is common for people with alcohol use disorder to have other psychiatric disorders like posttraumatic stress disorder, depression, bipolar disorder or anxiety disorders. It is often difficult to determine if the other psychiatric disorder is caused or worsened by the alcohol use or whether the other disorder exists without the alcohol use. If possible, it is ideal to be able to stop the alcohol use totally for a period of three to six weeks to help determine how much the alcohol might be contributing to the psychiatric symptoms. It is not usually necessary to stop for as long as 90 days. In many cases, the symptoms will substantially improve after stopping the alcohol. If the psychiatric symptoms do not improve with stopping alcohol, they will need specific treatment with medication and psychotherapy. For people who cannot stop the alcohol, it sometimes makes sense to go ahead and try treating the other psychiatric symptoms with medication and psychotherapy even while some alcohol use is still occurring, with the hope that treating the psychiatric symptoms will make it easier to cut down on or completely stop alcohol use.

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About the Expert:

Andrew Saxon, M.D.
Professor and Director, Addiction Psychiatry Residency Program
University of Washington
Director, Center of Excellence in Substance Abuse Treatment and Education (CESATE)
VA Puget Sound Health Care System
Seattle, Wash.

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