Tag: Kristance Harlow

What Is Evidence-Based Addiction Treatment?

12-step programs are an incomplete approach and do not meet the requirements for evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.

When looking for treatment for addiction, there is a lot of information out there and countless opinions. Friends, family, doctors, researchers, and people in recovery all have their own beliefs about what you need to do to get well. Unlike in other areas of healthcare, addiction treatment is often deemed “effective” based on anecdotal reports. In fact, most people who seek or are forced into treatment do not receive health care that is aligned with evidence-based practice.

A frequently-cited definition comes from a 1996 article in the BMJ Medical Journal: evidence-based “means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Other definitions also include the patient’s individual circumstances, preferences, expectations, and values.

These variables are not necessarily constant, and there is no one-size-fits-all solution; any list of evidence-based treatments is going to include a wide variety of approaches.

What is Addiction?

In the United States, addiction is still treated more as a crime than as a chronic illness or disorder. Until that perspective changes, treatments will not meet their full potential and will not be as effective as they could be. Addiction, or substance use disorder (SUD), is a chronic medical condition that has remissions, relapses, and genetic components.

Are Relapses Normal?

A relapse is not a failure but a symptom. The brain of a person with SUD has gone through neurobiological changes that increase the risk of relapse because the damaged reward pathways stick around much longer than the substances stay in the body. Stressful events and other painful life experiences can trigger that maladaptive coping mechanism and cause a relapse.

For other chronic illnesses we would consider a relapse to be an unfortunate symptom of the disease, and we might call it a recurrence instead of a relapse. When successfully managed, the condition is considered to be in remission. Remission is a term that is relatively new in addition treatment; substance use disorder was not always believed to be a disease but rather a moral failing and a problem of willpower. We now understand that addiction is a chronic medical condition and that remission is the goal of treatment. Remission, as defined by the American Society of Addiction Medicine, is “a state of wellness where there is an abatement of signs and symptoms that characterize active addiction.”

What Is Successful Addiction Treatment?

Let’s take a look at what it means to have an effective treatment outcome in terms of addiction. The primary goal is usually abstinence or at least a “clinically meaningful reduction in substance use.” To measure effectiveness, we must look at how and if treatment improves the quality of life for the patient. Improving quality of life is the aim when treating all chronic conditions that have no cure.

Evidence-based therapies do not support the notion of “hitting bottom.” As with any chronic disease, early intervention is going to provide the best outcomes. Even more effective than early intervention is prevention because SUDs are both preventable and treatable.

Pharmacotherapies to Treat Substance Use Disorders

Addiction is an overstimulation of the brain’s reward pathways, and as the condition progresses, the brain becomes less sensitive to the rewarding effects of a drug and requires more of the substance to get the same effect. This overstimulation can play tricks on memory recall, turning experiences that were not good into ones that seem better than they actually were. It creates false memories to encourage re-indulging in the addictive substance or behavior.

From a medical standpoint, this disparity needs to be interrupted and corrected. Akikur Mohammad, the author of The Anatomy of Addiction, argues that successful treatment of addiction “must first address the biological component and correct the brain’s chemical imbalance in the process.”

Pharmacotherapy is used in medication-assisted treatment and recovery. Depending on the patient’s individual drug history, different medications may be used to mitigate the brain’s compulsive race to stimulate the reward loop.

Therapy for Substance Use Disorders

Most research on therapy for substance use disorders has been done on cognitive behavioral therapy (CBT)—a form of typically short-term psychotherapy that combines talk therapy with behavioral therapy. Patients are taught how to adjust their negative thought patterns into positive thoughts. There is clinical evidence that CBT can be as effective as medications for many types of depression and anxiety. For treating SUD, CBT has been shown to have a “small but statistically significant treatment effect” but doesn’t necessarily have a long-lasting effect. As it’s a chronic illness, it stands to reason that SUD requires further maintenance beyond any short-term treatment.

Are 12-Step Programs Evidence Based?

Alcoholics Anonymous and other 12-step programs use a social model of recovery. They are built on the basic notion of peer support in a safe environment. There is research on the efficacy of 12-step programs, which shows it works for some people and that there are benefits to this social model of recovery. The steps, or rather the principles of the steps, must be internalized into a person’s psyche in order for the person to achieve lasting abstinence. 12-step programs are an incomplete approach and do not meet the requirements for the classification of evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.

One central tenet of the 12-step solution requires turning one’s will over to the care of a higher power. Certainly, letting go of the notion that force of will can change the trajectory of addiction is necessary for any treatment. It’s a disease, and willpower will no sooner cure addiction than it will cure diabetes or heart disease. An evidence-based approach could mean that a doctor recommends a patient attend a 12-step program, or other support group, as part of a maintenance regime.

The addiction treatment world is overrun with rehabs that primarily utilize 12-step programs, which are touted as the only treatment for addiction. That simply isn’t true. Addiction researchers have found that individually, cognitive and behavioral therapies, including social supports like 12-step programs, are incomplete treatment for a chronic disease that is both physiological and genetic in origin. From a treatment perspective that is grounded in evidence-based practice, involvement in a support group would be merely one piece of the puzzle.

Holistic Care

In evidence-based practice, the treatment process individualizes care and uses a holistic perspective to see what combination of resources will work best for a particular patient. The combination of treatment tools depends on a clinician’s specialized knowledge, the patient’s values and preferences, and the best research evidence. We need more specially trained addiction clinicians who can help people with SUDs make informed treatment decisions.

Are you in recovery from addiction? What worked for you? Tell us in the comments!

View the original article at thefix.com

2 April 2019
How Does AA Work? A Review of the Evidence

AA is cloaked in misconceptions and mysticism: a society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcoholism.

Alcoholics Anonymous (AA), as an organization, “neither endorses nor opposes any causes.” But AA, as a societal symbol, is very controversial. People have strong opinions about its benefits and its dangers. It’s an organization cloaked in misconceptions and mysticism: an anonymous society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcohol use disorder (AUD). There is no denying that many have found support and achieved recovery through involvement in 12-step programs. That has left researchers with the question: what mechanisms are at work behind the scenes?

Peer Support Groups like AA Increase Oxytocin

Participation in mutual help programs may increase levels of oxytocin, the feel-good hormone. Nicknamed the “love hormone,” it is released when people bond socially or physically. A neurobiological view of addiction recovery might look at how oxytocin plays on the brains of people in a treatment program. Oxytocin increases when bonding socially with others in AA and there are other neuroplasticity rewards that come from 12-step program participation. Interactions with other members improve the connectivity between the part of the brain that makes decisions and the “craving behavior” part of the brain.

The oxytocin system is created before age four and its development can be affected by variables such as genetic differences within the receptor itself, or environmental causes like stress or trauma. An underdeveloped oxytocin system is a risk factor for drug addiction. Healthy levels of “oxytocin can reduce the pleasure of drugs and feeling of stress.” Creating opportunities for healthy oxytocin production could benefit people in recovery from addiction.

Oxytocin also boosts feelings of spirituality, according to Duke University research. The study defined spirituality as “the belief in a meaningful life imbued with a sense of connection to a Higher Power, the world, or both.” Study participants who received a dose of oxytocin prior to meditation reported higher levels of positive emotions and feelings of spirituality. The effects lasted until at least one week after the initial experience.

Do AA Prayers Reduce Cravings?

Researchers at the NYU Langone Medical Center used brain imaging to see what, if any, effect praying has on the brains of AA members. They were able to see increased activity in the areas of the brain associated with attention and emotion during prayer which correlated with a reduced craving for alcohol. When exposed to triggers such as passing a bar or experiencing an emotional upset, people who were abstinent from alcohol but not members of AA were significantly less likely to experience the benefits of “abstinence-promoting prayers.” This brain activity seems to also be associated with a “spiritual awakening.”

A spiritual awakening is not necessarily about the divine; rather, it’s an awareness of needing resources that are beyond the reach of a person’s individual ego. This awareness causes a shift that alters one’s perspective about drinking. There are also physiologic changes that seem to occur with increased spiritual awakening/awareness. In previous research, those who were directed to pray daily for four weeks drank half as much as the study participants who were directed to not pray.

Research published in the last five years has tried to find ways to measure effectiveness in 12-step programs, in a way that is unbiased and scientific. One such study published in 2014 discovered that spiritual (rather than behavioral) 12-step work was important for later abstinence.

Spirituality Is Not for Everyone

Not everyone who enters AA experiences a spiritual awakening. According to a review of 25 years of research, it seems that only a minority of people with severe addiction experience this spiritual Aha! moment. While a sense of spirituality creates changes in the brain that can be measured on an MRI machine, there are other aspects of AA — social, mental, and emotional — that aid recovery for the majority of participants.

Twelve-step programs can help addiction recovery because of their ability to propagate therapeutic mechanisms similar to the coping tools and behavioral strategies that are utilized in formal treatments. AA has a lot of parallels with cognitive behavioral therapy (CBT). CBT is an evidence-based form of psychotherapy that is effective over just a short period of time. In CBT, patients learn new habits through increasing self-awareness, overcoming fears, taking personal responsibility, and developing shifts in perspective. These are the same underpinnings as the 12 steps.

Clinical interventions that encourage 12-step participation are more successful than clinical interventions that do not encourage attendance. Meeting attendance, sponsorship, and active involvement have come up in multiple studies as being positively correlated with continued abstinence, highlighting the critical nature of connection to others as part of an effective plan for managing addiction long term.

12-Step Programs as a Useful Management Tool

Addiction is a chronic illness with no cure, according to AA literature as well as the medical community, and chronic illnesses require lifelong management. AA can be a good ally in the quest to maintain a healthy lifestyle free of active addiction.

The International Journal of Nursing Education published a study that sought to learn about the quality of life for those attending AA as opposed to those who are not attending AA. They found a significant difference, with those who attend AA reporting a better quality of life than non-attendees.

When looking at meeting attendance over long periods of time, abstinence patterns can be predicted. For people who went through inpatient treatment, the pattern shows that meeting attendance is highest during treatment and reduces at a steady pace afterwards. With reduction in attendance there is also a reduction in abstinence from using drugs or alcohol. Findings from many long-term studies suggest that meeting attendance is important in early recovery and for successful long-term recovery. The reasons for this echo other research findings: community matters.

Dangers Inherent to 12-Step Groups

The nature of AA and other 12-step programs leaves them to be individually organized and without a central governance. There is no oversight and no quality controls. Abuse, inappropriate behavior, bad advice, and social ostracizing can happen.

Perhaps most dangerous is when a single solution is pushed on someone for whom a different angle would work better. Individual satisfaction with treatment plays a major role in “subsequent psychiatric severity,” which means that recovery rates are lower for people who are unsatisfied with the addiction treatment they receive. The World Health Organization suggests that to improve treatment outcomes and engagement with treatment, patient satisfaction ought to be a focus when caring for people with substance use disorders.

AA provides a range of pathways to recovery, but it is not the one-size-fits-all approach it claims to be. It’s particularly challenging for people who also have a diagnosis of (or just struggle with) social anxiety. It’s common for AUD to exist alongside social anxiety. The fear of being negatively appraised can impede progress in recovery. Long-term participation in mutual aid groups such as AA may reduce social anxiety but overcoming that hump in early recovery may require clinical interventions or alternative treatments.

Did you find recovery in 12-step programs or did you have a negative experience? Let us know in the comments.

View the original article at thefix.com

4 March 2019
Addiction or Mental Illness: Which Should You Treat First?

Substance use can alter behaviors, moods, and personalities so severely for people with addiction that without specialized knowledge and experience, it’s difficult to determine underlying causes such as mental illness or trauma.

I credit psychological intervention for pushing me into recovery from alcoholism.

Addiction is a mental illness, but is it one that needs to be treated before anything else? Or should we be stopping people from hitting their addiction bottom and helping them recover from their comorbid conditions concurrently?

What Is Addiction?

Before we can discuss treatment, we need to understand what addiction is and how it is defined. The two major guidelines for diagnosing mental health conditions around the world are the DSM and the ICD. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is the standard diagnostic tool for mental health conditions in the United States and often used in North America. The ICD (International Classification of Diseases) is endorsed by the World Health Organization and often used in Europe.

In the DSM-5, substance abuse and substance dependence are combined under the same name of substance use disorder, which is diagnosed on a continuum. Each substance has its own sub-category, but behavioral addiction is also in the DSM-5, with gambling disorder listed as a diagnosable condition. Other similar entries, such as internet gaming disorder, are listed as needing further research before being formally added as a diagnosis. In the ICD-11 there is a subset of mood disorders called “substance-induced mood disorders,” which are conditions caused by substance use. To qualify for this category, one must not have experienced the mood disorder symptoms prior to substance use.

Hypothetically, a person who has alcohol-induced mood disorder might find health with abstinence alone, but substance use disorders do not occur in a vacuum and no one can go through the experience of addiction without it altering their mind and body, sometimes irreversibly. With enough time, substance-induced disorders change the function of the brain and alter emotion regulation. That doesn’t mean that addiction will cause another mental disorder; addiction is a mental disorder.

Not everyone with an addiction is concurrently experiencing another mental disorder. Substance use can alter behaviors, moods, and personalities so severely for people who are addicted that without specialized knowledge and experience, it’s difficult to determine what, if any, underlying cause is responsible for the changes. Drugs, even those that are prescribed and used as directed, can have side effects that seem to mimic the symptoms of other diagnosable conditions. These effects can also appear if a person is in withdrawal. Because of this inability to isolate co-occurring conditions, there was a time when it was popular for doctors and clinicians to first treat substance use disorders before exploring the possibility of other mental illnesses. That is no longer considered the best approach to care.

My Story: Therapy Helped Me Recognize My Alcoholism

I started therapy before I could realize my excessive drinking was actually alcoholism. I was riddled with anxiety and constantly on edge. I lied compulsively about the most unnecessary and mundane things. My partner helped me start therapy, calling the first point of contact for me and taking me to my first two appointments, and then patiently waiting outside for me. He wasn’t enabling me by keeping me from hitting bottom, he was supporting me and protecting me in a loving way; in a way that worked.

In the early days of therapy, my psychologist gently guided me towards recognizing my alcohol use as problematic. My therapist convinced me to go to a psychiatrist who started me on antidepressants and gave me anti-anxiety medication to use when needed. My treatment was moving forward, but I was still drinking. I spent most therapy sessions crying, but my ability to live day to day was slowly changing.

I was Googling local 12-step meetings while hungover and then deleting my search history while drinking. I was taking my medications but still getting drunk on the regular. I had to do some work on my crippling anxiety and debilitating depression to get to the point that I could even fathom walking into a new space with new people. I drank because alcohol made it easier to have fun and to talk to people. I was living with undiagnosed post-traumatic stress disorder (PTSD) and alcohol worked to calm symptoms like hyperarousal and insomnia. I was using alcohol to cope with issues that my shame wanted to keep buried and my therapy wanted to draw forth. It took nearly nine months of therapy before I quit drinking.

Once I was able to cross that threshold, things really began to change for me. My medication was able to work as intended because I wasn’t combining it with other mood-altering substances, and my therapeutic work could go deeper because I wasn’t self-medicating with alcohol. I gained tools to manage my mental health challenges. My alcoholism treatment has gone so well because I have concurrently received care for my comorbid conditions.

Integrated Treatment

That’s just one personal story of recovery and successful treatment of co-occurring mental illnesses. But it turns out that’s actually the best treatment: individualized integrated care. In the book The Anatomy of Addiction, Dr. Akikur Mohammad writes that the “best approach to treating a dual diagnosis…is…integrating mental health and addiction treatment in a single, comprehensive program designed to meet the individual needs of the specific patient.” How do we determine a patient’s needs? According to Dr. Mohammad, “the best diagnostic instrument is the clinician’s experience in treating addiction.”

How many times have you heard the adage: “You have to let an addict hit bottom”? If you take a seat in any 12-step recovery meeting, you’ll likely hear someone speaking about their own experience hitting bottom. The idea is that one must reach a point of complete and utter desperation before being able to start recovery. Being desperate enough to change because your life is wretchedly entwined with addiction makes for a good story, but waiting to fall into such desperation doesn’t make for a solid treatment plan. The evidence base supports this view, but people don’t necessarily believe it.

Generally, public views about drug addiction are incongruent with current medical knowledge on the disease. A 2014 study that surveyed over 700 adults across the country found that the majority of Americans hold stigmatized views. Forty-three percent of those surveyed said they oppose giving people with drug addiction equivalent insurance benefits compared to 21 percent who believe the same about those with mental illness. Half of all respondents were against increased government spending for treatment of drug addiction, compared to 33 percent for mental illness. About a third of folks don’t believe recovery is even possible for someone with either a drug addiction or a mental illness. And the number of people who believe that treatment options are not effective? Fifty-nine percent for drug addiction and 41 percent for mental illness.

Consequences of Discrimination Against People with SUD

These public opinions have real world consequences. They translate into low support for policies that could provide equal insurance coverage and policies that could allocate government funds into public health programs to improve the success rate of (and access to) evidence-based treatment. Drug addiction or substance use disorder (SUD) is a mental illness, but in the United States it’s treated as distinct from mental illness as a whole.

Did I hit bottom? In retrospect, I find solace in the narrative that I hit “my” bottom. That’s the problem with the notion of rock bottom, it is a storytelling plot point that can only be defined in hindsight. Not even the precepts of Alcoholics Anonymous (the original peer support program that all 12-step groups are derived from) says that a person needs to hit rock bottom. According to the 12 Traditions, which are the general guidelines for 12-step groups, “The only requirement for membership is a desire to stop [fill in behavior or addiction here].”

One thing is undeniable: people with real or perceived substance use and/or mental disorders face discrimination and an uphill battle to a healthier life. Everyone is different, and different treatment plans will have different outcomes for different people. Relying on one method of recovery for all people is irresponsible, illogical, and ineffective.

View the original article at thefix.com

28 January 2019
The Importance of Women’s Recovery Spaces

Women’s meetings gave me the space to talk about the unspeakable, allowing me to move closer to becoming free from the fear that has kept me shackled.[Content Note: Discussions of IPV]

I started my sobriety journey in a foreign city where there was one English speaking 12-step meeting daily, and a relatively small number of attendees. During part of the year, there were few travelers coming through the city, which meant fewer attendees. It wasn’t out of the ordinary to be the only female in the room. I was struggling to accept the gendered language of the literature we read, and had difficulty relating to the stories of the men in that space. I appreciated their support and camaraderie, but I didn’t see myself often reflected in their experiences. I didn’t know it at the time, but what I needed was to connect with other women in sobriety.

When a recovery meeting for women was suggested by a few ladies who had recently moved to the area, it was met with some resistance. The same happened when I later moved and suggested a women’s meeting in the new city where I was living. The resistance wasn’t a force in numbers, but there was a strength of conviction in the small number of people who had a problem with it. I’ve been told that a women’s-only meeting (that is also open to all non-binary, gender non-conforming, and trans identifying folks) can’t possibly be considered part of a [insert 12-step group name here] program because Tradition Three states, “The only requirement for membership is a desire to stop [drinking/using/overeating/etc].”

When it comes to recovery from addiction, gender-aware spaces are important and there has been a long history of them within 12-step programs. Identity-focused groups have existed for decades, including men’s meetings. The first meeting for Black folks began in the 1940s in Washington DC. In 1971, the first gay and lesbian AA meeting began in the same city. While some binary-gender-specific meetings are open to trans folks, there are many that are not. The transgender community still struggles to find a place to recover safely, but there are some meetings in some large cities that are specifically for people who identify as trans.

The first women in Alcoholics Anonymous (AA)–the first and most common of the 12-step programs–didn’t have other women in recovery to guide them and would receive support and sponsorship from non-alcoholic women. The founders originally disagreed on whether or not to admit women into the fellowship, at all. The first women-only AA meeting began in 1941 in Cleveland, Ohio. By 1947 there were more than a dozen women-only groups throughout country and that number has since grown exponentially, worldwide. In 1965 the first forum for women alcoholics was held as the National AA Women’s Conference. Every February since, the International AA Women’s Conference has held a conference “just for women in AA.”

The gender we identify with and the gender we were assigned at birth both play major roles in how we are socialized growing up and how society treats us as adults. Our experiences and choices are, without a doubt, guided and influenced by these societal gender norms. Men and women (generally) benefit in different ways from participation in 12-step programs. According to a paper published in the journal Addiction which looked at AA specifically, women seem to benefit the most from “improved confidence in their ability to abstain during times when they were sad or depressed.” Men tend to benefit more from an increased “confidence in the ability to cope with high-risk drinking situations and [an increased] number of social contacts who supported recovery efforts.” In this study, men benefited from experiencing less depression and having fewer drinking buddies hanging around. Women needed the confidence to experience depression and still not drink.

Women’s meetings can foster validation for feelings of sorrow, and women share their experiences on not drinking despite those feelings. Men, on the other hand, frequently cite the need to combat “self-pity” and credit tough love for their early success in sobriety. For women, it’s often about learning to abstain while in the dark feelings, not escaping from the dark feelings altogether.

The majority of people entering into treatment for addiction are victims of trauma and they present trauma-related symptoms to a significant degree. It’s a vicious cycle: trauma increases the risk of developing a substance use disorder and substance use disorders increase the risk of experiencing trauma. Johanna O’Flaherty, a psychologist specializing in trauma, says that over the course of her career she’s seen people admitted for addiction treatment and “80 to 90 percent in the case of women, have experienced trauma.” Most of the trauma is related to physical and sexual abuse.

The most common trauma in the world is sexual violence and intimate partner violence. Active substance use disorders are positively correlated with an increased risk of domestic violence. Alcohol does not cause domestic violence, but someone who is controlling and abusive is more likely to carry out violence when under the influence. The interconnections of violence, traumatic disorders, and addictions are profound.

The truth is, most sexual violence is carried out by men. A 2010 National Intimate Partner and Sexual Violence Survey found that “90 percent of perpetrators of sexual violence against women are men” and 93 percent of perpetrators of sexual violence against men are also men and overall “men perpetrate 78 percent of reported assaults.” Asking women to talk about their sexual traumas in front of men is a violent act. Yet, trauma must be worked through or it will never heal. The only way to do that is to provide safe options for people to talk about things they wouldn’t otherwise feel comfortable discussing.

Google “women in AA” and the results are heavily saturated with critiques of the program. There are suggestions for alternatives and articles on predators in the rooms of AA and NA (Narcotics Anonymous). It happens, 12 step groups are not utopias and the people in the rooms aren’t there because their lives have always been amazing and their choices ethical. It is possible to meet manipulative and abusive predators there. Strong connections between women can be a buffer and a safety net for other women who might become entangled in an unhealthy or abusive relationship in early recovery.

As a paper written by Jolene Sanders in the Journal of Groups in Addiction & Recovery explains, “Women also feel more comfortable speaking about issues not directly related to their immediate concern of alcoholism. For example, women may talk about childhood abuse, sexual abuse or harassment, and other forms of assault. Similarly, women speak more candidly than men about their relationships with significant others and tend to focus on emotions more than men. Finally, women tend to discuss mental health issues, such as depression, more than men and focus more on building self-esteem, rather than deflating pride or ego, which are primary concerns for men in AA.”

When the women’s 12-step meeting began in the city where I got sober, it was a game changer for me. I had been in a state of traumatic symptom overload. I was experiencing intrusive and vivid recollections of my traumas. I was being triggered all the time about the emotional, psychological, and physical abuse in my past. There are some things my body will not allow me to speak about in certain scenarios. It’s a physical reaction, neurological in origin, and uncontrollable. My body becomes hell bent on protecting me from past danger, literally preventing me from talking.

If I attempt to speak when my body wants to protect me, I begin stuttering and tripping over each utterance. Unbeknownst to me, what I needed was the company of people who were not men. Women’s meetings gave me the space to talk about the unspeakable, allowing me to move closer to becoming free from the fear that has kept me shackled to the past.

Women’s only spaces in recovery from trauma and addiction can help people to express things they may have been taught to not talk about in front of people outside of their gender. Or about events that they have gone through or acts they have carried out or things that have been done to them in relation to their gender identity. I’ve heard rumors suggesting that women’s meetings are not good because they’re just “man-bashing.” This is unequivocally false; just because something isn’t for you doesn’t mean it is against you.

Victims of domestic violence often stay in their situations for financial reasons. To help with this issue, Credit Cards created a guide to help victims gain the financial independence needed to get away from their abusers safely and effectively.

View the original article at thefix.com

18 July 2018
Shame, Alcoholism, Stigma, and Suicide

In addiction treatment circles, conventional wisdom suggests we have to let people hit rock bottom before we can help them. But what happens if rock bottom is dying from suicide?

Historical records as far back as ancient Athens have the underpinnings of the stigmatization of suicide. In 360 BCE, Plato wrote that those who died by suicide “shall be buried alone, and none shall be laid by their side; they shall be buried ingloriously in the borders of the twelve portions the land, in such places as are uncultivated and nameless, and no column or inscription shall mark the place of their interment.” Fast-forward a couple millennia and suicide is still criminalized in many places around the world. In the Western Judeo-Christian tradition, suicide has long been considered the ultimate sin, to such an extent that even the body of a person who died by suicide was legally brutalized and dehumanized. This long history of shaming and penalizing suicide has created deeply seated (mis)beliefs that are engrained in cultural norms. Suicidal ideation is stigmatized, and those who experience such thoughts often suffer in silence.

Alcoholism (both alcohol use disorder and alcohol dependence) is also highly stigmatized. Past research has found that public attitudes are very poor towards people with substance use disorders (SUD). Across the globe, around 70% of the public believe alcoholics were likely to be violent to others. As recently as 2014, research has found 30% of people think recovery from SUDs is impossible and almost 80% of people would not want to work alongside someone who had or has a substance use disorder.

Alcohol dependence and alcohol use disorder (AUD) are high on the list of risk factors for suicide. Mood disorders, such as depression, anxiety, and bipolar disorder, are even higher risk factors. What is particularly concerning is that mood disorders frequently go hand in hand with AUDs. Alcohol causes depression, and it can be hard to distinguish whether the alcohol or the depression came first because they feed each other. In his book Alcohol Explained, author William Porter explains, “hangovers cause depression whether you are mentally ill or not…the real cause of it is the chemical imbalance in the brain and body. ”

People who have alcohol dependence are 60 to 120 times more likely to attempt suicide than people who are not intoxicated and individuals who die as a result of a suicide often have high BAC levels. Alcoholism is positively correlated with an increased risk of suicide and “is a factor in about 30% of all completed suicides.” A 2015 meta-analysis on AUD and suicide found that, across the board, “AUD significantly increases the risk [of] suicidal ideation, suicide attempt, and completed suicide.”

Suicide attempts with self-inflicted gunshots have an 85% fatality rate. If someone does survive a suicide attempt, over 90 percent of the time they will not die from suicide. That margin of survival gets smaller with alcohol dependence. Being intoxicated increases the likelihood that someone will attempt suicide and use more lethal methods, such as a firearm.

When a suicide attempt survivor encounters medical professionals, half of the time they will be interacting with someone who has “unfavorable attitudes towards patients presenting with self-harm.” (These statistics have cultural and regional variations.) When a patient with AUD encounters medical professionals, they are also likely to be met with negative perceptions. Myths about AUD and alcohol dependency are pervasive and not even nurses are immune to such prejudice.

So what improves professional perceptions and treatment outcomes? Education. Training works to dispel myths and reinforce the fact that SUDs are diagnosable conditions that require as much care and attention as any other potentially fatal ailment. Perhaps increased understanding of these conditions and experiences could fuel progress for treating addictions and preventing suicide. Doctors are sometimes at a loss for what to do with alcoholic patients; interestingly, the physicians who had more confidence in their abilities in this area were associated with worse outcomes. Meanwhile, there has been little progress in treatment availability outside of basic peer support groups such as Alcoholics Anonymous.

Peer support groups do help a lot of people get and stay sober and to live happier and healthier lives: 12-step proponents credit the steps and meetings for saving their lives; many say they were suicidal and that after getting sober they no longer had those thoughts. But while suicidal ideation may go away for some people who receive treatment, it doesn’t work like that for everyone.

People who are abstinent from drugs and alcohol still die from suicide. In the case of post-traumatic stress disorder, quitting drinking can exacerbate feelings of hopelessness and despair. Continuing to drink may reduce the severity of the symptoms in the very short term, but ultimately “a diagnosis of co-occurring PTSD and alcohol use disorder [is] more detrimental than a diagnosis of PTSD or alcohol use disorder alone.”

Suicide is a leading cause of death across the world and ranks as the 10th most common cause of death in the United States. For every completed suicide, there are an estimated 25 attempts.

It’s clear that we must do something to reduce the number of lives lost by suicide. Raising awareness of the relationship between alcohol-dependence and suicide attempts is an important part of the equation. Medical professionals, social workers, law enforcement, employers, and others who are frequently the first point of contact need better training to improve attitudes and fine tune skill sets for taking appropriate action. The public also needs to be armed with information that they can use to help their family and friends who may be at risk for suicide, and in particular what to do if that person has a co-occurring SUD.

Despite evidence to the contrary (particularly in the case of comorbidity with another mental illness) conventional wisdom in addiction treatment suggests that we have to let people fall to rock bottom before we can help them. But what happens if rock bottom is dying from suicide? It’s true that we can’t force health onto another person, but we also can’t help them if they’re no longer alive. For many people, prior trauma and mental health issues come before addiction. More evidence-based intervention and prevention programs are needed if we hope to make any headway in fighting this epidemic.

Until that happens, opportunities do exist to help prevent suicide. After Logic released his Grammy winning song titled “1-800-273-8255” (the phone number for the National Suicide Prevention Lifeline), calls to the Lifeline increased exponentially. There is nothing quite like hearing another human voice offering support and comfort. There is also a growing number of online crisis support services which provide help through live chat and email. These, unlike many crisis phone numbers, are not limited by location. Texting a crisis hotline such as the US Crisis Text Line at 741741 is also an option and can be done with just basic SMS, no data needed.

If you or someone you know is in immediate danger, call your local emergency number. Find your country’s equivalent to 911 on this wiki page or through The Lifeline Foundation. Find a list of additional suicide prevention resources worldwide on this page.

View the original article at thefix.com

20 June 2018