Untreated Early-Life Trauma – Missed Opportunities, Lost Lives

Unhappy child sitting
Several years ago, a colleague asked me what I thought about his “four months and done” buprenorphine treatment program. He believed that virtually all people with opioid use disorders could “learn” how to stay drug-free in that time. All his patients were titrated to an effective dose in the first weeks, maintained for the first two months, and tapered off over the next two months. He offered anecdotal evidence of the success of his approach, but it became clear that most of those he tapered simply disappeared. He had no meaningful data, even in the short term. I asked him whether he took a trauma history when his patients initially presented, and he had no idea what I was talking about. I am an individual in recovery as well as a treatment professional, and I have treated tens of thousands of patients with addiction. Most of those patients, when questioned, had...
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Prescription for the Nation

Prescription for the Nation
Most healthcare professionals promote the well-being of one individual at a time. Those who work in public health, however, promote the well-being of groups of individuals. The U.S. Public Health Service and the rest of the U.S. Department of Health and Human Services (HHS) promote the well-being of overlapping groups that taken altogether represent the entire population of the United States. Individuals do not always collaborate with healthcare providers. For example, only about 50 percent of patients with chronic diseases take their medications as prescribed. It remains to be seen whether the population of the United States will collaborate with HHS’s current initiative to protect the well-being of the Nation. In November 2016, HHS released FACING ADDICTION IN AMERICA: The Surgeon General’s Report on Alcohol, Drugs, and Health . Reports from the Surgeon General are not routine government publications. They address serious threats to the health of the population (e.g., HIV/AIDS)...
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ADHD—Focus on Adults

ADHD—Focus on Adults
Attention Deficit Hyperactivity Disorder (ADHD) is a condition characterized by inattention, disorganization, and/or hyperactivity-impulsivity that consistently disrupt a person’s activities and relationships. According to DSM-5 (p 32), “Inattention and disorganization entail inabil­ity to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, in­ability to stay seated, intruding into other people's activities, and inability to wait—symptoms that are excessive for age or developmental level.” This conception of ADHD is relatively new, although literature of the past 200 years depicts individuals who might meet current criteria for ADHD. In 1844, for example, German psychiatrist Heinrich Hoffman created a children’s story about Fidgety Phil (“Zappelphilipp”). In 1902, English pediatrician George Still described children with an “exaggeration of excitability” whose behavior was so disruptive that he considered them to have a defect of moral control. In 1937, Rhode Island physician...
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Hope & Caution – for Happy Holidays

Hope & Caution – for Happy Holidays
Once again, the holiday season is upon us.  The Addiction Medicine Update, Hope & Caution—for Happy Holidays,  originally published in November 2012, receives thousands of views, telling us that it strikes a chord in readers.  With that in mind, we are reprinting it this year.  As we approach the holiday season—the time of year from Thanksgiving through New Years when "joy" is the word but not necessarily the reality—it's worth reflecting on ways we can protect ourselves and those we care about from inconvenience and tragedy due to use of alcohol or other mood-changing substances. Start by believing that some measure of holiday joy and fulfillment, provided we are open to it, is available to us all.  Caution is needed. But the holidays evoke strong feelings, and strong feelings often override caution. Strong feelings could include the stress of keeping up with the seasonal parade of expectations and events such as...
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Nicotine Vapor Now Regulated with Tobacco

Nicotine Vapor Now Regulated with Tobacco
Efforts to create electronic cigarettes date from the 1930s. The first commercially successful devices were produced in China in 2003. Electronic cigarettes were introduced to Europe in 2006 and America in 2007. In the United States, regulation of these and similar products became much more stringent in 2016. The Family Smoking Prevention and Tobacco Control Act became law June 22, 2009, and gave the U. S. Food and Drug Administration (FDA) regulatory authority over the manufacture, distribution, and marketing of tobacco products. The FDA has deemed electronic nicotine delivery systems (ENDS) to be tobacco products and issued regulations that affect not only electronic cigarettes (e-cigarettes) but also other devices that produce an inhalable cloud containing atomized nicotine. Initial stipulations took effect August 8, 2016. Additional requirements are scheduled for 2018. Some ENDS resemble conventional means for smoking tobacco, such as e-cigarettes, e-cigars, electronic pipes, and electronic waterpipes. There are also hand-held...
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Unnecessary Debate: Is Addiction a Disease?

Unnecessary Debate:  Is Addiction a Disease?
Imagine two stalwart fans of professional wrestling locked in debate. One holds that the wrestlers are athletes. The other argues that they are not athletes but entertainers, performing in a variety of theater. Both fans are thoughtful and persuasive. Notice that their disagreement is not about the physical attributes of professional wrestlers, or about what they do inside and outside the ring. Their disagreement is about how to name, or classify, the group of people who engage in professional wrestling. Professional wrestlers are what they are and do what they do.  Naming and classifying, however, are conceptual, and therefore somewhat arbitrary.  This arbitrariness is no revelation.  As Shakespeare’s Juliet said:  What's in a name? that which we call a rose By any other name would smell as sweet But when debates about classification heat up, people often think and act as if the issues are absolute rather than arbitrary, especially if...
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There’s No Such Thing as a Disease

There’s No Such Thing as a Disease
Healthcare providers are charged with helping individuals who come to them with physical, emotional, and behavioral problems.  As they prepare to help, providers usually follow a routine—they get to know the person and their problem(s), examine the person, and, frequently, obtain additional information such as blood tests or x-rays.  Prior to recommending specific treatment, providers “make a diagnosis,” which then guides providers and patients to treatment options relevant to the problem at hand.     Diagnoses are commonly expressed in terms of the manifestations of a problem (hives, for example) or the cause of a problem (for example, penicillin allergy).  Clinicians sometimes make diagnoses quickly and confidently or, at other times, slowly and tentatively.  They may entertain several candidate diagnoses, “the differential diagnosis,” before settling on a provisional, or working, diagnosis.     A biology professor periodically reminded his students, “Variation is the law of life!”  Clinicians can testify to this.  No two...
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From Bar to Bars: Links between Alcohol and Crime

From Bar to Bars: Links between Alcohol and Crime
Crimes related to illegal drugs often make headlines—seizures of substances, arrests of drug lords and dealers, and laws broken to support habits. Crimes related to alcohol are also in the news, but we may have to turn to police logs to find them. Yet alcohol is implicated in 56.6 percent of incarcerations in America, which includes 57.7 percent of inmates who committed a violent crime such as murder, forcible rape, robbery, or aggravated assault. Alcohol has more links to crime than any other single drug. ( Behind Bars II: Substance Abuse and America’s Prison Population ). Consumption of alcohol does not in itself cause crime. But alcohol impairs coordination and judgment, which makes driving dangerous, especially for young, inexperienced drinkers. Estimates vary, but some authorities report alcohol-impaired driving contributes to more than 50 percent of motor vehicle crashes and more than 50 percent of highway fatalities. Driving under the influence (DUI)...
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Best Ways to Chill Out

Best Ways to Chill Out
We pay attention to our senses, which tell us about our bodies and the people and things around us. We notice our thoughts, movements, and feelings. In response to ailments or other concerns, we narrow our attention to particular body regions, organs, or organ systems—back, skin, or digestive tract, for example. But we rarely contemplate the smallest components of our bodies: the cells and molecules. Yet if you wish to chill out, you may want to take into account your brain cells and gamma-aminobutyric acid (GABA)—a chemical messenger that quiets brain cells down—lest your preferred means of chilling leads to consternation rather than relaxation. GABA, a common neurotransmitter in the human brain, inhibits the firing of mature brain cells by making the electrical charge within those cells more negative. Fluids in large and small compartments throughout the body have electrical charges reflecting the net effect of the positive and negative chemical...
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Curbing Addiction Is Everybody’s Business

Curbing Addiction Is Everybody’s Business
Addiction statistics are scary.  For example, excessive alcohol causes an estimated 88,000 deaths per year in the United States.  Deaths from cigarette smoke exceed 480,000 per year.  In 2013, about 100 Americans per day died from drug overdoses.  The annual cost to this country of addiction and other substance abuse—including healthcare, crime, and lost productivity—is over $600 billion. Such damage ought to prompt interventions that are swift and sure, but that is not the case.  Not only have severe social and economic consequences of addiction been with us for a long time; some measures are getting worse. Conflicts of interest impede the prevention and treatment of addiction by inhibiting individuals throughout society from adopting alternative actions that would reduce the toll of addiction.  If we attribute all responsibility for addiction to addicted persons themselves, we are like a naïve family member who says, “It’s your problem.  Take care of it.” People...
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