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Substance Abuse and Addiction

A STATEMENT OF THE FAMILY NEUROHEALTH CENTRE
UNDERSTANDING AND MANAGEMENT OF SUBSTANCE ABUSING PATIENTS
Based on the diagnosis and treatment of over 1,500 patients at this Centre since May 2001
www.DrNeilBeck.com 13/03/2007

  1. In our experience Substance Abusers and Addicts nearly all suffer from Pre-existing Underlying Factors such as Physical, Mental or Social Sicknesses or Disorders, and/or the after effects of Physical, Mental or Social Injuries. Over 90% of them were sick or injured before they turned to drugs or crime.

  2. They are also often ineffective managers and problem solvers due to their Disorders. Substance abuse is often not the only counterproductive solution, habit or strategy which they have developed, in response to their disorders and injuries, and the situations and relationships those disorders and injuries got them into.

  3. In our experience Substance Abuse and Addiction are nearly always either:
    1. a Relief Seeking Response to Distressing Feelings - to serious Discomforts, Miseries or Desperations arising from their Disorders or Post Injury States, or arising from the situations which those Disorders and States have got them into
    2. or an attempt to improve or correct Inherited or Post-traumatic Dysfunctions, Inabilities or Disabilities.

Experimentation, the Ready Availability of drugs, or Peer Pressure, may lead to dabbling with drugs. However we find that almost none of the patients we see who have progressed to Addictions, are free from very significant NeuroPsychoSocial Disorders and/or Post Injury Conditions. Just occasionally we see a fairly Disorder and Post-Trauma free patient, who has been caught out by the marked addictiveness of heroin, or who is using drugs because their partner uses drugs.

  1. Substance Use and then Abuse usually does provide temporary relief from suffering, eg from anxiety, depression, or serious insomnia, or does provide a temporary improvement in function, eg the ability to get moving, to be calmer, to pay attention and get things done. However in the longer term, for morning after, financial, health, legal or other reasons, Substance Abuse becomes very counterproductive, especially if it progresses to Addiction.

  2. People who have become addicts whilst seeking Relief from Distressing Feelings, or from Impaired Function or Performance, usually have multiple problems. One problem alone is very seldom enough to lead to addiction. It usually takes the cumulative effects of several serious problems for a person to become a substance abuser and to then sink into addiction. For many of these people a more helpful and accurate title than "addict" would be, "a person with multiple serious problems which have been dealt with by immediate relief, counterproductive means".

    As with drugs, other counterproductive measures can become regular habits or strategies for a person with multiple serious disorders, injuries, disabilities and difficult problems, relationships and situations. These measures then provide poorer and poorer results at greater and greater cost, eg mixing and dealing with the "wrong crowd", excessive costly borrowing, hocking things, running away from debts, lying, crime or exploiting and alienating the people who love or try to help them.

    The greater their initial disorders and dysfunctions were, or the greater their problems have become, because they didn't or couldn't take effective management and problem solving measures, the more their problems snowball. Eventually damage to health, loss of relationships and family, unemployment, poverty, homelessness and perhaps jail, institutionalization, or death may become almost inevitable.

  3. Any Healthcare Agency that seriously aims to help Substance Abusers and Addicts to effectively and lastingly deal with their Substance Abuse and Addiction problems, has a number of jobs to do in order to succeed in this work:
    1. firstly the addict's Pre-existing Underlying Factors must be discovered, by going through a comprehensive and systematic checklist, with provisional diagnoses being made of all their Underlying Disorders and Post Injury States,

    2. then an effective Multidisciplinary Treatment Plan needs to be developed and successfully implemented.

      It is not sufficient to just detox the patient off their drugs. Enough of the Pre-existing Underlying Problems must also be corrected, to allow the drug dependent person to start to feel more hopeful, stronger, more motivated, less desperate and less inclined to make kneejerk unhelpful decisions. Also to function better, and to have greater insight into the Underlying Disorders that are dragging them down.

      The drug dependent person then needs to be further supported, educated and trained, so that they progressively become better managers and problem solvers, and develop solutions to enough of their problems to get on top of life, instead of life being on top of them; so that they can take up their bed and walk.

      Detoxification alone often only puts an addict back to where they were when they first started substance abuse. Changes must be made to the patient's underlying NeuroPsychoSocial condition, if they are not to simply relapse to drugs again.

    3. A special part of the Treatment Plan may be a period of time on Drug Substitution/Blocking Pharmacotherapy, which allows sufficient time for all the other work to be done, for the patient to mature and stabilise (especially teenagers), for them to break all their drugworld connections, to recover financially, and to establish a stable home and new friendships. This Drug Substitution/Blocking Pharmacotherapy period is not necessary with cannabis and benzodiazapine abuse. However it is often necessary with the other two commonest drug dependencies we see, street amphetamine and opiate dependence.
      1. With street amphetamine abuse dexamphetamine or Ritalin substitution can be dramatically effective, although Health Department regulations now make it so difficult to access this treatment that we almost always prescribe Serotonin Noradrenalin Reuptake Inhibitors (SNRI's) instead eg. Zoloft, Edronax, Efexor XR, or Prozac in the morning, plus Avanza or Luvox at night.
      2. Narcotic dependence which involves street narcotics costing up to $50 per day, in a person whose Pre-existing Underlying Distresses and Dysfunctions are not too severe, and are promptly addressed and corrected, can usually be dealt with by using a fairly short, low dose course of buprenorphine eg. 4mgms per day for 3 or 4 days.

Where the street value of the narcotic intake is more than $50 per day and there are significant Pre existing Underlying Factors, a prolonged period of buprenorphine dependence may be the safest and surest way of keeping narcotic addiction patients out of trouble, whilst their Pre-existing Underlying Problems are being diagnosed and corrected. This is especially necessary in an outpatient situation, where compliance and participation in the Treatment and Management Plan may be erratic.

If opioid addiction patients are put on marginal levels of buprenorphine and are therefore often still partially hanging out, as soon as these patients get some money, and especially if for any reason they miss their buprenorphine dosing for a day or two, they often revert to street narcotics. There is no waiting list for heroin - it is only a phone call away and the first shot or two is usually available on credit and often home delivered. They then re-establish their drugworld connections, go through a period of risk of overdosing, get into debt to the wrong sort of people, and a lot of hard work goes for nothing for them, their families and their healthcarers.

For this reason I maintain many of my more serious narcotic patients, with more serious Underlying Disorders, on 12 to 32mgms of buprenorphine daily or alternate daily, for 6 to 24 months. We are now developing an intensive care, INTENSIVE MAKEOVER PROGRAM, to allow us to avoid the need for long periods of buprenorphine dependence, in many of these more serious cases.

Where severe physical pain is a factor and cannot be treated in other ways, methadone may be needed instead of buprenorphine, but methadone has many disadvantages, despite its superior analgesic effect.

  1. Detoxification from drugs of addiction is an essential step in the recovery of an addict, but it is only a start, if relapse is to be avoided. Getting off and then relapsing to addictive drugs again are the dangerous times, when overdosing can occur. If a Drug and Alcohol Clinic's patients have a high rate of relapse, that Clinic may be doing as much harm as it is doing good, and some of its patients may require urgent ambulance and hospital attention for overdoses.

  2. A properly investigated, treated, informed and trained ex-addict can in some ways become a more enriched person, than someone who has never been through such deep troubles.

  3. Teaching ex-addicts better problem solving and life management skills, and teaching them to be aware of and to manage their own moods and energy and arousal states, and to develop their knowledge, wisdom and strength, so that they can manage their own lives, is absolutely essential. No Drug and Alcohol Program will ever have the resources to be able to provide long term ongoing support or repeated periods of treatment for these people, as opposed to diagnosing and treating them, and facilitating their learning to support themselves and to become independent.

  4. Our experience is that the Commonest Preexisting Underlying Disorders and Post-Injury States by far, in Substance Abusers and Addicts, are Anxiety, Depression and Insomnia, Manic Depressive (Bipolar) Disorder, Post Traumatic Stress Disorder, and various forms of Attention Deficit Disorder.

    Other disorders, the symptoms and signs of which we often encounter, are Low Self Confidence/Self Esteem/Body Dysmorphic Disorder, Obsessive Compulsive Disorder, Adjustment Disorder, Dissociation, Personality Disorders, Psychoses, Repeated Chronic Relationship Problems and chronically painful head, neck, back and joint conditions. No addict who suffers from the symptoms of 2, 4, 6 or 8 of these Underlying Disorders, as most do, is going to develop a satisfactory and stable life just by being detoxed, or just by being maintained on buprenorphine, methadone or naltrexone for years and years. No amount of Talk Therapy alone, is enough to heal most of these people. Nor are their families or their communities able to live safe and satisfactory lives, until these people have been accurately Comprehensively Diagnosed, and at least the worst of their problems successfully treated, using Triple Therapy (Medications and Counseling and EEG Biofeedback.)

  5. The manifest shortcomings of Mental Health and Addiction Medicine in 2004 are indicated by the fact that dexamphetamine, still the main treatment used for ADD in Australia, was first used for this purpose in 1937, and Ritalin has been used for over 50 years; and methadone, still considered by many stragglers in the field to be the gold standard treatment for narcotic addiction, was discovered in 1938. In what other fields of medicine are we still so heavily dependent on 1930's treatments? When are we ever going to get on and get this job done, using the sorts of modern productive methods employed for decades in other branches of medicine, and in most other industries? If the rest of the economy was as unproductive as the Mental Helath/Drug and Alcohol Sectors are, they would long ago have gone into liquidation.

  6. At The Chemical Health Centre we have reached the conclusion that it is essential in the field of Mental Health/Substance Abuse/Addiction, that we should develop and make extensive use of modern technology and management methods. Only by doing this can we ever hope to achieve the level of productivity needed in order to empower local General Practitioners and Batchelor level healthcare professionals to be able to drastically reduce mental illness, injury and illicit drug dependence in our communities, in the next few years, with the limited resources that are likely to be available. Others before us drastically reduced the scourge of diseases due to infections by developing immunizations and antibiotics, half a century ago. We are well overdue to follow their example by developing new technology for use in the field of Mental Health/Substance Abuse.

    Conquering NeuroPsychoSocial Disorders, PsychoSocial Injury based Brain Dysfunctions, and Substance Abuse, probably the last great frontier in healthcare, will never be achieved by Psychiatrists and Masters of Clinical Psychology using one to one consultations. Nor will it be achieved by low productivity public clinics. There are not enough Psychiatrists and Clinical Psychologists and there never will be, to do all that needs to be done. The "mystery" of mental health and addiction causes many to stay away from this field, and others cling to traditional, comfortably familiar, 1 to 1 skilled craftsman methods, which were largely left behind in most other fields, 50 years ago.

    Private psychiatrists and psychologists are mostly located in the upper socioeconomic level districts and their services are largely confined by cost to middle and upper socioeconomic level patients. Residents of the poorer working class districts, to which the vast majority of people with NeuroPsychoSocial problems have gravitated, because of their chronic shortage of money, mostly have to struggle on without adequate care. Innovations that would allow new more productive methods, such as have revolutionized productivity, reduced costs and increased availability in almost every other field of human consumption and need, have to a large extent not yet happened in mental health.

    If this job is going to be done, especially in the poorer suburbs where the great majority of the problems are found, it is probably mostly going to have to be done by local GP's, assisted by on the ball Bachelor Degree Healthcare Professionals, empowered by new, highly productive technology and management methods. The scarce backup of Clinical Psychologists and Psychiatrists can then be saved for the really complex cases. The cooperation of The Health Insurance Commission will also be needed in extending Medicare rebates to necessary new methods and services eg. GP's being allowed to use the highly cost effective Group Therapy method at present only rebated when done by Psychiatrists. also State and Territory Health Departments will need to keep restrictions by out of touch "expert" officers and committees to an absolute minimum.
    It is essential that coalface Healthcarers are not held back by rules and regulations devised by ivory tower doctors and pharmacists and their consultant committees who, however eminent, rarely stray into the districts where most of the problems occur. We recently lost our psychiatrist, the only free psychiatrist in WA available to penniless ADHD, speed and methamphetamine addicts, because the WA Health Department made it almost impossibly difficult for patients with a history of self medicating with street amphetamines or heroin, to be treated with dexamphetamine, and greatly increased the paperwork and frequency with which the patients had to be seen.

    If he had stayed, our psychiatrist's waiting list would have blown out from 3 months to 12 months due to the new regulations. Many of these patients have now reverted to self medication with street amphetamines and opiates some went to jail. Some hardly managed to get out of bed for the first month after having their medication cut off, and suffered horribly from the consequences of this beurocratic bungling and ignorance. The backyard amphetamine manufacturing trade is the beneficiary. This trade exists almost entirely to profit from people with undiagnosed ADD, or those who can't afford, or are mentally incapable, because of the severity of their ADD and other conditions, of accessing the very expensive and difficult "proper" channels for the diagnosis and treatment of their disorders.

  7. From our work so far, we predict that the major advances that will provide the increased productivity needed, will include:
    1. Fast Accurate COMPREHENSIVE DIAGNOSIS done by comparatively low cost, plentiful, on the ball, Bachelor Level Healthcarers, Empowered by Modern Technology, who don't have 3 to 6 month waiting lists
      1. The use of carefully designed computerised checklists, which can be administered by Batchelor Level healthcarers, to systematically discover all of the major problems that a patient has, with a 90% degree of accuracy, in less than half an hour;

      2. Special Electroencephalograms (EEG's) - recordings of electrical flows from the brain - that yield substantial information about the nature, severity and progress of a patient's NeuroPsychoSocial disorders, and which can be done by Bachelor Level healthcarers, who can be taught to do and to interpret these EEG's, with a few months of on the job training.

      3. The use of computerised checklists which allow Batchelor Level healthcarers to accurately, meaningfully, and at minimal cost, to track and graphically display the progress, or lack of progress, of patients under particular treatments;

    2. Effective TREATMENT MODALITIES Which Can be Administered by Batchelor Level Healthcarers
      1. The development of systems that enable patients to go through a comprehensive, realistic and concrete program of goal setting
        which assists them to define and achieve what they want in order to have a better life
        to define and get rid of what they don't want, in their life
        to see clearly whether or not they are making progress,
        and to decide what their focus and goals are going to be in the next month.

      2. NeuroTuning (EEG Biofeedback), which will become an invaluable widely used additional treatment modality, and be administered by bright Batchelor Level healthcarers, allowing much more permanent improvement in patient's Disorders, than that achieved with pharmacotherapy or counselling/psychotherapy alone.

      3. Group Therapy, in which Bachelor Level healthcarers can play a support role, to replace a large proportion of the labour intensive, costly and often only modestly effective, one to one consultations, that are almost universal in "Mental" Healthcare today.

  8. So far our Family NeuroHealth Centre development of technology that allows us to take big strides, instead of small steps, includes:
    1. The development of both the clinical aspects and the software package of our MINI DIAGNOSTIC CHECKLIST for NeuroPsychoSocial and Substance Abuse Disorders (now available on CD).

      This package allows our clinical assistants, in 15 to 20 minutes, to collect most of the information we need about new patients, with the computer processing and printing out in a few seconds, all the significant symptoms found, and the provisional diagnoses of the disorders and dysfunctions present.

      The development of this Checklist was a major undertaking, started six years ago by Neil Beck. There were 5 printed versions over the years, and we now use the 4th generation of the computerised version, programmed by Doug Simpson and carefully refined by our team. The resulting instrument has transformed the effectiveness of our clinic.

    2. The development of a PROGRESS ASSESSMENT & GOAL SETTING CHECKLIST.

      We have developed a second computerised checklist that allows each patient, assisted by one of our staff, to review systematically and comprehensively, in a few minutes, where they are up to, to know what progress they made in the previous month, and to formulate and clarify realistic goals for the month ahead.

      This is also an invaluable check on the effectiveness of the Centre's Treatment Plan and its implementation, for each patient. It is a source of motivation for both the patient and the team, and will provide invaluable research data, when we or someone else has time to do research on our findings.

    3. We surfed and scoured the net for EEG and EEG Biofeedback programs that would be the most suitable and the most productive for our type of clinic. After having to get rid of our first software/hardware package, which is the one most commonly used, because it was too complex and insufficiently productive, we now have three sets of a software/hardware package which is simpler, very suitable for our purposes and highly productive. Two members of our staff are expert in the use of this technology for:
      1. confirming and enhancing our Diagnostic Checklist and Clinical Assessment findings, and for

      2. NeuroTuning, which helps patients, by a process of EEG Biofeedback, to normalize the strength of their brain electricity. This enhances their brain function, flexibility and resilience.

    4. We have developed A Medication Menu with Touch Screen Computerised Prescription Writing, which allows a doctor to more precisely select the most appropriate medications for a patient, and to spend significantly more time focused on patients, and less time focused on prescription pads. With 4 quick touches, taking only a few seconds, any of the most commonly needed medicines can be prescribed. This system will also allow research on pharmacotherapy in the future.

    5. We are planning to develop the use of computer recorded and processed data from the Diagnostic Checklist, the Progress Assessment and Goal Setting Checklist, the EEG data and the Computerised Prescribing including:
      1. the patient's distresses, dysfunctions and disorders,

      2. their illicit drug preferences and dislikes, and what these drugs do for them,

      3. the medications that have been helpful or unhelpful in the past, together with

      4. the results from our computer prescribing,

to predict which medications are most likely to be helpful, or to be unhelpful, for a patient with a particular problem. This should speed up success in the pharmacotherapy aspect of our treatments.

I trained in Group Therapy many years ago, in California and in Perth, and Lilian te Koppel has had experience of this form of counselling in Europe. In the early days of the Chemical Health Centre I ran some groups which were very productive, but could not continue when the Centre got too busy and we were unable to find other doctors to assist. We believe that a good Group Therapist, with some well adjusted Bachelor Level Healthcarers or students in the group, could greatly help some of our patients, ho suffered from defective parenting and social skilling in childhood, to develop their ideas, knowledge, understanding, values and social skills. With additional funding we soon hope to find a suitable Group Therapist and to reintroduce this treatment modality to our program.