Ask people if they’ve ever stepped on a nail and most will say yes. It can happen to anyone, although the odds go up when lots of boards with nails in them are lying around and people are not paying attention. No one wants or expects to step on a nail. It’s a no-fault wound. Addiction is more likely to develop when lots of addictive substances are within easy reach and people are not paying attention. Some people are more susceptible than others, but it can happen to anyone. No one wants or expects to develop addiction. It’s another no-fault wound. Concern and individualized assistance are appropriate responses to no-fault wounds. Blame and judgment are not. Our responses to people with addiction ought to be like our responses to people who step on a nail. We might begin by expressing concern for the injured person and then proceed to administer the...

After looking the other way for far too long, people and institutions in the United States are starting to face addiction. Respect for individuals in active addiction and resources to assist them into recovery are gradually becoming the norm. Previous Addiction Medicine Updates have identified two core responsibilities, stated as calls to action, that most individuals in active addiction need to adopt in order to achieve lasting recovery. Keep Your Distance! advocates modifying routines and lifestyles to minimize the risk of resuming substance use. Ask for Help! advocates repairing and creating relationships based on honesty and mutual respect. The latest neuroscience, as well as decades of practical experience, support the relevance of these actions, which I call The Two Pillars of Recovery®. But what about everyone else? What about all those who live with, care for, and work beside people in active addiction? What actions should family, friends, healthcare providers, and...

In the United States and elsewhere, addiction treatment programs routinely recommend that patients make use of mutual support groups, also known as “self-help” groups.  Twelve-Step programs, particularly Alcoholics Anonymous (AA) and programs modeled after it such as Narcotics Anonymous (NA), are recommended most often.  They are widely available and have been central to the recoveries of many individuals with addiction, some having achieved success with 12-Step or other mutual help programs as their sole support. Most often, however, peer assistance by itself is not sufficient.  To stabilize and emerge from active addiction, many individuals require formal addiction treatment programs that feature professional counseling in individual and group settings.  These programs may be brief or long-term and some provide residential separation from common relapse triggers.  Medications may be necessary for detoxification, medical or psychiatric problems, and/or relapse prevention.  Medications often are needed beyond the initial treatment episode, some indefinitely. Formal treatment is...

All physician recommendations to patients are, in a sense, prescriptions. Obvious prescriptions are written or electronic orders for treatments or procedures, including medications, diagnostic tests, and physical therapy. Prior to executing these orders for particular patients, physicians typically weigh the relevance of the medication or procedure to the individual based on factors such as cost, availability, accessibility, and patients’ physical and mental abilities. Prescribers routinely order a medication only if there are no special precautions or contraindications for that patient, and they educate the patient regarding potential adverse effects. Less obvious as prescriptions, but no less deserving of foresight and care, are the recommendations to patients receiving addiction treatment that they attend and gain support from mutual-help meetings, particularly 12-step programs. Providers make these recommendations often, but unfortunately make them without reflecting on their relevance to individuals and without educating patients regarding potential adverse effects. These omissions occur in primary care,...

In the face of our national opioid crisis communities across the United States are taking notice and taking action. They’re proactively addressing opioid misuse, opioid addiction, and overdose deaths by distributing naloxone nasal injectors to counteract overdoses, contriving ways to move individuals treated for overdoses directly into treatment, and making treatment for opioid use disorder (OUD) more accessible. Treatment for OUD has several potential components, one of which is use of three FDA-approved OUD medications: Methadone, buprenorphine, and naltrexone. Use of medication to treat opioid addiction has been controversial since the 1960s when methadone was first shown to help individuals addicted to heroin. But controversy is being replaced with acceptance as OUD medications are increasingly recognized as a potent tool to combat the opioid crisis. Treatment Improvement Protocol (TIP) 63 released by the Substance Abuse and Mental Health Services Administration (SAMHSA) in February 2018, Medications for Opioid Use Disorder, is an...

Individuals in active addiction sometimes say, “I don’t need another rehab, I could teach those groups.” Outpatient counselors sometimes say, “So-and-so isn’t doing well: S/he needs to go to rehab.” The first position discounts the value of addiction rehabilitation by equating it with the content of psychoeducational groups. The second elevates its value to that of a panacea for faltering recoveries. Rehabs—and, for that matter, outpatient addiction treatment programs that incorporate similar elements—are neither of these. Research has consistently shown that psychoeducation provides little or no benefit to those seeking addiction recovery. But interpersonal connection, such as an alliance with an empathic therapist, provides even more benefit than the actual method of treatment employed by the therapist. The wisdom of spirituality as well as the findings of science indicate that the way of recovery is not alone. Essential tasks for those seeking addiction recovery are to make sufficient lifestyle changes that...

People in rural America are dying from drug overdoses at a faster rate than Americans who live in other parts of the country, and opioid poisonings in rural counties are increasing at more than three times the rate of increase in urban counties. Why are rural Americans being hit so hard by the opioid crisis? While many factors contribute to substance misuse and addiction in rural regions of states such as Kentucky, Maine, and West Virginia, several are linked to the recent social and economic decline of rural communities. The dawn of the 21st century brought dramatic and rapid transformations in American rural life. The Great Recession took a significant toll on rural areas where employment dropped and has not yet returned to pre-recession levels. And rural job growth has lagged well behind urban job growth since 2011. Further, economic globalization and the relocation of production jobs overseas caused a shift...

Ethical principles stand behind healthcare providers who withhold medical treatments that are “futile or pointless.” But withholding treatment can be controversial. For example, the family of a gravely ill patient might not agree with professionals that an unproven treatment is futile. Even when scientific evidence in favor of a treatment accumulates, medical practitioners can be slow to embrace it. In Ontario, Canada, Debra Selkirk combined scientific reports with her powerful personal story, seeking to overturn the rule that individuals with advanced alcoholic liver disease must demonstrate six months of abstinence from alcohol to be eligible for a liver transplant. Debra shares her account of that process below. Mark Selkirk died on November 24, 2010 from liver failure caused by alcohol use disorder.  He was never assessed for a liver transplant because he had not been alcohol-free for 6 months, a restriction placed on alcoholic liver disease patients (ALD) around the world. The...

“It all comes down to your choices,” said a man in his fifties as he completed treatment following a brief return to drinking lots of alcohol. In the company of supportive peers and an empathic treatment team, this man had immersed himself for three weeks in mindfulness practices structured by Acceptance and Commitment Therapy (ACT). He also maintained connections with his sponsor and Alcoholics Anonymous. The man recounted how an offer of alcohol—made amid physical, interpersonal, and financial stressors—precipitated his most recent drinking episode. Similar situations had instigated previous binges. In the future, he plans to minimize exposure to stressors and drinking opportunities. When stressors or alcohol are unavoidable, he anticipates choosing to notice them without reacting in ways that conflict with his values. “Personal responsibility” for “choices” protects his paramount value, sobriety. Such clarity is too rare. Many others with addiction—and people around them—would do well to adopt this perspective....

Opioid misuse and overdose deaths in the United States have been rising for two decades. Between 2000 and 2013, the opioid overdose rate—among all ages, races, genders, and ethnicities—nearly quadrupled, increasing from 0.7 to 2.7 deaths per 100,000 individuals. Drug overdose is now the single greatest cause of unintentional deaths in America. Suffolk County, in downstate New York, has been hit particularly hard. With 337 heroin-related deaths between 2009 and 2013, Suffolk County reported more such deaths than any other county in New York State. And in 2014, the age-adjusted opioid-related death rate in Suffolk County was 12.6 per 100,000, compared to the New York State average of 7.2 per 100,000. This article explores why Suffolk County residents are at greater risk for overdose deaths and, more important, how they are now protecting themselves. The Community Suffolk County occupies the easternmost two-thirds of Long Island. Its population size of 1.5 million...