Who doesn’t like a good drink at the end of a long day? I’m a whiskey man, myself. There’s little better than having a good Kentucky bourbon with a friend.
Sadly, these days I find even 1-2 drinks can leave me foggy and irritated the next day. I take some solace from hearing my friends say the same (though that doesn’t always slow them down!).
Alcohol consumption is on the rise  in the U.S. during COVID, but alcohol has been taking some heat in the press lately due to health concerns. Many people think there are health benefits to having one drink a night, but some recent studies call that into question. More on that later.
First, let’s start by defining what we mean by “a drink.” According to the NIH ,one drink is the equivalent of one 12-oz regular beer (5% ABV), an 8-oz malt liquor (which includes most microbrews or specialty beers), 5-6 oz of wine, or 1.5 oz of hard alcohol, such as whiskey or vodka.
These volumes are typically less than a “social drink,” which is what we are served at most restaurants and bars or what we pour for ourselves. Because of this, most people underestimate their intake.
We’re frequently told as doctors to double whatever patients tell us about their alcohol use. I once had a patient who told me she only had one bourbon a day, but thanks to my superior interrogation techniques, I was able to find out that it was one 12-ounce bourbon/day!
But what’s the big deal? Alcohol is everywhere. It is an integral part of social events, celebrations, and even religious ceremonies.
You never have to drive far to find a bar in almost any part of the country. And for many people, a drink signifies a way to relax, to be social, or as a reward for a long day.
And 1-2 drinks is probably just fine in most situations. The recommended maximum, per the CDC, is one drink daily on average for women and two drinks for men. The problem comes in when you exceed the recommended amounts, especially on a regular basis, or when even moderate drinking starts to impact your health.
We’ve all heard that one drink/day can lower your risk of heart disease. But newer studies call that into question. The original studies were based on observations in France showing poor diets but low rates of heart disease (the so-called “French Paradox”). The conclusion was that wine was protective.
Looking back, it’s more likely that the French diet is not as bad as we thought. Also, they don’t drink as much as we thought, they walk more, and have lower stress than most Americans.
Newer, better-designed studies regarding alcohol and heart disease are equivocal and certainly haven’t shown a clear cardiac benefit with moderate drinking.
We also now know that even light or moderate drinking can increase your risk of cancer including esophageal cancer, throat cancer, breast cancer, and colon cancer. And moderate amounts of alcohol increase your risk of migraines, arrhythmias, high blood pressure, obesity, falls, osteoporotic fractures, and, as most can attest to, poor judgment.
In fact, any amount appears to be detrimental to your health. Just one drink per day for a year increases the risk of 23 alcohol-related conditions, including arrhythmias, stroke, and pneumonia, by 0.5%.
This may not seem like much, but if you continue this drinking rate year after year, the risk of these conditions becomes significant. And if you increase the amount to two drinks per day, which is considered the acceptable upper limit for men, these risks increase substantially to 7% per year.
But most importantly, alcohol can impact your quality of life. Alcohol has an immediate positive benefit of decreased stress, a feeling of happiness and well-being, and ease of falling asleep.
This comes at the cost of difficulty staying asleep, as well as feeling increased stress and a worse mood the next day. The net effect is more often negative. Even though this delayed negative impact can be worse than the benefits, the benefits are immediate, so we tend to weigh these more heavily, and therefore think drinking is a great idea.
That’s the insidious nature of alcohol. We have a few drinks one night, then have a “stressful day” the next day. Our perceived stress is often greater due to the alcohol the night before, but we blame work and other stressors. Then we have a drink again that night to relieve our stress. And the cycle continues.
Some fall down the rabbit hole as their drinking increases each night to help compensate for how poorly they feel during the day. The impact becomes greater the older we get.
I routinely see patients with insomnia or depression. However, when I address their alcohol intake, they tell me, ”It’s not the alcohol- I’ve been drinking all my adult life!”
I get it – no one wants to give up their ritual cocktail. But if you have anxiety, depression, insomnia, high-stress levels, or practically ANY psychiatric condition, alcohol makes matters worse.
Alcohol is categorized as a “depressant”, and it does its job very well. For almost anyone who drinks excessively daily, it’s typically a matter of when, not if, they become anxious and depressed.
This is difficult for me to write since I enjoy a good drink like most others. But I see the impressive negative impacts of alcohol on my patients every day. Having a few drinks with friends on a weekend night is fine.
However, if you drink every day, I challenge you to stop ALL alcohol for two weeks to see how you feel. I bet you sleep better, have more energy, and notice a better mood. If you notice these improvements, you have a decision to make – is the alcohol worth it?
 Michael S. Pollard, PhD1Joan S. Tucker, PhD1Harold D. Green Jr, PhD2 Author Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US – https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770975
 The Lancet – Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016 Open Access Published:August 23, 2018DOI: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31310-2/fulltext
 National Institute of Alcohol Abuse and Alcoholism What Is A Standard Drink?
 Centers for Disease Control and Prevention – Alcohol Use and Your Health
 Angela M Wood, PhD, Stephen Kaptoge, PhD, Adam S Butterworth, PhD, et el -The Lancet: Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies – Open Access Published:April 14, 2018DOI https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30134-X/fulltext
 William C. Shiel Jr., MD, FACP, FACR; MedicineNet, Medical Definition of French paradox
 American Cancer Center – Alcohol Use and Cancer
 Eurekalert – The Lancet: Alcohol is associated with 2.8 million deaths each year worldwide 23-August 2018
 The Lancet – What is Alcohol
The use and misuse of opioids in the US have reached epidemic proportions and women of childbearing age may be especially affected. Many of the consequences have been well-documented, including abuse, injury, and death from overdose. However, the impact of opioids on fertility and infertility treatment is largely left out of the discussion. That must change.
To define terms, opiate refers to natural substances that come from opium that is extracted from the opium poppy. They contain chemical compounds including morphine and codeine. Opioids, on the other hand, are synthetic or semi-synthetic products that work by binding to the same receptors as opiates. Synthetic opioids include fentanyl and methadone. Oxycodone and hydrocodone are examples of semi-synthetic opioids.
Greater awareness and education for both patients and doctors are needed on the use of opioids among women and men considering having children or undergoing infertility treatment.
The American Society for Reproductive Medicine (ASRM), the professional society of fertility specialists (reproductive endocrinologists) published a special views and reviews section on opioids and reproductive medicine in the August 2017 issue of the clinical journal Fertility and Sterility.1
The goal was to address the risks of opioids to those seeking fertility care, especially women of reproductive age: those “most at risk for opioid accidents and addiction.
”In response, former ASRM President Richard J. Paulson, MD stated:
“Most reproductive medicine specialists continue to practice as if it is not a phenomenon relevant to their patients even as the epidemic has escalated.”
He considers the special section “essential reading for all clinicians treating reproductive-age women.”
This class of drugs is traditionally prescribed for pain relief following surgery, an acute injury, or for chronic pain. Some women who undergo surgery or other procedures to correct issues related to infertility experience significant pain for which they are prescribed opioids.
Research on opioid prescription patterns following one procedure – egg retrieval for in vitro fertilization (IVF) – revealed surprising results. The study was based on a review of medical records for more than 55,000 women over an eleven-year period.
Those with a prior diagnosis of opioid or substance use disorder and women who filled more than one opioid prescription in the 12-week period before the procedure were excluded.
The researchers found an apparent “disconnect between expected procedural pain and the use of opioids:” 4
Although overall only 12% of women used opioids after egg retrieval. However, there was significant geographic variation:
Further, women were more likely to fill an opioid prescription if they had any of the following
The researchers concluded that only a small proportion of women undergoing an egg retrieval procedure fill an opioid prescription afterward. However, those who do,“receive a large quantity of opioids.”
The authors of the study suggested that since most women tolerate the procedure without opioids, “this should prompt physicians who routinely prescribe these medications to reevaluate this practice.”
Commenting on this research presented at the 2017 ASRM Scientific Congress, ASRM President Christos Coutifaris MD, Ph.D., concluded
“It is imperative that physicians treating couples with infertility not contribute to the widespread opioid abuse crisis. This kind of research raises our awareness of the potential for abuse and, hopefully, makes us cautious with our prescription patterns.”
Hopefully, the greatly increased attention to the potential dangers of opioids will alter physician prescribing patterns encouraging them to find alternatives or sharply limit the time frame for use and amount of drug prescribed.
It is critically important that physicians discuss alternatives to using opioids after surgery. This is because “recent data suggest that opioid exposure after other surgeries confers an increased risk for chronic opioid use” In addition, it poses at risk for relapse for those with a former opioid use disorder.
Alternatives to opioids for post-operative pain include:
A variety of strategies to reduce opioid use before and after medical procedures is discussed in the following article: Perioperative Pain Management Strategies Among Women Having Reproductive Surgeries.5
The stress of receiving a diagnosis of infertility and undergoing treatment can make patients “vulnerable to anxiety and depression, increasing their risk of developing a substance use disorder (SUD)” according to Tricia Wright, MD, MS in her 2017 paper in Fertility and Sterility.3 Further, she notes that pre-conception screening reveals,
“substance use disorders are more common than many other conditions and disorders in women trying to conceive”.
Misuse of opioids includes the following situations:
Dr. Wright says opioid abuse can “worsen infertility, complicate pregnancy, increase medical problems, and lead to psychosocial difficulties for the woman and her family.”
Given these serious consequences, she believes that reproductive endocrinologists have an “ethical and medical duty to screen patients” for such disorders, as well as provide initial counseling and referrals to specialized treatment.
As physicians treating women who are planning to become pregnant, she adds her colleagues are
“well placed to help their patients avoid the consequences of SUDs (substance use disorders) in pregnancy, such as pre-term birth, low birth weight, birth defects, developmental delays, miscarriage, and neonatal abstinence syndrome.” 6
At the same time, some opioids – such as methadone – are used to treat addiction. If someone is on this type of drug as part of addiction treatment, they should discuss the impact on fertility with their addiction counselor and other relevant health professionals. Some treatments are less harmful to fertility than others and should be considered.
ASRM acknowledges there is little information on the treatment of opioid use disorder among the infertility population. The best approach may be to learn from the successful treatment of pregnant patients with the condition.
Research shows that opioid use affects the endocrine system. This includes the hypothalamic-pituitary axis that controls the production of sex hormones.
Opioid-related hormonal suppression can lead to inappropriately low levels of gonadotropins:
There is also inadequate production of sex hormones, particularly testosterone which plays a role in male and female reproduction.
Opioids affect the female reproductive system including ovarian follicles and oocytes (immature egg cells). They may also affect the endometrium (tissue lining the uterus) and myometrium (middle layer of the uterine wall).7 All of these structures play a role in pregnancy.
Hormonal suppression may result in the following:
Using opioids long term can disrupt the signals controlling the production of testosterone resulting in low testosterone production. This in turn can decrease both the quantity and quality of sperm. The actual impact depends on the drug used, the dose, and the length of time it was taken.
Low testosterone also affects male libido. In one study, 20 percent of men on long-term, high dose opioids had evidence of sexual dysfunction.8 The researchers suggest the same may also be true for women but “evidence is scarce.”
There is no evidence that short-term use of opioids has a negative effect on male fertility. So, if the drug is taken to control pain after surgery or a broken bone, a patient should follow instructions to take only as prescribed.
Men who are taking opioids for weeks or months should talk to their doctor about cutting back. Opioid-induced hypogonadism is often a complication of long-term therapeutic use – for chronic pain or addiction – or illegal use.9 Experts suggest if this occurs that “nonopioid pain management, opioid rotation, or hormone supplementation” should be tried after “careful consideration of the risks and benefits.” 10
Your fertility specialist should work with you and your partner to understand how a variety of positive and negative lifestyle habits affect your ability to get pregnant and deliver a healthy baby. The use of opioids – whether prescribed for a specific condition or because of a substance use disorder – should be discussed.
Good patient-doctor communication should be two-way. In fact, a 2015 FDA safety report on opioids urges patients to report symptoms that may be related to reproduction to their doctors,11 including:
Opioids are frequently prescribed for chronic pain. It is important to be cognizant of the overlap in patient demographics for misuse and fertility treatment. That being said, there are important ways to improve patient care for these patients, including:
If you need pain relief from surgery, discuss alternatives to opioids. If treatment for opioid use disorder is needed, your physician can offer or arrange counseling – often through your fertility clinic and/or provide a referral to specialized treatment.
To address the “unique needs” of a woman planning a pregnancy who also requires treatment for opioid use disorder there are four “overlapping domains of treatment:
This is discussed in more detail here: Treatments for Opioid Use Disorder Among Pregnant and Reproductive-Aged Women.12
Undergoing treatment for infertility is challenging for patients. There are many lifestyle habits to follow or change in order to maximize your chances for success. As opioid use may affect the chances of getting pregnant and delivering a healthy baby, awareness and education should be part of the partnership between hopeful parents-to-be and their doctors.
Published 9/9/18. Updated by the author on 1/12/21 for republication
The holidays can present difficult challenges for people in recovery from drug or alcohol use disorder. Even in the best of times, people may experience anxiety and stress related to the holiday season whether due to increased family time, travel fatigue, or unrealistic expectations of holiday happiness.
2020 has not been the best of times. And, of course, the uncertainties surrounding the COVID-19 pandemic have added to the usual litany of holiday stressors. Some individuals in recovery may even opt out of seasonal festivities to avoid relapse triggers that can lead to feelings of loneliness and isolation.
While there is no one-size-fits-all plan to ease holiday anxiety for those in recovery, below are a few helpful tips that I offer my patients during this time.
Individuals can often feel a sense of shame about their addiction. Also, they may be reluctant to share their thoughts and feelings with friends and family over the holidays. This can further increase feelings of isolation
Remember, nearly 21 million Americans struggle with alcohol or substance use issues. So this is not a struggle that you are facing alone. People all over the world are trying to cope with the same challenges you are.
If any situation was designed to trigger a relapse, visiting family and friends in a setting of celebration is potentially at the top of the list. Although the holidays may look different for you this year.
Seeing family or friends in-person or even virtually may prompt emotional memories, even traumatic ones. This can elicit a desire to use drugs or alcohol.
If you are celebrating the holidays alone this year, loneliness can also be a potential trigger. It is important to mentally prepare yourself by identifying likely triggers that will test your sobriety during the holiday season.
Once you have written down your triggers, visualize how you would respond when confronted with each triggering situation, such as an emotionally fraught discussion with a family member.
It is important to develop an emergency plan in advance, so you are ready to navigate uncomfortable situations that place you at a high risk of relapsing.
You don’t want to have to figure it out on the fly. For example, you may want to bookend a therapy session or support group meeting both before and after a social engagement you suspect will be difficult.
Identify a sober friend you can check in with over the holidays. It should be someone who can help you with your emergency plan. Your friend can attend socially distant events with you or even check in with you virtually. This can help ensure that you are able to properly assess the situation and leave if any events seem too high of a risk.
You should always have an exit strategy. Your friend can help, or he or she can simply be available to talk during or after a challenging situation.
This past year has caused a lot of uncertainty for everyone. Many individuals in recovery have had to adjust their recovery journey to adapt to this unprecedented time.
It is important that you maintain your normal schedule as much as possible. If you usually attend in-person peer support meetings, but no longer have the option to do so, it is important that you take advantage of the many virtual meeting options available right now.
Further, it might be important to schedule a meeting before and after holiday celebrations to keep you on track. In addition to meetings, it is important to attend all scheduled therapy and medical visits (whether virtual or in-person).
The most comprehensive treatment for addiction combines two approaches:
If you currently take medication as part of your treatment regimen, it is important that you stay on track and take your medications as prescribed.
Holidays are a time for giving, and great thinkers over the centuries have reminded us that our acts of kindness benefit us as well as those we help. Science has now shown that reward processing  in the brain kicks into a higher gear when we perform altruistic acts.
Finding an activity that contributes positively to your family, friends, community, or a group that you are passionate about can help you refocus on the meaning of the season. It can also keep you preoccupied and away from potentially triggering situations.
Sometimes those in recovery look back on their previous days of substance use and find themselves romanticizing the situation. They may only remember the fun while forgetting the challenges and difficulties associated with using.
This year try redefining what “fun” means to you. Instead of getting together for drinks, perhaps have a cookie bake-off (virtual or in-person), play board games, or host a holiday movie trivia night.
Have fun during the holidays: 10 Smart Ways to Enjoy a Healthy Holiday Season
The acronym HALT stands for
These are states in which someone in recovery is particularly vulnerable to relapsing.
More fundamentally, the concept of HALT is a reminder for you to stop for a minute and think about whether you are truly caring for yourself. Are you getting too little sleep or feeling isolated? Now might be a good time to try some meditation techniques, eat a healthy meal, or call a friend.
If you are heading into a situation that is high risk, take a minute to do a quick self-check to see if you are hungry, angry, lonely, or tired and decide if you really want to attend. Or if you might want to eat, calm down, or rest before going.
Exercise increases the production of endorphins. These are “feel good” chemicals in the brain that reward us when we do the right thing. As I noted before, this is the same reward center that comes under attack with substance use.
One study  in morphine-addicted rats found that rats who underwent swimming exercises voluntarily reduced their consumption of morphine compared with sedentary rats. Studies  in humans  have also shown that people who participate in exercise programs reduce their drug use.
This year has been a challenging time for everyone, but if you are experiencing difficulties in your recovery, or are just getting started, don’t hesitate to reach out to a healthcare professional to get support. With these tips, people in recovery can set themselves up for success as we head into the new year.
Have you ever over-indulged, drinking four or even more alcoholic beverages in a short period of time. And then got up the next morning with a headache, nausea, and generally feeling run down the next morning? These symptoms are all quite common after a night of over-consumption. But how can you know if it is just a bad hangover or something more serious? Read on.
In addition to its pleasant, intoxicating properties, alcohol has several potentially adverse physical effects. Alcohol can do the following:
Physiological effects like these can help to explain the headache and nausea commonly associated with a mean hangover. In many cases, these symptoms resolve relatively quickly with some carefully selected food (I’m looking at you, breakfast burrito). Also, drink several glasses of water to replenish nutrients and rehydrate.
Warning: You could be experiencing a potentially dangerous alcohol withdrawal episode if any of these apply to you:
Acute alcohol withdrawal is a sure sign of physical dependence on alcohol. And, it could potentially be part of a larger alcohol use disorder.
Here are other physical signs that could be additional red flags.
These five warning signs will tell you that it’s more than just a hangover:
Rapid heartbeat, uncontrollable tremors, and excessive sweating are all signs of acute alcohol withdrawal, along with high blood pressure, irritability, and anxiety or agitation.
In more severe cases, complications such as seizures or delirium tremens—a rapidly progressive combination of altered mental status and autonomic nervous system hyperactivity—can be life-threatening developments that require immediate medical attention.
Everyone has a different withdrawal experience. But if what you think is a hangover lasts for a second or third day, it’s a sign that it might be more than just your typical hangover.
Withdrawal can progress over a period of several days as your body adjusts to the absence of alcohol. When a suspected hangover turns into a days-long ordeal, there’s a good chance it’s more than the result of just a little overindulgence.
With a typical hangover, you should start to feel better within a few hours after eating something and drinking water. But, if you’re 12 hours out from your last drink and symptoms continue to get worse, it could mean you’re in withdrawal.
In fact, some of the most severe symptoms of withdrawal can continue to develop as many as two or three days after the last drink. If you or someone you know is getting worse instead of better, it’s time to seek medical help immediately as the risk of seizures increases without treatment.
If you start to experience significantly troublesome hangover symptoms that interfere with your daily routine after every drinking session, that could be a warning sign of escalating physiological dependence and a developing alcohol use disorder.
And, you don’t necessarily have to drink every day in order for it to be a problem. For example, long recovery time after binge drinking every weekend could be an indication of maladaptive patterns of use and growing alcohol dependence.
Such developments may be especially problematic if you’re experiencing other negative impacts in your life as a result of drinking. For example:
If your frequent hangovers interfere with your life, it may be time to seek help.
Hair of the dog has been touted as a hangover cure for centuries. But drinking more may not be doing your body any favors. It could be merely postponing the onset of acute alcohol withdrawal.
If your body is accustomed to functioning with alcohol and it’s struggling to do so without it (hence the symptoms), of course giving it what it’s accustomed to is going to make you feel temporarily better.
But it’s certainly not helping the underlying problem. If drinking again immediately makes you feel better, this is definitely a red flag (and, furthermore, meets one of the criteria for the diagnosis of an alcohol use disorder).
Related Content: Alcohol, Not Opioids, is America’s Most Abused Substance
Overindulging on a rare occasion is common. Alcohol lowers your inhibitions and impairs judgment, after all. It doesn’t necessarily mean you have a problem.
However, when frequent, severe hangovers become part of your everyday life, you could be headed down a path toward alcohol use disorder. Problematic alcohol use is typically progressive. It’s not impossible to turn it around on your own, but it’s more likely to get worse without intervention.
If you’re concerned about your hangovers or potentially problematic or compulsive drinking behaviors, start by speaking with a physician, therapist, or other addiction treatment professional.
They can help determine your level of addiction risk and potential avenues of treatment, if necessary. You might also start by taking a self-assessment to see where you stand in terms of a diagnosable condition.
If you’re concerned that you’re already at risk of experiencing acute alcohol withdrawal whenever you attempt to slow or stop drinking, talk to your doctor. There’s no harm in acting early in addressing potential problem drinking. If knowing the risks of developing physical dependence and the dangers of withdrawal can deter excessive drinking, one might avoid the hangover altogether.
Related Content: Why Seek Professional Help for Alcohol Addiction?
Importantly, though, knowing how to get help if you need it can keep you safe. It can also ease the path for long-term alcohol recovery so you can enjoy many more holidays with family and friends in the years to come.
Published: 12/19/19. Reviewed and updated 11/16/20.
America’s opioid addiction problem began, in my opinion, over 30 years ago in what many consider an unlikely place: America’s medical schools. Prolonged anxiety, grief, isolation, and financial worries stemming from COVID-19 have only exacerbated an already growing problem.
There’s been a dramatic surge in opioid-related deaths during the past six months. In fact, just this month, the American Medical Association issued a statement citing rising cases of opioid-related mortality in more than 40 states, urging those governors and legislatures to take swift action to help curb the deadly tide.
In four years of medical school plus a five-year surgical residency, I had no formal instruction in substance use or addiction. In fact, it was mostly treated as an annoyance—doctors were tasked to “deal with the junkie in Room 208.”
I found this ironic, considering that as surgeons, we were frequently the cause of a patient’s pain—the result of a procedure to treat their primary affliction. Afterward, prescribing opioids for post-surgical pain was the standard operating procedure. Percocet, Vicodin, Oxycontin, and Dilaudid were all top of the list.
Pain was even viewed as a “5th vital sign.” It was seen as such a detriment to healing and survival that doctors were encouraged by specialty societies and medical boards to treat it aggressively for the overall recovery and well-being of the patient.
Unfortunately, physicians lacked training in the risks of opioid use. They also had limited understanding of how certain medications work (or don’t work) for acute injuries versus chronic conditions.
This opened a flood gate of excess opioid prescriptions. This, in turn, resulted in the growing consumer demand for more powerful drugs, creating an entire class of addiction patients.
Now, of course, things are much different. We know the dangers of opioids. And, we’ve come light-years in drug research and alternative pain therapies to minimize the risk of addiction. But we now face the daunting task of undoing years of damage.
The good news is that we have made some progress, including
However, more than 90% of patients who need treatment for addiction still can’t get the help they need.
Societal attitudes and the stigma and shame associated with addiction play a large role in creating those hurdles, but one of the biggest obstacles lies within the treatment community itself.
One of the largest hurdles in getting more treatment for more people is the lack of access to the right kind of care, specifically addiction medicine. Most people are familiar with the different types of clinical treatments known to be effective, including
But they may not be familiar with the medical specialty of addiction medicine which deals specifically with the physical aspects of drug addiction treatment.
It encompasses a full range of medical needs, including detoxification, vital patient care, and medication therapies to treat co-occurring diagnoses that must be managed simultaneously, including but not limited to:
A myriad of treatments can help with these needs, including medications that can minimize the damage and discomfort of detox and prevent co-occurring issues from undermining clinical therapy. These therapies must dovetail perfectly within a comprehensive treatment program to ensure the best possible outcome and avoid unintended consequences.
Unfortunately, 98% of addiction treatment providers are untrained in addiction medicine. This creates a huge shortage of specialists that have the expertise that is desperately needed in order to effectively tackle the opioid addiction epidemic from a holistic approach.
To address the addiction medicine shortage, River Oaks Treatment Center, an American Addiction Centers facility, has partnered with the Brandon Regional Hospital to launch a new Addiction Medicine Fellowship. HCA Healthcare/USF Morsani College of Medicine GME Programs is a sponsor of the program.
Led by Brandon Regional’s Dr. Abbas Sina and River Oaks’ Dr. Michael Murphy, the fellowship aims to provide in-depth, hands-on experience for two clinicians in direct addiction medicine treatment.
Through this ambitious program, two medical fellows, myself included, will partake in clinical rotations at both Brandon Regional and the River Oaks Treatment Center. We will receive a full and intimate view of the entire addiction treatment process, including
As part of the one-year program, the fellows will gain experience in managing co-occurring conditions as part of a high-volume comprehensive care center,. This will allow them to follow patients’ progress throughout the addiction treatment journey.
The program also includes a unique introduction to addiction treatment within pediatric populations. It will include taking care of neonates born to addicted mothers and going through withdrawal.
Addiction has truly become one of the most vexing medical conditions of our time. It’s the only disease in which even getting patients to accept that they have the problem that needs treatment is a formidable challenge.
There’s no denying colon cancer or a coronary artery blockage—almost no one refuses surgery to fix those. But, with an estimated 10.3 million people misusing opioids a year, and overdoses up nearly 20% since the COVID-19 pandemic began, it clearly remains a public health crisis of epic proportions.
With the right kind of treatment and resources in place—which includes a much-needed expansion in the number of qualified addiction medicine providers—we can close this critical gap in medical care and get more Americans the help they need to overcome opioid use disorder.
Here is the link to learn more about the addiction medicine fellowship at River Oaks and Brandon Regional Hospital.
[Editors note: We have not received compensation for publishing this article. But we have included links to commercial entities because they add to the strength of the story.]
Here’s the story of how I learned the profound honor and responsibility of giving bad news to loved ones.
The fire doors to the stairwells are fairly thick in the hospital. Still, when I opened the door to the stairs on the 3rd level, I could hear a distinct sound coming from the ground floor hallway. It was something like an animal howl, loud and uninhibited but also vaguely familiar.
I couldn’t make out any words or clear emotions due to the muzzle of the two-inch-thick metal fire doors. However, I knew that I did not need to walk into whatever situation was sparking this noise.
The ground floor hallway contains the trauma waiting room. That’s where friends and family of those unlucky patients did all that they could do. Wait.
Whenever the doors are closed to the MedStar Trauma waiting room, someone is receiving bad news. Doctors and nurses are telling patients’ families that “we did everything we could” and “I am sorry for your loss.” It is difficult news to give. And, it’s even harder for loved ones to hear.
I remember that when I passed by the waiting room earlier that morning, the door was open. I saw a middle-aged woman sitting alone.
The Code Yellow alert, an alert to an incoming major trauma that I had come down to investigate, was not going to be one of mine. A teenage girl had been brought in with a gunshot wound to the head.
It was a Wednesday. She should have been in school. But none of this mattered to me or my job. I only enroll patients into our traumatic brain injury research who have blunt head injuries. We are not interested in penetrating head injuries.
When I left the unit to go see my other patients, the commotion in Trauma Bay 1 seemed to be winding down. I didn’t think she made it.
The next time I passed by the trauma waiting room that day, the door was open, but no one was inside. The chairs had been rearranged so that two chairs faced one as if three people were having a close conversation.
It clicked in my head that the sound I had heard earlier was the howl of that girl’s mother after receiving the news that her child had been killed. There was a reason that sound was familiar. I had heard it before.
“Hey, Bethie, I’m on campus for a meeting and want to take you out to lunch. When are you free, and where should I meet you?”
“Hey, Pam! I have class until 11:30 and then a meeting at 1 for a project. Can we meet at The Golden Bear Café? It’s on Sproul. Food isn’t bad, and that’s where I always go for lunch!”
“That works. I’ll see you there at noon.”
I slid my phone back into my backpack. Dr. Fish was very clear on the first day of PolSci2: if he caught you with your phone out during the lecture, you would receive an automatic fail in the class.
I knew I shouldn’t have even checked my phone, but I was a popular girl! I needed to make sure I kept up with my texts.
Honestly, I didn’t want to go to lunch with Pam. Sure, she was the closest thing I had to the family at Berkeley. Further, rarely did she make the half-hour trip over the Bay to campus.
But I was less than two weeks away from my first set of college finals. I was stressed. I did not have time to waste on trivial matters like eating or relationships.
Then again, Pam and Dennis were basically my aunt and uncle, and I was thousands of miles from home in Chevy Chase, MD. It was not like I had many family commitments out at Cal.
I guess I could spare time for lunch.
I walked from Wheeler Hall to The Golden Bear Café (GBC for short). The sky was brightly overcast that Tuesday, just like always. It was in the 50s and foggy, and some leaves were still on the trees. Rotund squirrels were digging through the trash cans. In my opinion, everything was pretty damn near perfect.
I was wearing my usual uniform of jeans, scuffed Frye boots, a white V-neck, and an effortlessly cool thrifted cardigan. In reality, I put a lot of effort into looking so effortless, but this is one of the accomplishments of a freshman college girl.
I was starting to get annoyed. It was already 12:30 with no sign of Pam. I needed to get moving if I was going to make it on time for my Chemistry research project meeting.
I was just about to text that I was leaving GBC when I saw her walking through Sather Gate with Dennis. Huh, she didn’t mention that Dennis was coming too. Dennis is my mom’s cousin, and Pam was my mom’s best friend in college.
I guess it worked out pretty well when they got married. I was also close to their daughter, Sandra. She was the same year as me in school.
At the beginning of the year, we joked that Sandra and I switched families for college since she was only a 20-minute drive from my parents at Georgetown University. My mom also said many times that if I was going to be so far from home, it made her feel better knowing I had family nearby in case of emergencies.
I waved them over and gave both of them a hug. Dennis took one look at my outfit and said, “you’ve turned into such a hippie.” This made me smile even bigger.
Hippies are cool! That means I’m cool! Look out world, new and improved Beth was making her way onto the scene.
But it was then that I noticed something was a little bit off. I had tried to make eye contact with Pam, but she shifted her eyes behind her sunglasses and wouldn’t look at me.
It was also definitely not sunny out. Why was she wearing sunglasses? I turned to Dennis about to ask what was up when he put his hands on my shoulders.
“Beth, Charlie had an overdose.”
Ok, this is ok, I thought in the ensuing two-second pause. He’s probably in a coma or in the hospital, but he’s ok. I’ll just go home for a week and be back in time for finals—nothing to freak out about.
“And he died.”
No, he didn’t. He’s 21. Or wait, he’s 20. His birthday is next week. I haven’t bought his present yet, but I swear I was going to get him something this week. They’re wrong. This isn’t right. My brother isn’t dead.
I looked at Pam again and realized that she was crying. Dennis was crying too. I felt a slight sting in the corners of my eyes. “You’re wrong. He’s not dead.” They needed to know this. This was not possible.
Dennis tried to hug me, but I pushed him away. I didn’t need a hug right now, especially not from him. Why would he joke about this? This wasn’t a funny joke. He could stop now.
“I’m so sorry, honey,” Pam choked. She looked like she couldn’t stand without holding onto Dennis.
My eyes were getting blurry. I wasn’t one to cry that often, especially not in public. I wasn’t even sure why I was crying because I knew this wasn’t true. Why are they saying this? My wrist reflexively went to my face as I felt the tears run from my eyes. My sweater sleeve came away damp.
“He can’t be dead,” I kept arguing. My breath started to shorten as the sobs swelled. I focused on my tuna melt and saw that I had only eaten a few bites. When I swallowed now, it felt like my throat had narrowed to half its size.
“Let’s call your mom,” Dennis said. I could call my mom? That was allowed? Dennis handed me the phone, and all I heard was my mother howling. I had never heard a sound like that before. It was guttural. I don’t know what I did with the phone.
It was then that I broke. People sometimes use the term “broke down” to describe their reaction to events like this, but I just broke.
I was both totally inside myself and unable to think; I just kept wiping my face because the tears kept coming. Somehow, I wound up on the ground, sobbing. I was in the middle of the busiest part of campus right as classes were changing.
I only saw one person looking at me before I went back into myself. And, then, I was in the back of Pam and Dennis’ car.
Pam asked me which friend I wanted to call. I could call my friends? I mean, I get that I could call my mom, but isn’t this a family thing? Don’t we keep things like this to ourselves? We never told anyone when George or Charlie were in rehab.
Isn’t this the same thing? Pam told me I could call my friends, so I looked at my most recent calls. There was the call to Mom, and then the next call was from Alexis Newman the day before. Right, Alexis is my best friend. I called her.
“Hey! What’s up?” Alexis said.
“My brother died,” I wept.
“Where are you. I’m on my way,” she said immediately. I think I said something about being in a car with my aunt and uncle. And then, I just cried.
She kept asking me what had happened, but I didn’t know. What did happen? Dennis said it was an overdose, right? I don’t know if I told her that. I think I just cried.
My final memory of that extended day was seeing my family at Dulles baggage claim. Pam told me that they were coming to pick me up, but I didn’t know what to expect. I mean, it wasn’t my whole family picking me up. But I guess it would never be my whole family again. We were officially broken.
When I saw my mom, it didn’t look like my mom. Yes, I recognized her. Of course, I did. But when did she get so small?
She saw me and made that sound again. As I hugged her, I could feel that she had shrunk to the size of a child. I actually felt like I might break her if I hugged her too hard.
Her frailty shocked me more than the gaunt look on my dad’s face or the anger shown on my brother, George’s. As we all walked down the corridor to leave the airport, my mother turned to the wall and wretched. Vomit sprayed all over the floor, but she just wiped her mouth and kept walking. We would never be the same.
“I just don’t get what they won’t understand. If you walk them through and clearly explain everything that happened to the patient and why they’re not going to recover, how would the patient’s family not understand that?”
Edward  made that comment in our class on the ethics of end-of-life care. It was part of a broader discussion on how to talk to our future patients and their families about the end of life. It also included an exploration of what our role should be as their doctor at this painful time.
We had veered a bit off topic from discussing the readings. But this was always when the more interesting discussions happened in these groups. Besides, our ethics facilitator, one of the lead medical ethicists at Georgetown, did not seem to mind the direction we were heading.
I replied, “I don’t think you get that logic might not work in this situation. There are so many emotions involved for the family members, and they might not even want to listen to you.”
I was starting to get fired up. We were discussing how to break bad news to a patient’s family about the brain death of their loved one.
As first year medical students, we had the luxury of having these theoretical discussions with our classmates and professors long before we would ever be expected to have them with patients.
Try as I might, I sometimes got heated in these small group discussions. I probably came across as a little intense. However, I was starting to realize that not many of my classmates had encountered death or dying as I had. Maybe I could use the shock and grief I went through to help educate my peers.
I thought about a surreal story my mother relayed from that day years later. She was alone in my childhood home when the police knocked on the door.
They asked her “are you the mother of Charlie Glowacki”? After confirmation, they said, “I am sorry ma’am, but your son has passed.” “Passed what?” my mother asked in confusion. I think about that whenever I am told to “avoid euphemisms” when communicating with a patient.
I remember that day in chunks and swathes. Little stitches of human interactions come through and stick in my mind to this day. There was Alexis’s concerned voice, the look of abject horror on my dad’s face, and the flight attendant’s offer of an extra blanket when she saw the tears in my eyes.
There was also the sound my mother made. I have only heard it once since then. It was the same sound the mother at MedStar trauma made. It hollowed my bones and carelessly sliced through my chest.
I hope never to elicit a howl like that. However, I know that sound will haunt me again sometime in the future, given my chosen career.
I also know that it is a great responsibility and privilege to interact with someone on the worst day of their life. I will show the utmost compassion and humanity that people showed me that day.
 Name changed for anonymity
This story was initially written for a course the author was taking called “Reflective Essay: Writing Your Experience.” It is one of the most popular electives at Georgetown University School of Medicine where the author is a medical student. It was developed and is taught by an adjunct faculty member, Margaret Cary, MD, MBA, MBA, PCC. In addition to being a writer and educator, Dr. Cary is a leadership development coach, trainer, and contributor to TDWI.
It was only a few months ago that vaping among teens and young adults was making headlines with stories of vaping-related deaths and lung injuries. Now, there may be another danger for those who vape—the risk for serious illness from the COVID-19.
That’s frightening considering the use of vaping or e-cigarettes has exploded among American youth. Last year alone, we saw a 78% increase in the number of high school kids vaping. According to preliminary data from the National Youth Tobacco Survey, 27.5% of youth are now using e-cigarettes.
With more than 2,800 reported cases of severe lung injury related to vaping in all 50 states, the dangers are evident. Not to mention, a disturbing 52% of all patients suffering these ill effects from vaping are under the age of 25 — a direct correlation to the surge in e-cigarette use among teens and young adults.
Many people think COVID-19 will only affect older adults, those who are immunocompromised, and those with pre-existing conditions. However, we have learned that the potential of devastating effects of infection with the coronavirus are not limited to those groups.
Also, we now know that smoking and vaping can lead to irreversible lung damage, some of which have yet to be diagnosed. We are already aware of the toxic soup of chemicals that youths who vape are filling their lungs including nicotine, of course, but also:
All of these chemicals are present along with nickel, lead, cadmium, and many other trace chemicals. Each of these chemicals can wreak havoc on the lungs of developing teens and young adults. They can cause a host of pulmonary issues that can exacerbate the effects of COVID-19.
Related article: Toxic Chemicals Are a Threat to the Health of Our Children
There are a few illnesses that can develop from the use of vapes/e-cigarettes that may increase vulnerability to the virus:
It is a life-long condition that thickens and widens the airways causing mucus to collect due to the inability of the airways to clear. Having this condition makes individuals extremely susceptible to respiratory infections, including COVID-19.
It is an interstitial lung disease resulting in the inflammation of the lungs due to a reaction from an inhalant – in this case, vape juice. Progression of this condition can require lung transplantation.
In November 2019, doctors at Henry Ford Hospital in Detroit, MI, performed what is believed to be the first double lung transplant due to vaping-related illness. While this has been reported once, we now know that it is possible. Should this procedure take place, the individual will be immunocompromised indefinitely and at great risk of suffering from the worst symptoms of COVID-19.
In addition to us not knowing what the long-term effects of heating, vaporizing, and inhaling these substances might be, we also don’t know the level of susceptibility people who vape have to COVID-19.
While health officials have been warning seniors and those with underlying medical conditions about their risks with the coronavirus, we are doing our young people a disservice if we don’t sound the alarm for them as well.
We must do everything we can to educate teens and young adults about the dangers of vaping. This is especially as we endure this pandemic because as of now we just don’t know for certain what the impact of vaping will be related to COVID-19 severity.
We also shouldn’t assume that these young vapers know the risks of vaping and the effects that could arise as the number of COVID-19 cases increase.
Already there have been anecdotal stories about the possible effects. In early March, New York City Mayor Bill de Blasio informed the public that a 22-year-old Brooklyn man was diagnosed with COVID-19 and was hospitalized.
The man didn’t appear to have any pre-existing conditions besides the fact that he was a vaper. “Why is a 22-year-old man stable but hospitalized at this point? The one factor we know of is he was a vaper. So, we don’t know of any pre-existing conditions, but we do think the fact that he is a vaper is affecting this situation,” said de Blasio during the press conference.
Related content: Why Some People Struggle with Addiction and Some Do Not
As a nation, we are in uncharted territory with COVID-19. We should not wait for the science to catch up–we need to act now.
Related COVID19 Content: Greater Risk of Blood Clots in COVID-19 Patients
It could take months or years before we have all the answers. If we act now, we may be able to save lives, prevent unnecessary hospitalizations, and reduce the risk of overburdening our healthcare system at a time when we must all do our part to end this pandemic.
When severe substance use disorder or addiction strikes, it often has devastating consequences to individuals, families, and communities across our nation. The recent to attention the opioid epidemic raises the question: why do some people struggle with addiction and some do not?
It is human nature to try to figure out the root cause of the crisis. Unfortunately, the search to find what causes addiction may lead to blaming one source over another. This adds to its stereotype and myth.
As a clinician who works with individuals and families who are making the transition from active addiction toward a pathway of wellness and recovery, I am often asked what causes addiction.
Most individuals and family members who are seeking to understand why this is happening to them, and those they love, are earnest and desperate to find answers. Many of them are coping with the loss of sons, daughters, fathers, and mothers who have died from the disease of addiction.
Others are in a state of manic fear as they reach out for help in their difficulty and suffering before the disease takes their own life or that of a loved one. Although there are no easy answers to these questions, being able to discuss the complexities of the disease is helpful in alleviating blame, frustration, and fear.
There are many parties, in the recovery and mental health field, who point to specific biological, psychological, and social factors contributing to someone developing and suffering from addiction.
Addiction is a chronic brain disease, that is clear.1 However, like most diseases, the formation of the disease of addiction is complicated and complex. In my mind, addiction is best explained by the biopsychosocial model.
Before we discuss its application to addiction, a working knowledge of the components of the biopsychosocial model is important. Created by George Engel and John Romano in the 1970’s to help physicians understand the holistic nature of disease formation, the biopsychosocial model compelled clinicians to consider the biological, psychological, and social “dimensions” of illnesses.2
The biological components of illnesses are incredibly important to understand. However, an over-focus on biology can promote seeing patients as objects instead of within the multiple social contexts and internal psychological factors impacting diseases.
The more “subjective” elements of a person’s life, the psychological and social, are incredibly important to be considered and can be studied and measured. This study can encompass disease prevention, disease formation, and the healing and recovery from disease.2
Within the model, the “biological” considers the genetics of an individual. This includes the vulnerability or susceptibility an individual has to different illnesses and disease processes due to genetic factors.
Beyond this, the biological includes our gender, brain functioning, and the general functioning of the body. An example of functioning impacting general health includes someone with a physical disability, someone who experiences chronic pain, or both.
The “psychological” part of the biopsychosocial model encompasses thoughts, emotions, and behaviors. When stress is present in the environment, the psychological dimension informs how people experience, feel, manage and deal with that stress.
Understanding how we cope with the stress in our life is essential in considering the prevention of diseases, disease formation, and healing. Psychological factors that are important to consider in the model also include identity and self-esteem as well as attitudes, memories, and beliefs.
More Information on Addiction:
Vaping Could Put Youth at Risk for Complications of COVID-19
Social factors also contribute to disease prevention, formation, and healing. Components include elements such as,
All are included in understanding the whole person. For example, experiencing trauma within our social environment can impact both our psychological and biological well being and vice-versa.
To answer the question(s) about the origins of the brain disease of addiction and what causes it, we, as professionals within the field, must be able to explain the complicated factors associated with disease.
Foremost, biological factors including genetic predisposition play a role in all diseases including addiction. For whatever reasons, not of our choosing, we are born with our genetic makeup and must deal with both the strengths and weaknesses of what is passed down to us through our genetic line.
What this means is that some people have a stronger genetic “pull” to suffer from addiction than others. Some people may not have any susceptibility at all. In individuals who have less of a genetic pull, psychological and social factors may interact to provide the context where the disease of addiction manifests.
The best parallel I have found to help those who suffer and those who love them is a comparison between addiction and diabetes. Some diabetics, mostly Type I Diabetics, have a strong genetic susceptibility. Some will develop diabetes early in life.
Others, mostly Type II Diabetics, may have less of a genetic pull and often manifest the disease later in life. Factors that contribute to the onset of this type of diabetes include psychological and social factors such as stress, diet, exercise, etc.
Although different, both Type I and Type II diabetics must deal with the ramifications of having the disease of diabetes.
In addition to the biological, psychological factors influence disease formation. This is seen in the connection between the prevalence of mental health disorders and addiction.
The National Institute on Drug Abuse reports:
“Many people who are addicted to drugs are also diagnosed with other mental disorders and vice versa. For example, compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true.”2
Thus, the psychological factors leading to depression and anxiety disorders impact the creation of the disease of addiction and vice versa.
How one internally manages and copes with the stressors of life certainly impacts anxiety and depression symptoms. Often these symptoms pre-date the initial use and subsequent suffering from addiction. In fact, alcohol and drug use may begin as a powerful and readily available coping mechanism to deal with fear, stress, crises of identity, and low self-esteem.
Social dimensions can serve as protective factors of disease formation as well as contribute to addiction manifesting. Additionally, social factors are incredibly important in the healing and recovery for those who suffer from addiction.
In my clinical experience, pain derived from social factors is the most common element distinguishing between those who suffer from addiction and those who are pursuing a recovery journey. The source of the pain can come from a variety of social contexts (e.g., family, peers, community, culture, etc.).
Trauma, in all its forms, is experienced by most people who suffer from addiction. Social factors should never be used to blame families for the disease of addiction. I am, however, pointing out that social factors do play a role in the context of disease formation. More importantly, social factors, including healthy family interaction and social support, are critical in recovery from addiction.
In conclusion, it is important to note that no one factor is the “cause” of addiction. There are multiple culprits and, as stated earlier, all are complex and complicated. The culprits are biological, psychological, and social in nature.
The “cure” for those who suffer must be equivalent in complexity and holistic to tackle all three dimensions. Recovery and healing from addiction must consider the biological, psychological, and social. Anything less will continue to result in poor outcomes and more suffering.
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First published March 26, 2018, the post was reviewed and updated for republication.
I started regarding pornography as addictive after a friend, a physician’s assistant working in a urology clinic approached me with concern. He told me that several emerging adult men, ages 18-25, were coming into the clinic with problems associated with Erectile Dysfunction (ED). This is an unusual problem in this age range.
When he examined them, he found them to be healthy with no physical explanation for their ED. Most of these men, in fact, were particularly fit individuals.
Further assessment revealed the common denominator amongst these young men was their high consumption and daily viewing of pornography. This sparked some important questions about pornography that I would like to explore. It also raises the issue of whether or not pornography is addictive.
The simple answer is that pornography acts like a drug in the brain. It can become very powerful in some individuals.
Researchers Love, Laier, Brand, Hatch, and Hajela (2015) conducted and published a review of several studies exploring the neuroscience of internet pornography. What they found and reported is compelling. Studies examining the neuroimaging results of subjects who viewed internet pornography reveal brain region activation similar to craving and drug cue reactions for alcohol, cocaine, and nicotine.1
People who identified as engaging in compulsive sexual behaviors showed more reactivity in the brain compared with those who identified as non-compulsive. Thus, viewing pornography, especially when it becomes compulsive in nature, activates the same underlying brain networks as alcohol and other drugs.
These studies offer profound evidence that the compulsive and consistent use of pornography is potentially as powerful as drug use. A detailed review and discussion of studies on the neuroscience of pornography use can be found at the Your Brain on Porn website.2
Other posts on addiction:
It is reasonable to declare that not everyone who drinks alcohol becomes addicted to alcohol. The same can also be said for internet pornography. Not everyone who views pornography will become addicted.
The journey to becoming addicted to pornography most likely follows the same pattern as drug addiction. For example, at some point, a person is exposed to pornographic images and begins to experiment with pornography.
This experimentation may progress to abuse and then, dependence. The individual views more and more in-depth types of pornography. And, also starts to experience physical and psychological withdrawal symptoms when attempting to stop. Then, for some, addiction sets in due to a variety of genetic, environmental, and psychological factors.
The American Society of Addiction Medicine (ASAM) acknowledges that engaging in addictive behaviors, apart from alcohol and other drug use, can be a common manifestation of the chronic brain disease of addiction.
In their definition of addiction, ASAM presents an important section on the “Behavioral Manifestations and Complications of Addiction.” This section provides strong indicators that addiction can also manifest in sexually compulsive behaviors including internet pornography.
The following are excerpts from ASAMs long definition of addiction highlighting these behaviors (the bold has been added for emphasis)3:
Thus, internet pornography behaviors may reach the level of addiction when they are accompanied by the following:
How can someone tell if they are addicted to pornography? Besides the behaviors and symptoms described above, some great researchers have put together instruments that measure sexual compulsivity and internet pornography use.
For example, Grubbs, Volk, Exline, and Pargament (2015) revised and validated a brief measure of internet pornography addiction. It is called the Cyber Pornography Use Inventory (CPUI-9).4
There are nine questions in the instrument. They can be rated on a scale from 1 (not at all) to 7 (extremely). Or the questions can be answered true or false. The total score provides an assessment of perceived porn addiction.
The potential for Internet pornography addiction and the factors that make up such addiction can be found within the intent of the questions. These include a person’s efforts to access internet pornography, the emotional distress caused by viewing pornography, and a person’s perceived compulsivity to the behavior.
For those who are grappling with internet pornography use or addiction, help is always available.
What is most important is once a problem such as Internet pornography is realized, you need to reach out to meaningful help. Holding onto hope and developing new and healthier ways to cope is always possible.
this post was first published on June 20, 2017. It has been reviewed and updated for republication on March 2, 2020.
“Excessive drinking and alcohol use disorder is the biggest drug problem in the world”
Ria Health (formerly DxRx Medical) is a digital health startup focused on helping people with problem drinking. According to John Mendelson, MD, Chief Medical Officer of Ria, excessive drinking and alcohol use disorder is the biggest drug problem in the world. During my interview with him, he went on to say,
“It is estimated that one in ten people have a bad relationship with alcohol…they drink more than they should, they are unable to control their intake, they are unable to stop when they want, they do things that they don’t want while drinking, and they have harm from their drinking.“
Alcohol abuse disorder is a progressive disorder. “It starts with heavy drinking in their 30’s and it progresses on in their 40’s to having measurable problems with their families, with their work and with legal issues. Virtually…everyone who has had a DUI has a drinking problem.”
There are serious and even fatal consequences of the disorder including medical sequelae such as liver failure, pancreatitis, brain disorders, heart rhythm disturbances. There are also injuries and deaths due to drunk driving, falls, and fights. Despite alcohol abuse being a common and serious disease, Dr. Mendelson says that “in the United States and the rest of the world, these problems are largely unaddressed.”
There are a number of reasons why alcohol abuse has not been addressed as much as it should. First of all, there is a stigma to having an alcohol problem that makes people reluctant to talk about it even with their physicians.
In his remarkable opinion piece published in the March 23, 2017, issue of the New England Journal of Medicine, Adam Hill, a pediatric palliative care physician and recovering alcoholic with a history of depression and suicidal thoughts, puts it this way:
“Alcoholics are stereotyped as deadbeats or bums…an alcoholic isn’t a bum under a bridge or an abusive spouse: I am the face of alcoholism…it is ironic that mental health conditions are so stigmatized in the medical profession … when mental health conditions come too close to us, we tend to look away – or to look with pity, exclusion, or shame.”
Dr. Mendelson thinks that another reason why alcohol abuse hasn’t been addressed adequately is that “the recovery community has insisted that abstinence is the only outcome that is meaningful.”
But, he says, “there is a lot of data that says that is not the case. For example, for people who go into abstinence-based treatment programs after 5 years, 80% of people are drinking, but they are drinking less. So it is a problem that can get better…abstinence isn’t the only pathway.”
Although vastly underutilized, there are a number of drugs that can be used to help people control their drinking, including naltrexone and acamprosate. There are many studies that show that medications can decrease the number of days of heavy drinking in people seeking treatment or decrease the number of heavy drinking days.
According to Dr. Mendelson,
“When people drink…almost everyone stops drinking….when you go out with your friends to have wine, you have some wine, some beer, or some alcohol and you stop at some point.
What’s that point? That point is when you are happy, you are intoxicated, but you are not having any bad aversive reactions. You are not slurring your words, you are not stumbling, you don’t feel bad, you don’t feel out of control.
That set point, that point between how much you take and when you stop is actually biologically determined and it’s amenable to medication. What the medications appear to do is to decrease the amount of pleasure you get from drinking—they don’t decrease it severely. You can still have enjoyment, but they decrease it enough so that the signals stop to emerge sooner.”
Ria Health uses naltrexone as the first choice medication in their treatment program. It has been approved by the FDA for the treatment of people who want to control their drinking.
Mendelson says that “it appears to work by blocking opiate receptors. It turns out when you drink, some of the pleasure is caused by the release of opiates in the brain. If you block that part of the pleasure, you don’t drink as much.”
Joseph Volpicelli, MD, Ph.D., Associate Professor of Psychiatry at the University of Pennsylvania School of Medicine and an expert in the treatment of alcoholism, explains it this way,
“Naltrexone sort of gets at the core of what addiction is. The way I like to describe it is that addiction is a condition in which when you do something, you want to do more and more of it.”
Instead of stopping after a few drinks, people with alcohol use disorder want to have more and more and more drinks. Dr. Volpicelli says that naltrexone seems to break that positive feedback loop so that people can have one or two drinks and then stop because they don’t feel like having anymore.
I asked Dr. Mendelson why people should use Ria Health instead of just going to their primary care physician and getting a prescription for naltrexone. He said the challenge with that approach is that there is more to reducing drinking than just relying on medication alone.
For example, people struggling with alcohol dependence often don’t know how much they are drinking. Therefore, it is hard to know if the medication is helping them to cut back.
Also, the drug doesn’t work for everybody. So, it can be beneficial to work with a specialist should the patient require other FDA approved medications for alcoholism.
Lastly, people are shown to have greater success with medication treatment when it’s combined with a form of behavior change therapy such as cognitive behavior therapy (CBT).
Ria Health’s program addresses all of these challenges in a comprehensive way. They provide a HIPAA complaint App and Bluetooth breathalyzer to help monitor people’s drinking daily. That way they can actually quantify the impact of the program on the participant’s alcohol consumption.
Further, their physicians can make adjustments to treatment as needed. Ria also provides coaching support to help its members change behaviors around alcohol consumption.
Because Ria Health is a telemedicine service, it is more convenient and less time-consuming than other types of alcohol treatment programs. It is also more private. Participants are contacted via telephone to determine the goal of treatment:
“Do they want to control their drinking? Do they want to get to the point where they can be social drinkers again—defined as consistent blood alcohol concentrations of below .08? Or do they want abstinence?”
“Some patients do choose abstinence,” Mendelson says, “and the ones who wanted abstinence have gotten there.” Also, the ones who want controlled drinking have had a “pretty good response.” The ones who don’t respond may be on the wrong medication or, perhaps, some were not that motivated to start with. Finally, some people have more severe disease and may need residential treatment.
Everyone in the program receives a breathalyzer and picks up their medication prescription at a local pharmacy. Before starting the medication, the breathalyzer is used for two to three days in order to obtain some baseline data. That way, “we get objective proof that you are improving.”
Participants are also asked to take “pill photos”—taking a picture of the pill in your hand just before you take it. That way, adherence to the treatment can be ascertained.
Mendelson says that his lab “pioneered this method of automating this particular technology to measure adherence to medications.” And, he says, “it does work. People will take pill photos and pill photos are directly related to whether they take the pills or not.”
If adherence starts trailing off or alcohol levels start going up, Ria Health staff will contact the patient to suggest a change of medication. It turns out, he says, that “there are actually six medications that have adequate phase two evidence, showing decreased days of heavy drinking or decreased heavy drinking days in the medical literature.”
According to Dr. Mendelson, participation in Ria Health costs less per day than a drink at dinner and is covered by major insurance plans. He goes on to say that they are looking for six months of continuous treatment based on the literature.
Ria Health started seeing patients in 2016 and has treated over 1,000 people through it’s evidence-based, at-home program. On average, Ria members see a 75% reduction in their Blood Alcohol Concentration (BAC) levels after 12 months in the program.
John closed the interview by saying that they are often asked about Alcoholics Anonymous (AA)…why not just go to AA?
“We are big supporters of AA. We think you should go to AA if it works for you…But we offer something on top of AA, that is very useful – that is the suppression of alcohol intake…so you end up with the ability to make the choice to go to AA, to seek abstinence, or just get your life back together and keep moving forward while drinking in a controlled fashion.“
Currently, Ria Health is offered in 12 states across the US and growing. These states include California, Florida, Georgia, New York, New Jersey, Pennsylvania, Texas, Tennessee, Ohio, Virginia, Rhode Island, and Missouri. Click the link to learn more about Ria Health.
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This post was first published on April 11, 2017. It has been updated to reflect the current status of the Ria program. The video was filmed in 2017 and so does not reflect all of the new information.
Financial disclosure: The author has no financial relationship with Ria Health.
There are many problems with how we approach the disease of addiction. A particularly troubling one from a medical perspective is the practice of random drug testing. This method of monitoring tends to treat many addiction sufferers punitively, instead of effectively addressing the underlying disease of addiction.
If we want to change the course of the addiction crisis in America changing the way we conduct drug testing should be an aspect we carefully consider. There are methods we can apply to substance use disorder (SUD) recovery, whether it coincides with an actual criminal offense or not, that would do away with the punitive approaches that are now ubiquitous in the treatment industry. Moreover, implementing more data-driven positive reinforcement methods would help reduce the stigma which is so damaging and hinders better treatment outcomes.
A healthy start to a transition away from punitive practices would be ending “random” drug testing and replacing it with planned and regular drug testing. Planned and regular drug testing fits within a strength-based clinical approach to treating the disease of addiction.
All other chronic diseases, like cancer or diabetes, have some form of ongoing deliberate and consistent testing in order to manage the condition. If we approached drug testing in the same way, it allows us to gather better data, helps to normalize the SUD diagnosis, and creates a trustworthy standard across the treatment spectrum in patients, their families, treatment providers, and officials.
This idea of “random” drug testing being counterproductive is not actually new by any means. This makes our current system seem even more archaic and outdated.
The United States military replaced “random” drug testing with what has been termed “consistent drug testing” almost a decade ago. This method has been used with incredibly effective results to treat certain service members suffering from SUD.
Dr. Kevin MacCauley, who started the Institute for Addiction Study, was first exposed to the military’s approach to drug testing and recovery from SUD while serving as a naval flight surgeon for airborne divisions of the Marine Corps. In this role, he witnessed many pilots self-report their addiction, get necessary medical treatment, and be returned to flying status under monitoring. As he puts it:
“These were charismatic and otherwise highly-capable, self-disciplined pilots who did come forward and ask for help – and they all got better and went back to flying! That just destroyed the prejudice I had picked up in medical school that addicts never ask for help and once an addict, always an addict.”
The willingness of these service members to be so forward about their addiction struggles was due, in large part, to the Navy’s policy of treating SUD primarily as a safety issue rather than a moral or criminal issue. Their treatment outcomes numbers far exceed those of the addiction treatment industry. So perhaps at the civilian level, we should adopt at least some of those measures to more effectively combat the addiction crisis in America.
Drug testing as a common practice in America, to some degree, finds its roots in the military. This is interesting given that the military is also leading a positive reform to the practice they introduced. After the Vietnam War, the military had to figure out how to deal with the plethora of veterans that came back home addicted to heroin.
This issue created the initial practice of monitoring recovering veterans through random drug testing. Unfortunately, the parts of civilian society which adopted this seemingly logical solution to monitoring substance abuse did so without the same infrastructure or goals of the American military.
Drug testing, by and large, was adopted by civilian society as a marker for punitive action. This is true in the justice system, the workplace, and other areas of society. Because of this, the first exposure that many individuals have to a SUD diagnosis is as a result of criminal charges or a punitive measure on behalf of employers.
This has created a system in the addiction treatment continuum that exacerbates the punitive aspects of treatment and monitoring, instead of focusing on the disease, its’ symptoms, and the legal and behavioral consequences that led to trouble in the first place. This creates a sort of endless cycle of negative reinforcement surrounding a SUD diagnosis.
Often, people, under this type of stress and threat, seek to hide the initial onset of the problem and their progressive suffering over time. The potential shame, embarrassment, and devastating effects of losing employment or going to jail actually keeps the addiction in the dark where it grows and becomes worse over time.
Random drug testing and the punitive actions that follow create a culture of secrecy and shame that keep people from reaching out for meaningful help. An entire industry has developed in support of hiding drug use and people spend significant resources in buying products to hide their use.
Because of this culture some SUD individuals entering treatment, either by choice or as a legal repercussion, directly associate any type of ongoing substance use monitoring as a punitive measure.
In addition, many times people in recovery are under threat of legal, financial, or other repercussions if they do relapse. This low or no threshold approach to relapse in recovery is one of the worst ways to approach treatment for any type of condition with a mental component. Especially for a chronic disorder like addiction that generally has been created in some part by past negative social determinants.
Beyond those who are introduced to their SUD diagnosis through legal trouble, even those who come to treatment as a result of family, friends, or professional environments—the idea of “random” drug testing inherently creates a negative consciousness. This is no surprise given the social image that’s been created around drug testing. This culture of testing deters people from entering treatment earlier or being forthcoming about substance issues they may have. This is because the system is built around punitive and psychologically discouraging measures.
Ongoing drug testing and extended recovery support can be approached in a more clinical manner through frequent and deliberate testing. This would reduce some of the negative aspects associated with our current system.
Instead of random drug testing, an individual in recovery would participate in consistent drug testing. This would be administered on an ongoing scheduled basis, and they would know the exact schedule on which they would be tested.
This is a more effective approach for multiple reasons, including:
Some might criticize this approach by saying if an individual in recovery knows exactly when they will be tested, then they are more likely to “cheat” on the test or resort to quick detox methods. However, the available data from this type of drug testing seems to show that the opposite is true. The Institute for Addiction Study conducted trials utilizing almost this exact type of approach and have shown more positive impacts on addiction recovery outcomes as a result.
Regardless, our current testing methods do not display outcomes data that support continuing to pursue those same methods if our goal is indeed to improve recovery. Any transition can bring with it unexpected bumps in the road. This would be countered by observing longitudinal data and adjusting testing methods over time.
Any responsible method of treatment is created and maintained through a foundation of positive longitudinal outcomes data. So, once we replace random drug testing with consistent drug testing there needs to be systems in place to monitor the outcomes data of those involved in such drug testing.
With any other disease that health care providers have eradicated or improved outcomes for, there has been an adjustment period for treatment methods that led to more positive outcomes. As of now, random drug testing is the primary monitoring option that we utilize, and the results of this method are not good. Consistent drug testing needs to be implemented on a larger scale so that we can test the efficacy of this method and the positive benefits it could hold in our efforts to combat the addiction crisis that is currently taking so many American lives.
In addition to implementing consistent drug testing on a larger scale, we also should utilize the data we already have from military treatment to educate the general public about the positive benefits of treating addiction as a chronic disease, a public safety issue, and not a moral failing. This would help destigmatize the disease of addiction further and help those who suffer silently in active addiction to be more willing to come forward and receive treatment.
Related Content: 8 Drug-Seeking Behaviors That Might Signal Addiction
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Have you ever asked yourself what can you do in your daily life to improve your mental health? Believe it or not, this is a very important question to ask.
Our mental health is just as important as our physical health, but unfortunately, we seldom give it the importance and care it deserves. When our body gets sick, we do everything we can to feel better. We try home remedies. We go to the doctor and follow his/her instructions. We stay home and rest.
But when our mind is sick, we try to ignore it and carry on with our lives. We do this even though by not actually giving it the care it needs can only make it worse.
Mental illness has been a taboo for a very long time. Only recently have people began to speak up about it. However, there is still a stigma around these types of illnesses. Someone with a mental health issue might be scared that people will think of them as crazy, or faking it to get attention, or just weak.
Some people actually think these things about mental illnesses, mainly because they haven’t had access to any trustworthy information about mental health. And since we don’t know much about mental illnesses, we don’t know what we can do to prevent them.
That was my case. I struggled with alcohol and drug addiction ever since I was a teenager into my early adulthood. During my adolescence, I started suffering from anxiety and depression.
Since I didn’t know anything about mental health, I thought I was going crazy. I didn’t understand back then that there was a correlation between my substance abuse and my mental health. I came to realize this when I decided to get clean and my anxiety and depression went away.
I have been sober for nine years now and I have learned a lot about what drugs and alcohol can do to your mind and body.
The brain is the most complex of all body organs. It regulates and coordinates every single process in your body through a communication system in which neurons pass messages back and forth among different structures within your brain and other parts of your body.
Drugs interfere with the way neurons normally send, receive, and process information. Different parts of the brain are affected depending on the type of drug involved.
Though you might feel momentary pleasure from using drugs, sometimes the side effects can be permanent. Some of these effects include impaired learning and cognitive function, memory loss, lack of self-control, among others.
Just like drugs, alcohol disrupts your brain’s communication system. While alcohol can initially make you feel energized, happy and inhibited, it actually works as a nervous system depressant. You can witness that when after a few drinks, you start having trouble coordinating your movements and speaking fluently.
Alcohol abuse has long-term effects on both your physical and mental health such as liver damage, cancer, cognitive impairment, memory loss, psychosis, anxiety, and depression.
Sometimes when you drink too much, the next day, you have trouble remembering some parts of the night. People might even tell you what you said or did, and you still have no recollection whatsoever of these events.
These “blackouts”, as they are often referred to, are an indication that you are drinking too much. Though experiencing one doesn’t mean that your brain cells associated with memory are damaged, frequent heavy drinking can actually damage your memory cells permanently.
There is a two-way relationship between substance addiction and anxiety and depression. Substance abuse can triggers anxiety and depression. And, anxiety and depression can also lead to becoming addicted to drugs and alcohol.
According to the American Psychiatric Association, depression is an illness that causes feelings of deep sadness and loss of interest in activities you used to enjoy. If not treated, it can cause problems in your personal life, relationships, work, or school.
Anxiety is when you frequently have intense, excessive, and persistent worry and fear about everyday situations. These feelings are hard to control and out of proportion to the actual danger.
These illnesses can trigger substance consumption as a way of self-medication in an attempt to feel better. But, in reality, as soon as the effects of the substances pass, the person is usually left feeling bluer than before, which can lead them to consume again and eventually create a dependency.
We often use alcohol, sometimes even drugs, to cope with the daily stress in our lives. While there is nothing wrong with having a glass of wine every once in a while after a long day, frequent alcohol and drug consumption as a way of dealing with stress can actually be counterproductive. Even if you feel relaxed for a couple of hours after using a substance, when the effect passes, you have to face the same stress again, which can lead you to use again, creating a vicious cycle.
Also, think about it, when you’re drunk or high, you tend to make bad decisions, such as maxing your credit card, getting involved with someone you shouldn’t have and ruining a relationship, getting into a physical fight, and so forth. As soon as the effects of the substance go away, you have to face these situations, which, obviously, will leave you feeling more stressed.
Now that you know how drugs and alcohol can affect your mental health, the next step is to reflect on your habits regarding these substances. Maybe, even if you think you are consuming them responsibly, they might be actually affecting your mental health.
Even though everyone’s mind works differently, in my experience, eliminating these substances from my life made me feel better both physically and mentally. I hope this post can help you make the best decisions for your mental health from now on.
Have you ever had trouble with substance abuse and mental health? If you’d like to share your story, please leave a comment below. I would love to hear it.
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First published on 5/7/18, this article has been reviewed and updated, including new references.