"Unlike most of our crowd, I did not get over my craving for liquor much during the first two and one-half years of abstinence. It was almost always with me......" Doctor Bob's Nightmare. Alcoholics Anonymous, Fourth Edition, New York City, 2001, p 181.
Craving to use drugs and alcohol is a common problem. As Doctor Bob points out in the above quote, craving is rare for alcoholics beyond the acute detoxification phase, but protracted for many other drugs depending on the class of addictive compound and the pharmacological properties of the specific drug. Apart from the biological determined heterogeneity of response to addictive compounds there are also the subjective aspects. In order strive for more objectivity, modern psychiatry has established diagnostic criteria for disorders of interest. These disorders are grouped in categories to seem uniform. Depending on the criteria of interest there is a broad range of subjective experience and description when describing common problem like anxiety and depression. Some people don't know the difference between them. Others have a mixture of both. Some people are anxious all of the time independent of their surroundings. Others get depressed or panic only in certain situations. The interpretation of what a person considers to be a craving is as diverse.
Craving for an addictive drug or alcohol comes in many forms. It can be a perception of a physical property of the actual compound itself such as the taste, odor, appearance or consistency. It can be physical acts associated with its use and a common example there is a feeling that cigarette smokers get when they feel like they need to do something with their hands after they stop smoking. It can be cue induced like being offered a drug or being in a place where previous drug transactions occurred. It can be recall of the first intense and protracted euphoric experience of using the drug even though that has long passed related to tolerance. The overwhelming affect associated with craving is anxiety and fear because of the sign on an impending withdrawal or relapse. The negative reinforcement that keeps addictions going after the initial states of positive reinforcement due to the euphorigenic effects of the drug is avoiding withdrawal. Craving may be a signal that acute withdrawal is imminent or that there is a state of chronic withdrawal.
Craving has had an uncertain place in the field of addiction and the diagnosis of addictive states, largely because of the broad range of experiences associated with craving. This diagrammatic summary shows that various groups have considered the definition to be too vague. In other cases there was no consensus that craving was a universal enough phenomenon to be considered a diagnostic criterion. That changed this spring when the DSM-5 added craving and eliminated legal consequences of drug and alcohol use as a diagnostic criterion. Medications used to eliminate cravings probably led to that consideration, but people with cravings are more likely to relapse and have significant distress during recovery.
The addition of cravings to the DSM-5 opens up a whole new area of focus during encounters with people who have addictions. Prior to this change the two major texts on addiction devoted about 3-4 pages to craving phenomena. Addiction psychiatrists and addictionologists may have already been focused on this area, but I think that overall it makes ongoing assessments more dynamic because it is an intervention point for physicians and there are a number of medical and non-medical interventions that are possible. Omar Manejwala, MD reviews the options in his very readable book entitled Craving. This book is interesting because it gives a number of practical tips on how to counter cravings based on the substance involved as well as the importance of psychosocial interventions like 12-step recovery and how that might work. Addiction science has probably been at the cutting edge of neurobiology for at least the past decade and with this focus there is often the implicit understanding that we are searching for some medication that will be an immediate solution to craving. In some cases we have that medication, but I always emphasize that cravings at some point disappear and that there are non medication approaches to addressing them.
George Dawson, MD, DFAPA
Manejwala O. Craving: Why We Can't Seem To Get Enough. Hazelden, Center City, MN, 2013.
Definitions:
Neuropsychopharmacology The Fifth Generation of Progress (2002): Craving is a powerful, "must-have" pull that causes addicted people to risk and sometimes lose, their relationships, families, money, possessions, jobs and even their lives. (p.1575)
Showing posts with label Alcoholics Anonymous. Show all posts
Showing posts with label Alcoholics Anonymous. Show all posts
Sunday, October 27, 2013
Saturday, November 10, 2012
Being Flynn - Another Cinematic Portrayal of Alcoholism
My previous post looked at the accurate portrayal of alcoholism in the film Flight. I recently saw Being Flynn starring Robert De Niro in the role of an alcoholic father and self proclaimed novelist. This film is also a study of alcoholism.
Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men. In this case we meet De Niro's character Jonathan Flynn in a downward spiral. We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years. We first see Jonathan Flynn when he is driving a taxi. He is drinking vodka on a regular basis. We see him lose his job and then his housing and end up at a homeless shelter. Nick is floundering as a poet and author. He lacks direction and the flashbacks suggest that childhood adversity has played a big role. He comes to be employed at a homeless shelter where his father eventually seeks shelter.
The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character. Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted. It is the reason he was evicted. At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies. He uses a lot of expletives and at times seems incoherent. In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors. When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.
Nick is on his own parallel journey. He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff. The shelter staff and the environment at the shelter is expertly portrayed and very realistic. The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable. Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him. He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year. Jonathan predictably acts like he relishes the thought and that living on the street is nothing. When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology. There is a time when we are not sure whether Jonathan will survive or not.
There are a number of fascinating articles available that look at the process of making this film. The gold standard for any film is the book and many critics suggest reading that as a starting point. The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America. When did it become acceptable? The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.
As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years. At some point in time they all create the anger, frustration, and hopelessness portrayed in this film. Many of them are not only grandiose and paranoid, but permanently delusional or amnestic. The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself. This film is similar to Flight in that there are no proposed solutions. The are no public policy statements. It is an accurate depiction of real people dealing the the problem of addiction in their daily lives. Despite those significant problems there are hopeful messages everywhere. After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.
I also had associations to what I consider to be some of the most important work in alcoholism. The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author. Most of the original articles online are available only with steep fees for a one time read. It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library. It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995. The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem. In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston. At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized. One of Dr. Vaillant's characterizations of the recovery process in alcoholism: "... alcoholics recover not because we treat them, but because they heal themselves. Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime. Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384). Self healing was evident in this film.
The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila. Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research. He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol. These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery. An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.
This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family. It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.
George Dawson, MD, DFAPA
Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.
Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men. In this case we meet De Niro's character Jonathan Flynn in a downward spiral. We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years. We first see Jonathan Flynn when he is driving a taxi. He is drinking vodka on a regular basis. We see him lose his job and then his housing and end up at a homeless shelter. Nick is floundering as a poet and author. He lacks direction and the flashbacks suggest that childhood adversity has played a big role. He comes to be employed at a homeless shelter where his father eventually seeks shelter.
The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character. Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted. It is the reason he was evicted. At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies. He uses a lot of expletives and at times seems incoherent. In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors. When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.
Nick is on his own parallel journey. He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff. The shelter staff and the environment at the shelter is expertly portrayed and very realistic. The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable. Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him. He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year. Jonathan predictably acts like he relishes the thought and that living on the street is nothing. When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology. There is a time when we are not sure whether Jonathan will survive or not.
There are a number of fascinating articles available that look at the process of making this film. The gold standard for any film is the book and many critics suggest reading that as a starting point. The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America. When did it become acceptable? The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.
As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years. At some point in time they all create the anger, frustration, and hopelessness portrayed in this film. Many of them are not only grandiose and paranoid, but permanently delusional or amnestic. The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself. This film is similar to Flight in that there are no proposed solutions. The are no public policy statements. It is an accurate depiction of real people dealing the the problem of addiction in their daily lives. Despite those significant problems there are hopeful messages everywhere. After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.
I also had associations to what I consider to be some of the most important work in alcoholism. The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author. Most of the original articles online are available only with steep fees for a one time read. It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library. It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995. The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem. In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston. At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized. One of Dr. Vaillant's characterizations of the recovery process in alcoholism: "... alcoholics recover not because we treat them, but because they heal themselves. Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime. Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384). Self healing was evident in this film.
The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila. Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research. He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol. These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery. An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.
This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family. It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.
George Dawson, MD, DFAPA
Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.
Sunday, November 4, 2012
Zemeckis portrayal of addiction in "Flight"
I went to see Robert Zemeckis film Flight starring Denzel Washington as pilot Whip Whitaker yesterday. Spoiler alert - if you are a person who likes to see new films knowing nothing about the plot - stop reading this post right here. I work at a large residential addiction facility and ran into one of my colleagues in the lobby. He told me he was there to see the film because it was a good film about addiction. I was completely surprised. Robert Zemeckis made the film that I have seen more times than any other - Forrest Gump. I generally see anything that Denzel Washington does. Like everybody else, I like his work and he does not make any bad movies. His last transportation themed movie Unstoppable cast him the role of a wise engineer trying to stop a runaway train. The trailers I had seen for Flight suggested a similar role. I expected a heroic pilot with a similar outcome.
From the outset, it is obvious that Whip Whitaker has a tremendous problem. He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on. Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure. Subsequent analysis proves that he is the only pilot who could have saved the plane. But even those facts are not enough to preserve his fleeting hero status.
Throughout the film we see Whip drinking in an uncontrolled manner. There is some ambivalence. He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor. He dumps out his stash of marijuana. There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with. As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance. In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka. As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer. There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him. The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.
This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot. On the surface he is a "functional alcoholic." His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade. He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time. He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic. There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries. There were so many scenes in this film that captured the problems of addiction.
As an audience member you cannot help getting caught up in his fight with alcohol. He is after-all the hero of this film and that is firmly established in the first 20 minutes. You are hoping that he will not pick up another drink. You are left with a situation where the hero will be dealt with according to technicalities. His heroism does not count. The only thing that matters is that he has an addiction.
This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not. It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop. It is a lot more than that and hopefully that message will be clear from watching this film.
George Dawson, MD, DFAPA
References (Doug Sellman has done a great job of distilling out the scientific points of addiction):
1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.
2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.
3. Alcohol Action New Zealand web site (various resources)
4. Alcoholics Anonymous. Grounded. Alcoholics Anonymous World Services, New York City, 2001.
From the outset, it is obvious that Whip Whitaker has a tremendous problem. He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on. Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure. Subsequent analysis proves that he is the only pilot who could have saved the plane. But even those facts are not enough to preserve his fleeting hero status.
Throughout the film we see Whip drinking in an uncontrolled manner. There is some ambivalence. He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor. He dumps out his stash of marijuana. There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with. As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance. In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka. As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer. There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him. The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.
This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot. On the surface he is a "functional alcoholic." His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade. He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time. He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic. There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries. There were so many scenes in this film that captured the problems of addiction.
As an audience member you cannot help getting caught up in his fight with alcohol. He is after-all the hero of this film and that is firmly established in the first 20 minutes. You are hoping that he will not pick up another drink. You are left with a situation where the hero will be dealt with according to technicalities. His heroism does not count. The only thing that matters is that he has an addiction.
This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not. It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop. It is a lot more than that and hopefully that message will be clear from watching this film.
George Dawson, MD, DFAPA
References (Doug Sellman has done a great job of distilling out the scientific points of addiction):
1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.
2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.
3. Alcohol Action New Zealand web site (various resources)
4. Alcoholics Anonymous. Grounded. Alcoholics Anonymous World Services, New York City, 2001.
Wednesday, September 26, 2012
Response to Dr. Willenbring
I wrote this response to Mark Willenbring's post on his blog. I reposted it here because the links do not work in the reply section of his blog in case anyone is interested in the references:
------------------------------------------------------------------------------------------------------------
I generally agree with what you are saying. I think the no fault aspect of the illness is
very difficult for many to grasp - most importantly the policy makers and
health plan administrators. I think it
is captured very well in the latest ASAM definition. I think that Sellman’s Top Ten list and the
responses to it are also instructive especially item 7 “Come back when you are
motivated” is no longer an acceptable therapeutic response’ is part of your
message.
From a systems standpoint, the lack of a full array of
services to treat addiction is striking.
Over the course of my career I have seen detox services essentially
moved to mental health units and then to the street. I wrote a post about this several weeks ago
that was read by current detox staff who agreed with it. It is hard to believe that in many if not
most cases people with addictions are sent home from the ED, sent home with a
handful of benzodiazepines, or sent to a facility with no medical coverage for
a complex detox process. I think the
test of any health care system is whether a primary care doc can ask themselves
if they have a safe detox procedure for any of their regular patients who are addicted
to opioids and benzodiazepines and needs surgery.
Medical systems in general have a very poor attitude toward
people with addictions. I think that
these healthcare systems and their personnel are much more likely to take a
moralistic attitude toward addicts and not treat them well. I have seen that theme repeated across
multiple care settings. Many rationed
care settings disproportionately reduce resources necessary to treat addiction. I think it is safe to say that most
cardiology patients with suspicious chest pain get a $10,000 evaluation and
reassurance or appropriate treatment.
Most patients with addictions do not even get a $300 evaluation. They may actually see a physician who provides
them with medications that fuel their addiction. Institutionalized stigma plays a big role in
that. There are no billboards in the
Twin Cities advertising state-of-the-art addiction treatment. There are many advertisements for heart
centers.
I am less pessimistic about the effects of 12-step recovery
and time in a residential setting whether it is a high end recovery facility or
a state hospital. I think if you are in
a setting where there is no active treatment or sober environment you are
probably wasting your time. I have seen
people who were declared hopeless recover with time away from alcohol and drugs
on the order of months. Vaillant’s study
of severe alcoholism is a great example of the different paths to recovery and
there are many. His subsequent analysis
of how AA might work suggests that affiliation rather than blaming may be the
most curative element. AA is difficult
to study but I think that the message is positive and embodied in #3 of the Twelve Traditions. Up to that point the founders were looking at
the issue of exclusion but decided against it because alcoholism was a life
threatening disease and they could turn nobody away.
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