Cravings

"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)

Don Draper loses it - Can he be saved?

Don Draper, the main character in AMC's MadMen is without a doubt the most complicated character I have ever seen on television.  I have often thought about whether or not I have seen him over the years. What would be the most likely way that he would come to the attention of a psychiatrist?  I can remember several years ago he went in to see his primary care physician and was told that he had hypertension (150/100).   The prescribed course of action was a combination of a barbiturate and reserpine.  Being seen as a complication of that therapy might be one way.  He also has demonstrated that he has a progressive problem with alcohol.  Everyone on MadMen drinks at work, and it is typically hard liquor.  At one level it seems to be part of the Madison Avenue culture, but Don has taken it many steps beyond that to overt intoxication and vomiting in the office.  Even in the 1960s, this behavior could result in a period of detoxification and residential treatment.  If he really was mixing alcohol with barbiturates that is a setup for an accidental overdose or a withdrawal seizure.

Another avenue to consultation might have to do with his philandering behavior.  Over the course of the show he has had two wives and he has had extramarital affairs in both marriages.  During his second marriage, he befriends a cardiothoracic surgeon in his building.  He admires this man and he seems like the only real friendship that Draper has been interested in over the course of the series.  That does not deter him from sleeping with the surgeon's wife.  During his previous marriage, he had affairs with numerous women resulting in his wife finding out and on one occasion he was punched in the face by an irate husband.  None of that has had much of an impact on his lifestyle that consists of drinking a lot at work and frequently using work as an excuse to neglect his wife and family and continue extramarital sex.

Whenever I think of philandering, I think of Frank Pittman's work that I read fresh out of residency training.  In outpatient practice, anxious and depressed persons have two major sources of stress - their job and their significant relationship.  It is fairly common to see significant others and spouses during the treatment of an individual.  The usual requests are for a basic explanation of the diagnosis and treatment plan, but in more complicated circumstances an analysis of the spouses behavior.  I think that Pittman may have seen Don Draper as a subtype of philanderer that he refers to as a "hostile philanderer" who is not empathic toward women.  A more psychodynamic approach might suggest that Draper is narcissistic and that might be the driving force behind his lack of empathy.  In either case, the therapy focused on this problem is complicated and requires skills that focus on neutrality and a focus on the goals of therapy rather than an endless description of the problem.

A more recent approach might employ a model of sexual addiction rather than looking at the problem as repetitive marital infidelity.  One of the conceptualizations of the problem is that it can be a behavioral addiction like food and gambling and that it involves and activates the same neurobiological substrates that addictive drugs and alcohol do.  Some authors have developed criteria sets for sexual addiction based on the characteristics of substance use disorders, but this disorder is not listed in the main DSM or the section on "Conditions for Further Study."  Some people will come in for assessment based on someone telling them that they have a sex addiction or their participation in 12-step recovery groups with that focus.  Experts in the field have produced reviews of psychotherapy and pharmacotherapy that might be useful for this problem, but at this point most psychiatrists would see this as an issue for psychotherapy and would have reservations about the medical treatment of a model that has not been widely accepted.

There is also a more biological approach to infidelity.  Some people may present with requests for a medication that has decreased libido as a side effect or a medication that produces that result by its physiological effect.

In the season 6 finale, Don Draper is trying to seal an advertising deal with Hershey.  The staff knows they are swimming up stream, because Hershey has outstanding brand recognition and packaging.  Don has to sell them on a campaign that takes their advertising to a new level.  He tells a poignant story about mowing the lawn as a kid and his father taking him to the store later so that he could buy a Hershey bar.  That candy symbolizing the bond between a father and son and a bridge to those memories in the past.  His associates in the room are beaming.  They think he has hit it out of the park.  A few minutes later, he tells everyone in the room that the story he has just told never happened.  He says he was raised in a "whorehouse" and one of the prostitutes would ask him to go through the trousers of her clients, looking for extra money.  He would get some of that change and buy a Hershey bar.  When he ate it he was living vicariously like the kid in his original story.

Can Don Draper be saved?  In a way he already has.  He was at a clear disadvantage in terms of childhood trauma and adapted to that by becoming somebody who he was not and trying to consciously block out that previous existence.  We get a glimpse of one of his strategies from an earlier scene.  I think that from an artistic point of view the writers are saying that he cannot.  He could no longer suppress the truth about himself at a critical juncture in his career.  That is true not only with his clients and coworkers but also with his children.  In the final scene of the season, he is standing with his children in front of the whorehouse where he was raised.  His daughter looks at him for some kind of reaction.

From a psychiatric standpoint the answer is a qualified yes.  Certainly any psychiatrist could come up with a plan that might address some of the areas highlighted above.  It would take a comprehensive formulation of his problems.  Framing the problem as simple anxiety or depression or some other DSM-5 diagnosis is an obvious mistake.  In many practice settings that pressure is there.  There is also the chance that he might walk into an AA meeting for any number of reasons and make some changes to get his life back on track.  He might even get some advice from a friend or coworker about a particular aspect of his problems that he might decide to pursue and that could lead to some changes.  The main drawback to advice from a peer is that he has no peers and no close friends.   Human consciousness is complex and there are many roads to change.

George Dawson, MD, DFAPA

Frank Pittman.  Private Lies - Infidelity and the Betrayal of Intimacy.  WW Norton and Company, New York, 1989.

Shoptaw SJ.  Sexual addiction in Ries R, Fiellin DA, Miller SC, Saitz R. Principles of Addiction Medicine. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009:  pp 519-530.

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.

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.

Why Are There No Detox Units Anymore?

Acute withdrawal from drugs and alcohol can kill you in the worst case scenario and at best can prevent you from initiating the recovery process.  So why are there no detox units anymore or at least very few of them?  You can still end up in a hospital going through detoxification or in a county facility where the priority is more containment of the acutely intoxicated than appropriate medical detoxification.  There are probably a handful of detoxification facilities where you will see physicians with an interest or a specialty in addiction medicine using the best possible standards. Why is the government and why are the managed care systems that run healthcare in the United States not interested in "evidence-based" medical detoxification?

As a person who has seen the system devolve and who has successfully treated a lot of people who needed detoxification this is another deficiency in the system of medical care that is never addressed. Over the course of my career I have seen patients admitted to internal medicine services for detox in the 1980s. When insurance companies and managed care companies started to refuse payment for that level of treatment intensity patients requiring detoxification were then admitted to mental health units.  When mental health units started operating according to the managed care paradigm of no treatment for people with severe addictions, they were either sent home from the emergency department or sent to county detox facilities.  Those county detox facilities were often low in quality and one incident away from being shut down.

I currently teach physicians about the management of opioids and chronic pain in outpatient settings.  I am impressed with the number of addicted patients who are taking opioids for chronic pain.  This population frequently has problems with benzodiazepines.  There is a general awareness that we are in the midst of an opioid epidemic and in many counties across the United States the death rate from accidental drug overdoses exceeds the death rate from traffic fatalities. The question I get in my lecture is frequently how to deal with the addicted pain patient who is clearly not getting any pain relief from chronic opioid therapy and has often escalated the dosage to potentially life-threatening amounts.  In many chronic pain treatment algorithms this is the "discontinue opioids" branch point.   During my most recent lecture I posed the question to these physicians: “Do you have access to a functional detoxification facility?"  Not surprisingly  - nobody did.

I can still recall the denial letters from managed care companies when I was taking care of patients with alcoholism and addiction in an inpatient setting. They had been admitted to my inpatient mental health unit and many were also suicidal. The typical managed care comment was "this patient should be detoxified in a detox unit and not admitted to a mental health unit.”  This is an example of the brilliant concept called "medical necessity" as defined by a managed care company. In the majority of these cases, the patient's county of residence did not have a functional detox unit and there were also clear-cut reasons for them to be on a mental health unit.  County detox facilities do not take people with suicidal thinking or associated medical problems.  I wonder how many letters it took like the ones I received to permanently disrupt the system so that patients with alcoholism and addictions could no longer get standard medical care.

The end result has been no standards for medical detoxification at all. Some patients are sent out of the emergency department with a supply of benzodiazepines or opioids and advised to taper off of these medications on their own. That advice ignores one of the central features of substance abuse disorders and that is uncontrolled use. Without supervision I would speculate that the majority of people who are sent home with medications to do their own detoxification take all that medication in the first day or two and remain at risk for complications.

Appropriate detoxification facilities staffed by physicians who are trained and interested in addictive disorders would go a long way toward restoring quality medical care to people who have a life threatening addictions.  It would restore more humanity to medicine - something that business decisions have removed.  As far as I can tell, people struggling with addictions and alcoholism continue to be neglected by both federal and state governments and the managed care industry.

George Dawson, MD, DFAPA