64,000 and counting


The numbers are in for 2016, and they are not good. According to the National Center for Health Statistics, Centers for Disease Control and Prevention, drug-related overdoses in the United States reached their highest level. What’s more, the rate of drug overdose deaths for people under the age of 50 is occurring at a faster rate than HIV at its peak. Given the rise of fentanyluse and easy access to heroin, the number of deaths from opioids is likely to climb for this year. The New York Times published a revised breakdown of data related to the opioid epidemic. Equally as troubling with the numbers is the news that prescription opioid-related deaths have leveled off, while cocaine and methamphetamine have reared their ugly heads as contributing factors in the surge of fatalities.

So far, the recommendations made by the newly formed Commission on Combating Drug  Addiction and the Opioid Crisis appear to be unoriginal and vague. The effort to have real mental health parity in the treatment of mental health and substance abuse disorders has been echoed for decades to no avail. While the commission encourages easier access to opioid replacements (“MAT”) such as subutex  , there is a greater need to understand and analyze the reason drug use is on the rise across various socio-economic, cultural and racial groups. The epidemic has not and is not affecting just white suburbanites, inner city minorities and Appalachia. In fact, the three states that saw the highest increase in opioid-related deaths were Delaware, Florida and Maryland.

State legislators have begun to implement prescription drug monitoring programs to detect the rate patients have been prescribed pain medication. However, this system regulates the patient, not the doctor. It is widely known that doctors (see pill mill crisis of 2011) routinely overprescribe, but 300 million prescriptions for pain medication were written in 2015. The commission does discuss the need for more screening tools to assess addiction and pain, but tools already exist.

One place to look for a new solution is the state of Ohio, where new rules for prescribing opioids caps doctors at dispensing a maximum of 7-day prescriptions for adults in chronic pain. Additionally, the state will require diagnostic codes on all prescriptions for pain medications beginning in December.

As I have written about in the past, practioners on all levels who work in medicine, psychology, addiction and the like, must look at the rise of addiction from a multi-disciplinarinary approach. The guidelines and suggestions handed out by the commission focus primarily on reactive measures. Those on the front line of treating the epidemic must return to analyzing family structure, mental health pathology, performance in school and other societal factors that are being sidelined as explanations for the explosion in opioid-related disorders and subsequent fatalities.


On the struggles with grief



I wish I could have done more. More for my client who suffered. More for his family who suffered. More for the pain, the emptiness, the despair. But I couldn’t. I couldn’t keep him to prolong his treatment. Not long enough to make a dent in an otherwise broken, hurt and lonely soul. I thought about him when he left. I thought about him when I slept. And now, I think about him as I type. Today was the first, but likely not the last time I will hear that a client of mine has died. My reaction was not of surprise or shock, but of sorrow. Sorrow for the man who had decided his time was up.

As therapists, we are faced with mortality. As clinicians in the field of addiction, we are faced with the cruelty and the hostage taking drugs and alcohol become. And yet, we still hold out for hope. We still strive to make a difference and we still have hope that our clients can obtain the ultimate recovery- inner peace. But like so many of the suffering, that task was not fulfilled.

I was angry when I heard the news. I was angry at myself, angry at others, angry at him. I was angry at addiction. I was angry at depression. I was angry at work. But my anger will not succeed nor flourish. My anger will be invested into what I know how to do best- work with those in need of healing. The only way I can grieve is to continue with the work I do everyday. The grieving means advocating for my clients when they cannot advocate for themselves. My anger and shortcomings will be met with a continued passion for treating those who have been unable to treat themselves.

My client’s passing is a reminder of the tremendous difficulties we face as soon as we walk into work. We work with chronic and persistent drug abusers and mentally ill men and women. We work with altruists, sinners and criminals. We work with the sad and the angry. The confused and the hopeless. And on this day, I am mourning the loss of the sad. I am mourning the loss of the angry. I am mourning  the loss of the confused. I am mourning the loss of the hopeless. And I will continue to work alongside the individual who needs help.

Why “sober coaches” can be harmful

Today’s rehab industry is booming with personalized care that provides horse-back riding, spa treatment, gourmet foods and the like. For upwards of $50,000 per month, it better. While this style of treatment does not sit well with me, I am even more surprised by the new profession of  “sober coaches.” No, a sober coach is not someone you would meet in an AA or NA meeting, but instead, someone who often times attends social functions with you, attends the gym with you and even lives with you! Talk about boundary issues. In this morning’s New York Times, Marisa Fox exposed the world of “Mothers Finding  Helping Hand In Sobriety Coaches.” In her article, Fox focuses on successful women in cities like New York, Boca Raton and the beachfront communities of California who have experienced both alcohol and drug addiction, and have turned to sober coaches for help.

After reading the article, there are several takeaways worth noting that shed light on the current state of therapy (and more specifically, alcohol and drug treatment). One of the mothers who is discussed throughout the article is Tamara Mellon, one of the founders of the Jimmy Choo shoe company. Ms. Mellon, according to the article, works with a London-based psychotherapist on her addiction. What raised a red flag was her comment “he’s the most enduring relationship I’ve had. I’m his one and only.” Often times, many patients have similar feelings toward a therapist. This is not to say the therapist has the same views. In therapy, the views she just expressed would be analyzed (transference) and hopefully explored. After all, this apparent paternal or even erotic attraction to the therapist is a significant factor in treatment. But, how can her overt expression of affection be explored in person when she is in New York and her therapist is in London? Also, has the therapist sent cues or signals (consciously or unconsciously) that would lead a patient to feel such a connection? We don’t get that answer in this piece and my guess is, this theme is not brought up in session (most addiction-based treatment modalities do not have components of psychoanalytic or psychodynamic theory).

There also seems to be a lack of clear boundaries with the sober coaches mentioned in the article. One patient, a female marketing executive in California, reported that “for three months, [her] sobriety coach slept in a spare bedroom, and got [her] to work out, to go to meetings, and even traveled with her.” This seems to demonstrate not only a potentially unethical relationship, but also, a sense of reliance on a therapist to help one navigate everyday life.

For some, rehab can feel like a “protective cocoon” as the marketing executive stated. For the women mentioned in the article, sober coaches can assist in transitioning to living outside of rehab. But, my skepticism for these professionals still outweighs their positive influences.

For many, drug and alcohol use is a replacement or substitute for companionship, relationships and connection. During my time working with addicts in recovery, their description of the bond and love for use can often times mirror the way non-addicts talk about a girlfriend or boyfriend. When talking about her clients who are mothers,Patty Powers, who is a recovering heroin addict and is now a recovery coach, said “they’re starved for companionship.” My intrigue into this statement is: What’s going on in the home? In the marriage? We cannot and should not treat addiction without a full understanding of family dynamics. Issues of boundaries, roles and alliances must be explored.

As I have noted before, these new trends in treatment and therapy do not offer the most in-depth, comprehensive approaches. Sober coaches, as outlined in this morning’s article, seem to cater to a select clientele who are looking for companionship as part of treatment.

Critiquing the AA/12 Step model

Let me begin this post by disclosing that I am not affiliated with AA, have never been in AA nor participated in any outpatient treatment center or program for alcohol use or abuse.  Prior to reading about the faulty and scarce research about the efficacy of 12 Step Programs, I formulated my own opinions about the AA-model from my work in an outpatient substance abuse clinic in New York City.

Many of the men in treatment are homeless and have extensive histories with battling addiction. What came across in group sessions was a division between those individuals who subscribe to the 12 Step Program and those who cringe when they hear the language of “powerlessness” and “shortcomings.”  I was first turned off from the ways of 12-Step because of the rigidity of the steps. They came across as finite and restrictive. Relapse was a black or white concept. No middle ground.

I began to think about the term addiction and place it into the overall context of mental health.  Despite the evidence that addicts have fewer dopamine receptors in the brain’s reward pathways than non-addicts, it is hard to label someone’s choices as a disease that one cannot control. What is striking about the AA model is that there is little separation or distinction between someone who has been clean for 2 months or 20 years, a relapse is a relapse and that individual has to restart the steps from the beginning. This rigidity seems to assert that if an individual “slips up,” his disease has gotten the better of him.

AA’s rate of success is also relatively low. A Cochrane Collaboration study that ranged almost 40 years (1966-2005) found “no experimental studies unequivocally demonstrated the effectiveness of AA.” The success rate is somewhere between 5-10%. A 1991 New England Journal of Medicine study found addicts treated in hospitals fared better than those treated in an AA setting.  This lack of success only prolongs an addict’s recovery, as most outpatient treatment programs in the country integrate a 12-step model.

In recent years, AA meetings have made room for atheist and agnostic members who are uncomfortable with step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.” This inclusion is a sign of progress.

Much of AA’s evidence for success is anecdotal and thus, is prone to criticism. Although I am critical of the model as a treatment, I do believe AA offers a support system that does not discriminate based on any race, gender, income bracket or sexual identity.  While an insight-oriented approach that helps the client/patient identify underlying thoughts and feelings is preferred, it is a timely and costly modality that might not yield a positive result.

Spirituality and Recovery

Throughout the year, I have been working with homeless men in recovery. Many struggle daily to fight the urge to stop drinking, smoking, snorting, shooting and using various substances. Many will use AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) terms and themes to talk about recovery. But lately, I have been struck by the overwhelming use of religion and spirituality to come to terms with and rationalize one’s addiction. The other week, I walked into a group I facilitate to hear a few gentlemen quoting scripture. A few minutes later, one man is talking about “God’s plan” and another about “Jesus’ plight.” Now, I am not a religious or spiritual individual, so I am unable to truly relate to this. What I do think about is what this means clinically.

My supervisor often tells me that people come to treatment when their defenses (defense mechanisms) no longer work. No, it is not a character defect (as AA often teaches), but rather a breakdown in one’s ability to regulate his or her emotions and conflicts. I have come to view my client’s connection with religion in the same way. In many cases, the men I work with have been let down by factors outside of their control: family dysfunction, poverty and violence to name a few. Religion becomes an outlet for one’s rehabilitation. One does not need to be a religious scholar or history professor to see the appeal of biblical stories. They are filled with heroes and underdogs who overcome tremendous obstacles. In addition, religion and spirituality act in conjunction with one’s superego. Honesty, honor and respect become pillars in one’s recovery.

In addition, the connection to religion* seems to allow individuals to not be consumed with death, revenge and regret. To many, the triumphs and hurdles that have been overcome were a test by God. Now, I do not agree with this, nor am I sure the men in recovery truly believe it either. However, it does seem that spirituality plays an intricate part in the recovery process.

*: Most, if not all of my clients are of the Christian faith. The religious and spiritual connection I mentioned is based on only the clients I see.