Medication for alcohol use problems coupled with sleep and psychotherapy can help with anxiety and depression.
There are three main points in this post
There are medications which assist your self control and reduce the urge and frequency of drinking alcohol.
Very often anxiety and depression can be influenced by sleep problems and alcohol intake.
“But at my back I always hear/ Time’s winged chariot hurrying near” (Andrew Marvell).
The Best Ways To Change
Good changes may happen. Problems may go away and they often do without any professional help. You may come up with something that you can do on your own without seeing a doctor. But it may take a long long time. I am thinking of people whose lives are right now, each day, being damaged (or seriously shortened) by alcohol, opioids, tobacco, depression. We have medications or psychotherapies which can improve or control these problems, and which can result in improvement within days or weeks.
Some people are opposed to medication because of a fear of side effects, or a preference for “natural” remedies, or prefer free will and choice in changing negative habits. They don’t have time to see a therapist, even though five or ten sessions may be sufficient. And we hear stories of herbs and vitamin success; of waking up one day suddenly changed and free of the problem; of new treatments not yet familiar to doctors; of amazing cures. And improbable things do happen all the time, and some people will prefer to wait. We tend to remember the unusual and dramatic happenings and cures, and pay less attention to what works on an everyday basis, weighing the evidence for and against.
The thing about published evidence based treatment is that we do know the expected success rate, the possible side effects, and the usual time it will take to work.
Medicine Or Self Help?
People are generally familiar with Chantix (varenicline), which reduces interest in smoking by tweaking brain receptors into thinking they don’t really need more nicotine (or at least that’s how I consider it.) The medication naltrexone does something similar for alcohol use, helping reduce desire to drink and making it less likely you will finish the drink you started. Another medication also approved for alcohol treatment by the FDA is acamprosate (Campral) which soothes glutamate brain receptors and helps reduce likelihood or amount of drinking. Several other medications including topiramate (Topomax) have had success in this arena.
Of course, before prescribing any of these medicines we look at the various risks and benefits as well as other options including the well known group programs (AA 12 step,etc), cognitive therapies, motivational treatment, stages of change therapy. But there is usually no conflict in combining medication treatment with another mode because the goal is to improve health and reduce illness, and each individual may have a unique solution.
Unfortunately, it occasionally seems like a political situation in which one person says “you shouldn’t take medicine because true cure can only be achieved by my way….”. And another says “All those meetings are nonsense, just give me a pill….” People are also influenced by family members or friends who may or may not be knowledgeable about alcohol or other substance use disorders.
When faced with a strong opinion, I suggest you ask for data and evidence which support that opinion, preferably not just one happy ending anecdote.
A common syndrome I see is a person complaining of anxiety and fear mixed with moodiness and irritability and depressive sadness; and these issues are associated with relationship conflicts and/or work problems. Very often there is no absolutely single right diagnosis because these experiences are so complex with so many causes. Therefore there is no one right way to treat or correct this set of sufferings.
I tell people that the brain is the organ most heavily involved; that each of your eighty billion neurons (and there are billions of other supporting and modifying cells) has thousands of synapses. So we are dealing with a supertanker of trillions or quadrillions of cargo variations. Your conscious self is a kind of captain wanting to maneuver this vessel but without any knowledge of what is really going on below deck.
We will try various approaches to include self help, social support, psychotherapy, medication, etc.
First, I have discovered that if I begin to pay attention to sleep patterns, especially insomnia and insufficient sleep, this begins to allow the other therapies to start working. Sleep allows the synapses to reset or recharge, and without efficient synapses (connections) the other therapies can’t do their thing. We don’t have to get to the ideal 7.5 hours of uninterrupted sleep: we just have to make progress and feel more rested.
Second, if regular alcohol use is occurring, particularly more than two daily drinks on a regular basis, then reducing the toxicity burden of alcohol will also allow the various therapies and medications to begin doing their thing.
We don’t have to reach complete alcohol abstinence, since often just reducing the total daily or weekly burden of alcohol in the brain will allow the psychotherapy or medication to be effective. The goal is to reduce the time spent suffering.
Notice, I said “medication AND self control”, not “medication OR self control”.
I think of putting medicine into my body as a method of improving my ability to achieve something I want. Analogies include putting on glasses to focus my vision; wearing shoes to protect my feet; using pencil and paper/ calculator/computer/cell phone to enhance my cognition or communication.
Objections to this line of thinking are that messing with the brain with chemicals is wrong and different from the above. Also, that harm can be caused. We always want to balance risks against benefits. If we have medications that rearrange some connections among brain synapses, with the goal of reducing suicidal thinking or incapacitating depression, is it worth it? How about the goals of getting through school, reducing anger, keeping a job? We have medications that reduce alcohol consumption, decrease nicotine dependence, eliminate the need to seek Percocet or heroin.
You can also change brain synapses (and thereby change behavior) by reading about self help ideas or listening to new information from friends or therapists. Or belonging to groups. Your self control of behavior is improved by being aware of laws and speed limits and punishments: these all change the brain connectome.
There is a lot of room for philosophical conversation in the above comments, and my patients don’t seem afraid to ask difficult questions or to disagree. My goal is to present options for the best ways to improve brain function and results. There are many things that can help improve self control in addition to medication, and I want to share what I know of the pros and cons of various methods.
POSTSCRIPT: I will resist the temptation to do more than just mention recent work on machines that think, transhumanism, and memes.
The symptoms and conditions we suffer from are not usually constant, or at least they vary in intensity. When is my worry diminished? When is my pain more intense, or of a different quality? It’s hard to study these things because when I suffer, I am less motivated and less focussed. On the other hand, figuring out these variations may be the toehold or wedge to making changes. Here are a few ideas and suggestions to get more of a grip (and perhaps more self control.)
Seasons of Change
There are recurrent cycles which don’t grab our attention unless we look for them. Seasonal variations in up or down moods are common. During winter, just opening the curtains or shades first thing in the morning may dispel sad moods and apathy. Hormonal changes in the several days before menses can cause irritability not only in the person but in significant others. Weekend use of alcohol or caffeine can prevent restorative sleep (inefficient synapses) and interfere with feeling good the next day.
Keeping a diary or brief daily checklist or chart can show patterns as you review it once a week. Being aware of holiday patterns, travel stresses, family visits, or anniversaries of a period of suffering can all help to predict increased risk. Just being aware of the risk is a self control measure.
Bringing It into Focus
The ability to focus and pay attention (along with positive or negative feelings) will change depending on
Who you are with
The task before you
The time of day
Your biological drives (hunger, sex, fatigue, security).
And all the other things ahead of you that your brain is busy anticipating on its own. Yes, your brain is always 100% busy doing the best it can to get you into the future successfully. My intended audience for these posts are my patients and anyone potentially interested in improving self control.
Just showing up is said to be a key to doing well. Regular psychiatric checkups to identify brain risks is usually helpful, like annual physical exams or periodic blood pressures. If you are seeing a psychiatrist or therapist, and if you trust him or her, some periodic check, even once a year, is likely to help you spot things like cycles and variations which will assist you in controlling your future.
Prepare for some additional travel time if you are using Peachtree Road anywhere between 14th St and Roswell Rd. The utility poles are being set back by Georgia DOT/GA Power.
The project started on 2/18/2019 and is estimated to go through November. Please leave extra time
One alternative route is Northside Drive to Deering Rd, crossing over Interstate 85/75 and then left on Standish Ave and in one block turn Right on 25th St and this will bring you to correct side of our building for parking.
Of course, if you have any questions or need any help getting to the office, you are always welcome to contact us.
See the following maps for more info on the alternate route to avoid the traffic on Peachtree.
“I don’t need much sleep.” “I pulled an all-nighter.” “I can always catch up.” We have the illusion that we control what happens in our brains, that we can forgo a sleeping state in favor of a waking one without penalty.
No, not true. There is a price to pay- you may decide it is worth the price, but the billions of brain cells and their trillions of connections will have their say. The “I” of my personal self, Ross, is itself constructed by these interacting neurons and doesn’t have much more say about what my brain is doing than it does about how my skin or my liver is behaving. We’re getting into tricky philosophical territory here, but my overall point is that insufficient sleep leads to unintended consequences:
Your brain may enter “microsleeps,” brief periods of snoozing which are well known to night drivers or tired classroom students. These can be dangerous.
Your brain may produce “local sleep,” in which a few neurons at a time are offline and resting- not enough to be aware of, but definitely capable of causing inefficiencies and omissions.
You don’t feel rested; you don’t look forward to rewards; there is a background dullness or tension to your life.
You may be more inclined to overuse alcohol or drugs, including caffeine or nicotine, in order to improve your emotional state. This developing feeling bad/feeling good/feeling bad cycle leads to self defeating habits.
Lack of sleep is usually associated with weight gain (not what you expected!) and metabolic and hormonal changes associated with various illnesses (see also my version of Pascal’s Wager).
Memory, decision making, pain tolerance, moral choices, negotiating ability, and other cognitive and emotional functions are hurt when we are deprived of sleep.
As I said above, you may decide that lack of sleep is worth the payoff, but your decision can be informed by a balanced consideration of risks and benefits.
What is the biggest mistake I’ve made over the years in treating alcohol, tobacco, and other substance use problems (heavy use, problem use, addictions)? It’s the failure to remind myself to distinguish between two large groups of substance users, A and B. Which two groups? A little background:
Think of the brain as billions of circuits with trillions of connections, like railroad tracks with chemical (neurotransmitter) switches from one track to another, ceaselessly working to control thinking, emotions, actions- all with the goal of getting you successfully into the future. Think of substances you use as messing with these switches, sometimes for benefit, sometimes not. Imagine switches which, once they are changed by a substance, they stay changed and don’t return to previous “normal” status. The train gets stuck on an alternative set of tracks going somewhere else. It’s like oversweetening your tea or oversalting your food: you can’t just reverse the process. You’re stuck with that one glass of tea or plate of food, even if you promise not to add any more sugar or salt. Some people, for genetic or developmental reasons, are stuck with that set of train tracks: the switch has been thrown and they can’t un-throw it.
Sometimes I was totally focused on life-saving, detoxification, reducing and eliminating the alcohol or drug use. I was not yet thinking: will this person be in Group A, where he or she will be able to switch back to previous patterns of living, even without the substance? Or will this person be in Group B: handicapped for a long period of time, feeling abnormal without the substance, the craving never going away, dealing with others who believe “just don’t do it” is a solution. Sometimes a member of Group A joins group B and vice versa. This can be a fluid situation, so the most important part of treatment is probably the long term follow up, check-ups, observing over long time periods. A three-day “detoxification”, a thirty-day “program,” a six or twelve-month “recovery residence”: these are only baby steps because we are not yet technologically able to see how the brain circuits are functioning.
Now it may be true, considering the entire population, that most people will be in Group A: they throw away that last pack of cigarettes and feel fine thereafter. They have an occasional drink or hit (or not) and go on with successful lives. But of the people who seek treatment, those I see, a large number require something else, something more, to enable a good quality of life. Group A people do well with abstinence or sobriety. Those in Group B experience life as if it consists of daily repeating cycles of pain, hunger, difficulty breathing, itching, anger. The word “craving” is too general and has lost its impact. In these circumstances, it is hard to function at work or in relationships. Have you ever thought, “I’ll do anything to stop this?” Then you know why substance use disorders are characterized by “relapse”. (I sometimes use quotation marks, or scare quotes, around certain words to indicate that I have reservations about the usual use of the word). And you know why those who say “She is not trying hard enough” or “He should be taking care of his family” are technically correct but are not addressing the real life problem. Adults or children, for example, who experience severe thirst or hunger or sleeplessness or oxygen deprivation will not do well in school or at work. Altered brain circuits produce these kinds of problems. And they often last for years.
What are the alternatives to pure “self-controlled” abstinence or complete sobriety? There are many:
Continuing to always feel dysphoric and learning to tolerate this state of missing something or needing something; accepting reduced quality of life.
Having binges and relapses.
Using a replacement substance (replacement therapy), for example with nicotine patches for tobacco or another opioid such as buprenorphine (Suboxone, etc.) or methadone for heroin-oxycodone, etc.
Using a receptor-modifying medication such as naltrexone for alcohol or varenicline (Chantix) for tobacco.
Using a lower dose of the problem substance so as to stay out of trouble, such as controlled drinking or regular prescribed dosing of the problem substance, e.g., alprazolam or clonazepam.
Secret use of the problem substance, hiding it from others.
Finding an activity or hobby which substitutes another pleasure, usually in a compulsive manner.
Intense socializing, such as attending frequent addiction oriented meetings.
Psychotherapy, individual or group, cognitive, behavioral, dynamic, or other.
I will have later blogs on self-control and the various talking and communicating therapies. For the moment, I just want to identify opioid replacement therapy as an underused and misunderstood treatment for opioid drug problems, since there have been so many recent deaths from overdose. I was also personally affected when a good friend with an opioid problem was seen at a large sophisticated urban medical center and no mention was made of the most effective opioid use treatment, namely buprenorphine. Many physicians seem still unaware of this option.
One last point:
In adolescence drug use is particularly fraught because there is a surge of growth and pruning and reconnecting that enables the transition to adult brain status. I’m “afraid” to say so, but for example, marijuana is particularly dangerous in adolescence since the brain’s cannabinoid receptors are busy modifying and adjusting brain networks that will have to do with adult cognition, mood, reality testing, etc. THC will cause changes in these railroad track circuits that may not become undone later (see above). Adults seem to be at less risk for this problem.
So much is always going on in psychiatry that it’s easy to follow the 11th Commandment, “Don’t Be Bored.” We are beginning to look at psychiatric problems not just in terms of DSM 5 diagnoses, and not just in terms of brain chemistry and genetics, and not just as the interactions of genes and environments (including fetal and early childhood happenings). With the help of increased computer power and newer mathematical statistics, research is burgeoning on the brain networks in which the 80 billion neurons (and the more numerous brain cells which are not neurons) are connecting and interacting. Some of the identified networks are those of executive control (decisions and planning), salience (meaning and importance of incoming data), attention, and default mode (related to baseline inner awareness, thinking, daydreaming, sleep onset, and much more). The activation and deactivation of networks is where the action is; I expect we will be directing our therapies to these before long. I refer to this exciting new direction in psychiatry as the Brain Connectome Project. There will be more to come about this expanding field exploring the network of the brain.
In my practice I look forward to listening and conversing and working with people and helping them figure out what is going on. I sometimes say that I am here to help them protect their brains from risk and use their brains most effectively as they want to. For example, in addition to problems we read about in the news, there are more subtle things going on. I have found an increase in the symptoms of depersonalization and derealization, in which we may feel we are somehow the wrong person, or in the wrong body, or that life is not as meaningful or real as it seems to be for other people. Just identifying this issue may suddenly allow someone to make more sense of what they have been suffering with.
Medical practice is always interacting with public health in general. Since July 1 of this year we are required to use the Prescription Drug Monitoring Program (PMP Aware in Georgia) whenever we prescribe certain scheduled drugs, to see what other prescribers and prescriptions are out there for any particular patient. Pharmacists must enter all scheduled drug prescriptions they fill into the data base within 24 hours. This data base has provided significant information, and has helped me identify and discuss risk issues with my patients. “Scheduled” means medicines the DEA (Drug Enforcement Administration) considers can be misused or are habit forming, such as opioids, benzodiazepines, and others. The public health goal is to reduce opioid deaths and other harms.
The number of meetings, journals, updates, courses, books, and conferences require us to be selective. Earlier this month I attended the GPPA (Georgia Psychiatric Physicians) meeting in Amelia Island with about one hundred colleagues. There were excellent presentations of new research on, of course, the management of opioid disorders (by Dr. William Jacobs, Jr.), post traumatic stress from the Grady Trauma Project (by Dr. Charles F. Gillespie) which is nationally known, and the connections among sleep disorders, depression, stress, and suicide (by Dr.W. Vaughn McCall). I was particularly interested in findings which confirm that insomnia is not just problems sleeping, but a 24 hour type of hyperarousal which interferes with decision making, causes inflexible thinking, and increases suicide risk. We lose a lot of valuable information because drug research trials almost always exclude people with known suicide risk.
I have been reading about the increase in “deaths of despair” labeled by two Princeton economists, which includes some familiar foes:
Overdoses and poisonings with drugs, suicidal or not (usually opioids)
Deaths from alcoholism (liver disease)
All of these have been significantly increasing since 1998 in a particular population group, namely middle age and older men and women who are white and have not attended college. Of course we are all vulnerable to these disorders, but this group has seen an unusual increase.
I used the term “boring” in the title of this piece. Could it be that boredom is a protective type of emotion which signals it is time to get curious in order to survive? Think of emotions as signals which give color and motivation to thoughts and experiences, notice what is going on in your brain as if you are in an audience and your brain is onstage.
Many adults have been hyperactive, restless, or inattentive when they were children. These problems may still be present, especially difficulty reading and remembering the beginning of a sentence when they get to the end. But what most interferes with successful living is a particular handicap: a lack of skill in making decisions, being able to prioritize, and therefore not completing tasks, not finishing things. This impairment has been described as an executive function problem, or as a triage (“tree-azh”) difficulty.
This French term, triage, was originally used to describe rapid assessment of battlefield wounds and deciding which soldiers needed immediate surgery, which could wait, and which were not likely to survive no matter what was done. A related strategy for decisions was described by Eisenhower: incoming items are matrixed into one of four boxes: urgent and important (do now), urgent and not important (delegate), important but not urgent (to-do list), and neither important nor urgent (trash).
People with ADHD brain circuits have special problems in these decision activities. Many are above average in cognitive intelligence and have been able to easily get through elementary and high school despite a handicap. Quite a few have special aptitudes and are able to hyperfocus and be very successful in subjects or activities that are highly meaningful to them. On the other hand, they have problems delaying action- they may speak or interrupt before thinking it through. Or follow another car too closely because getting somewhere quickly crowds out the issue of caution. Or not get important things accomplished because something else is suddenly available.
Adults commonly become aware of the decision making problem when:
They have finished the structured school experience and are in a job where there is time pressure or peer pressure or billable hours pressure to “get things done”.
They experience an added pressure to perform or have many more tasks, as when they marry, have a child, take a second job, get promoted and have to check on many more things/people.
Common outcomes of the above problems are:
Anxiety (fear of making more mistakes)
Sadness (about lost opportunities for success)
Insomnia (worries about things left undone).
Successful diagnosis and treatment of ADHD will often improve these emotional problems.
In making the right diagnosis of ADHD, it is necessary to consider other causes of decision making (“executive”) dysfunction. These include sleep disorders, especially insufficient sleep or obstructive sleep apnea, as well as other medical problems like thyroid disease, anemia, neurological disorders, etc. Substance use disorders with alcohol or cocaine or opioids may complicate the picture.
A future blog will cover medication issues including prescriptions and formulations and pharmacy and risks, travel, and other Frequently Encountered Problems. Also non-medication options and the role of counseling, therapy, and coaching.