The Therapist's Guide to Addiction Medicine. Barry Solof

they “don’t have a problem,” there are people who simply don’t want to stop using alcohol and other drugs and are not yet ready to stop, despite the adverse consequences they have experienced to that point.

      In order for addiction treatment to be effective, addicts usually have to get to the point where the pain of using and everything that goes along with it significantly outweighs the pleasure and/or relief that using brings. We used to talk about the need for people struggling with addiction to “hit bottom,” but at a minimum, addicts need to get to a place where they are confronted unavoidably with the reality that the negative consequences of using far exceed the perceived benefits. Ambivalence is common, even if technically, a person is not being “forced” into treatment.

      A skilled counselor can tip the scales of this ambivalence by helping the patient to specifically identify the “good” things that he or she gets from using, as well as what using has cost, continues to cost, and is likely to cost him or her in the future. As this list is formulated and processed, it usually becomes clear that the costs of using are greater than its benefits, that the advantages can no longer compete with the disadvantages. This helps people come to the realization that they really don’t wish to continue living the way they have been, and they become willing to enter treatment.

      Over the last decade or so, drug courts have evolved as an innovation wherein both drug abuse/addiction and criminal acts can be addressed in an integrated way. The most effective models incorporate criminal justice considerations with drug treatment that includes screening, placement, counseling, testing, monitoring, and supervision, and often include attendance at twelve-step meetings. Treatment should also include assessment and counseling for high-risk infections such as hepatitis C and HIV. Intravenous drug users, in particular, are going to be at considerable risk for these viruses. I’ve rarely met an IV addict who didn’t have hepatitis C. Many of the patients you will work with in addiction treatment are going to have HIV, they’re going to have hepatitis C, they’re going to be pregnant (with complications), and they’re going to have a range of medical problems from their using. We’ll cover these commonly seen medical comorbidities later.

      Sometimes it isn’t possible to motivate clients externally to seek treatment. I recall one patient many years ago who had AIDS and was addicted to crystal meth. The only reason he periodically came to the hospital was because he was running out of money and running out of drugs. He had abscesses all over his body from injecting drugs and by the time I saw him, he had wasted away to about ninety pounds. He needed antibiotics and medical stabilization, as well as to get some food and hydration in him. Rather than let him die, we’d admit him to the hospital for a few days. One day I said to him, “Why don’t you give this up?” He said, “Doc, I don’t have much to live for. I’m going to die in a year or two anyway, if I live that long. At this point, the only enjoyment I get in life is shooting up crystal meth.” I didn’t have an answer that would satisfy him. I told him that his life would get better if he didn’t use, even if he only had a year or two. I never saw him again and I guess he died. In this field you see people who, for whatever reason, don’t want to stop using.

      I had another case where a woman brought her husband in for treatment. They had been married for a long time and their marriage had reached that critical moment where she said, “Look, either you follow the doctor’s advice and get into treatment, or I’m leaving you. I don’t care how many years we’ve been married, I’ve had enough. It’s either me or the booze.” He said goodbye to his wife, right there on the spot in my office.

      It’s not possible to force help on someone who absolutely doesn’t want to be helped. There are times when, faced with that choice of treatment or incarceration, people will actually choose to go to jail. For some people, especially if they have a history of incarceration, the idea of going to jail is more comfortable and (believe it or not) less scary than entering treatment.

      You can put somebody in a psychiatric hospital against his or her will on what we call a seventy-two-hour hold, sometimes called a psychiatric hold, but that’s only if the person is acutely suicidal, an imminent danger to other people, or gravely mentally disabled. In this situation, there is a judicial hearing within seventy-two hours. But no one can be hospitalized against his or her will simply for using drugs, even if continuing to use puts his or her life at risk. Sometimes this is very difficult to explain to family members.

      One of the ways to tell that someone is unmotivated to enter treatment or to complete it and achieve recovery (regardless of what he or she may say) is when the family, the doctors, and the therapists seem to be working harder on behalf of the patient than the patient is. Everyone else is pulling their hair out while the patient is drunk and stoned and often doesn’t care one bit. This is an example of codependency. Officially, codependency is defined as “a psychological condition or a relationship in which a person is controlled or manipulated by another who is affected with a pathological condition (as an addiction to alcohol or heroin).”²

      More broadly, codependency is a psychological condition wherein a person’s view of him- or herself and self-esteem is dependent upon the welfare of others, most often the primary partner and/or family. Someone who is codependent defines him- or herself only in relationship to others, rather than as an independent individual. Codependents are much more concerned with the needs of others than their own needs. As as result, people who are codependent are overly responsible and controlling. They take responsibility for the feelings of others and can only be happy when those they are in codependent relationships with are happy.

      Codependent caretaking of the addict by family, friends, or others enables him or her to avoid taking responsibility for his or her behavior and actually helps keep that person in active addiction. Codependents often have the best possible intent: With their pleading, they convince the addict to begrudgingly enter treatment; they may call all over town to find a treatment program, transport the addict there, make arrangements to pay for treatment, and after two days, the addict wants to leave treatment because “he had a fight with his roommate” or “didn’t like the way that counselor talked to him” or “doesn’t like the food.” So he calls his mother or whoever is likely to be the easiest to manipulate, who then agrees to allow him to come home and picks him up, thus saving him from the “horrors” of treatment and potential recovery.

      Amazingly, it’s not that unusual for addicts, whether adolescents or adults, to get money for their drugs from their parents. Often the parents have not been told what their child needs the money for. But at a certain point, it’s evident and people are just kidding themselves. Allowing children to continue to live at home rent-free while they use whatever money they can get for drugs is another common way that parents practice codependency. Somewhere along the line, the parent comes to you, the addiction treatment professional, and says, “I want you to fix him, to cure him.” This is not to assign blame, but to clarify that active addiction generally has the unwitting assistance of people close to the addict. Their reactions to the addiction and its related problems enable it to continue.

      How do twelve-step programs fit with addiction treatment? Many people who could benefit from addiction treatment have neither health insurance that covers it nor the resources to pay for what are often expensive services. Most addiction treatment programs require patients to have health insurance with the appropriate coverage or the ability to self-pay for treatment. Although many communities have some publicly funded or subsidized addiction treatment that is accessible to people without financial resources or health insurance, these programs are often limited in size and types of services they offer (for example, they may provide detox only), have narrow eligibility criteria, and may have long waiting lists for admission. It is an extremely positive development that the new federal healthcare law, the Affordable Care Act, mandates some coverage for addiction treatment, but how long it will take to become widely operational and how much positive difference it will make in terms of facilitating access to addiction treatment remains to be seen.

      AA, NA, and the other twelve-step addiction recovery programs are free. As I noted earlier, as necessary as professional treatment is for many people, many others achieve and maintain recovery through twelve-step programs alone. Sometimes patients will ask me, “I go to twelve-step meetings, so why do I have to come to your treatment program? Or, alternatively they may ask, “I’m