Addiction

Addiction takes many forms. Whether it’s a drug or behavioral addiction, the consequences are often the same. Addiction occurs when one is willing to sabotage their life and relationships in order to indulge in a habit. Despite negative outcomes, addicts continue investing a significant amount of time, money and energy into their addictive experiences. They may or may not feel guilty about it. They may have tried to cut down or they may freely indulge in it. It doesn’t matter, as all forms of addiction have the same effect on the brain: when a craving occurs, it prevents the chemicals in the brain (dopamine) from releasing until an addictive habit is satiated. By not quelling this craving, an addict will experience discomfort, varying from mild to severe withdrawal symptoms. It’s a disorder with nonstop episodes that typically prove to be destructive, unbearable, and eventually, unsustainable.

I am a general psychiatrist with a specialty in addiction psychiatry. I treat both drug and behavioral addiction using medication management as well as psychotherapy. My fellowships in clinical addiction at Mount Sinai School of Medicine and addiction research at Albert Einstein College of Medicine provided me with the professional training to understand and treat patients using medication and psychotherapy, including patients with behavioral addictions. 

Overcoming addiction is a multi-layered process with paths that depend on the specific individual in recovery. Treatments include pharmaceutical and psychotherapeutic options, recovery requires motivation and a strong doctor-patient relationship, and the overall philosophy is one that both patients and doctors have to buy into.

My practice treats addiction to opiates and heroin, stimulants (adderall, cocaine and crystal methamphetamine), alcohol, and benzodiazepines (xanax, Ativan, Klonopin and Valium).  I offer motivational interviewing, a proven strategy of psychotherapy that focuses on altering the mindset of a patient into one ready for change. Along with psychotherapy, I prescibe suboxone, sublocade, naltrexone, and vivitrol, while methadone is not prescribed in my practice.

For decades, methadone was the main treatment for opiate and heroin addiction, and since then new drugs with more availability have come out. Suboxone is one such treatment, and acts as a unique opiate receptor blocker taken for thirty days after the patient and doctor have stabilized and maintained an appropriate daily dosage. The same regimented rules that apply to methadone likewise apply to suboxone treatment, and it is this rigidity that helps patients improve and beat their addiction. Some doctors are of the belief that Suboxone should be given for life and never lowered. Conversely, I believe in tapering down the dosage so that the patient can become medication free. Therefore, the patient needs to understand their doctor’s plan for treatment, and their reasoning. Otherwise, a lack of insight into what the doctor believes to be best for the patient may leave the patient unclear of what to expect or unhappy with the trajectory of their treatment.

Additionally, I provide sublocade injections, of which is essentially sublocade that lasts thirty days per injection. This is ideal for patients who relapse frequently or have difficulty taking subxone on a daily basis. It may not be easy for the recovering individual to take suboxone every day, and this is usually a specific psychological problem with the individual. One has to have the discipline, dedication, and most importantly, motivation to be able to consume this medication on a daily basis. That’s why motivational interviewing is the main psychotherapy for addiction. Following sublocade injection, I may bring the patient back to suboxone when they have shown progress and developed enough commitment to taking a daily suboxone medication. Finally, I prescribe oral Naltrexone, an opiate receptor blocker that acts as a general anti-craving medication. The beauty of Naltrexone is that it helps patients improve their willpower and overcome any final obstacles to behavioral or drug addiction recovery. Naltrexone and Suboxone cannot be mixed, as a patient may undergo Suboxone withdrawal, because it is an opiate. Despite this, replacing the source of addiction with Suboxone allows patients to be functional, hold a job, and have a relationship; feats impossible if the patient were to continue to use heroin or painkillers illicitly.

Similar to Suboxone and Sublocade, Naltrexone and Vivitrol are the same chemical compound, except Vivitrol is a monthly injection. Not everyone is a candidate for Vivitrol or sublocade. As mentioned previously, only specific patients receive these monthly injections. They are safe and bypasses the liver metabolism because when they are injected into the muscle they bypass the stomach, liver and gastrointestinal tract and go straight into the bloodstream and to the receptors. This also removes the nasea component that can occur with non-injection opiate addiction treatments. Still, not everyone is a candidate for Vivitrol or sublocade. It takes a knowledgeable and empathic doctor to make that decision with the patient.

However, any bad habit or maladaptive habit can be addictive.Addiction means one is willing to sabotage their life and relationships in order to obtain a drug or indulge in a habit. A few examples of behavioral addictions are gambling addiction, internet addiction, sex addiction, being a workaholic, being addicted to pornography and social media on smartphones. These behaviors become addictions when they start to negatively affect other aspects of life, including work, family, friends, and relationships.

The Sinclair method is effective in treating behavioral addictions. The Sinclair method features a combination of motivational interviewing Psychotherapy and Naltrexone oral medication given, in tandem. The patient can choose to do motivational interviewing Psychotherapy alone, and many patients choose that. A lot of patients don’t want to take Naltrexone medication and that’s fine. However, when the patient’s will power has not been sufficient, I prescribe Naltrexone. This has been very effective with motivated patients. Finding the motivation to beat an addictive behavior is extremely psychological and that’s why motivated patients do the best on Naltrexone. On this medication, patients feel that they do not have a craving for their addictive behavior. As a result, it is able to reduce gambling in patients suffering from gambling addiction. It reduced impulsivity and risk-taking behavior in the patients who with a sex addiction.

Today, behavioral addiction has been able to hide better than ever before.  Technology, mobile phones, the internet, and social media have reached new heights in terms of popularity and use. We are attached to our phones and plugged  into the internet at all times.  Yes, some people function just fine and may even function better. However, this new aspect of society has affected others in their professional or personal relationships. This has become both a sociological and a generational matter.  For example, Generation X was born before the internet, Millenials straddle both pre-internet and the beginnings of the internet and social media, and Gen-Z  entered the world when the internet and social media were everywhere.  There is no doubt that the internet affects the way people see the world. The articles we read, the  images we see undoubtedly shape our worldview and reality. 

As a result, now more than ever, it’s necessary to have objective feedback in life. Likewise, it’s important to get feedback from loving friends and family, but they may bring their own biases and limitations into their advice. Psychiatrists and therapists are able to provide objective feedback. However, the skill level of each psychiatrist and therapist is different. It helps when the mental health provider has had their own psychotherapy so that they’ve achieved a certain level of self-realization so they can know where their biases lie and the patients’ begins. It’s like going to a physical trainer to work out and become more healthy; you want your trainer to be well-versed and accomplished in exercise and the psychology behind it so they can push you to improve and to achieve your best.  Yet, even physical trainers have different levels of skill and experience. Naltrexone and Psychotherapy have helped patients reduce internet and mobile phone use whether they are on Instagram or looking at pornography. The key element is a strong belief in oneself and having faith in the doctor and their treatment plan. Belief and dedication are core values for success, not only in addiction, but in overcoming general mental health issues and other facets of life.

My practice provides a very customized Psychotherapy because everyone’s life story and experiences are different. Here we help dissect all the emotional experiences in order to help the patient regain control. People do things unconsciously, people engage in their bad habits and they’re not aware of it. This is human nature, no one should feel bad for it. This is why individuals come to a psychiatrist or therapist so that they can utilize their conscious mind and understand why they are indulging in these bad habits. That shift has to occur in the unconscious. Behavior must become conscious, that is the essence of psychodynamic psychotherapy. Thus, psychodynamic Psychotherapy is a part of motivational interviewing. Many people have difficulty waking up on time and getting to work.  Many have difficulty showing up to their personal engagements on time.  Everyone struggles with time management to a certain extent. The first step is to become conscious of these mistakes.  Then may one take the humble steps to fixing this problem.  This is the object of cognitive behavioral therapy (CBT), a goal-oriented treatment. CBT is also a part of motivational interviewing. It may be obvious that therapeutic style uses bits and pieces of  psychodynamic therapy, CBT, and motivational interviewing.

I believe beating addiction is possible. Psycotherapy and motiviational interviewing is important for this. Believing in oneself and having faith in the process is undeniably important for this.

Addiction recovery is never a linear progress. It always goes up and down, and small lapses and relapse are part of addiction. Depending on the severity of the addiction, sometimes drug addicts have to go to rehab. Patients classically become angry with this decision, and it speaks to why the trust between patient and doctor is so important. All patients should know that discussions with their doctor are confidential. If a patient does not tell their doctor the full story, they are sabotaging their treatment. One must accept that failure may be part of the process, and that failing sometimes can be necessary before they succeed. Sometimes the doctor will discharge the patient or terminate care. This is the reality of life. This is true of most success stories, including athletes who lose before they win a championship, teams that have failing seasons after they have won a championship, or artists who struggle to achieve notoriety at first. The idea is that perseverance is key. This is the reality of addiction as well as psychological growth. Sometimes the doctor will discharge the patient or terminate care. This is the reality of life. 

Addiction treatment can be difficult for patients as well as the doctor. The doctor cannot be a pushover, they have to maintain certain rules, boundaries and discipline to help the patient beat their addiction. Often, the patient is so used to their habit that it’s difficult for them to change and they can become frustrated with the doctor. As a result, it’s very important that the patient and the doctor discuss the boundaries of treatment in the very first session. It is important for the patient to trust the doctor in the darkest of times, or the relationship will not work. The therapeutic relationship between the patient and doctor is practice for the patient’s real relationships. The patient should be aware that addiction has caused problems in many of their relationships, and that these riffs will inevitably occur between the patient and doctor. The doctor and patient should discuss this in the very first session to build a relationship based on trust. It’s important to sign a contract regarding this.

This applies to treating General psychiatric and psychological issues as well.

Sadly, when a breach of rules occurs too frequently, the doctor may discontinue treatment with the patient. This is the honorable thing to do because if the doctor allows boundaries and rules to be broken then the addiction treatment will likely fail.  Treatment depends on both parties, and it is important that a doctor has undergone their own psychotherapy so that they are aware of what pushes their buttons. This is the main psychological crossroads where mental health of differs from the General Medical Doctor’s practice. Ideally, the general medical doctor should be aware of this too, so the doctor does not react negatively toward the patient’s bad habits. However, we are all only human.

One of my favorite things about psychotherapy is developing an idea of the unconscious mind. Patients benefit if the doctor can be objective and is able to see psychologically what the patient is unable to see themself. There’s a reason why the patient is coming in, why the patient feels bad. Usually, there is something the patient is doing to perpetuate that bad feeling and it’s tough for them to see it without professional help. Psychiatrists and psychologists are taught to listen first and speak second. The doctor has to wait until the patient is ready to hear certain unconscious interpretations, otherwise certain interpretations can be received poorly and the patient may feel judged or misunderstood. The doctor should proceed at the patient’s pace.

However, when certain controlled substance medications are prescribed, the addiction psychiatrist’s work begins to differentiate from that of the general psychiatrist. Mis-prescribing and over-prescribing have become a national epidemic and prescription drug addiction is a problem throughout the country. Patients have been consuming an overwhelming amount of prescribed medications, and are sometimes led to believe that they need this medication or too high of a dosage by their doctor. This may result in a full-fledged addiction.

That’s why the psychiatrist and addiction psychiatrist should determine what is happening both consciously and unconsciously within the patient. It is the psychiatrist’s duty to cause no harm to the patient, couple or family, and guide them in a positive direction. As a result, developing this unconscious vision in psychotherapy is an intangible human skill, that not even artificial intelligence could replicate.

            Individuals potentially suffering from addiction need to be aware that their behavior, whether it involves drugs or not, is treatable and beatable. They should know that medication and psychotherapeutic strategies are available and what their options are. People in general should know about the unconscious mind and how it affects behavior, the philosophies of their doctors, and the importance of objective feedback. Ideally, the relationship between a patient and their doctor is to help one another get better.

Writing about the specifics of the Psychotherapy sessions is outside the scope of this article. If you are curious about taking a deep dive into your personality and why you engage in these negative habits, please call to see if my practice is suitable for you.