A Collaborative Initiative for Patients and Clinical Professionals

A.T.F. Volume IX #2 Spring 2000

Clinical Concepts - Sexual Dysfunction & Addiction Treatment
Survey Results - Patient Battling Stigma & Prejudice
Events to Note
From the Editor: Methadone Millennium
Brainstorm: Spiritual Road to Recovery Part 4


Clinical Concepts - Sexual Dysfunction & Addiction Treatment

Suffering in Silence
Most substances of abuse and dependency potentially wreak havoc on sexual performance and reproductive function. Consequently, sexual dysfunction (SD) is apparently common among patients coming into addiction treatment,[1,2] yet most suffer in silence.[3,4]
These problems must be addressed by program staff or adverse outcomes could result. Patients plagued by SDs may resort to self-medicating with drugs such as stimulants, by reducing doses of prescribed medications, and/or by dropping out of treatment.[5]
A Common Concern
Studies have found that up to 87% of females and 85% of males entering methadone maintenance treatment (MMT) have had sexual difficulties while using heroin.[1] Women typically reported irregular periods or infertility, and both sexes experienced lack of sexual desire, difficulties achieving orgasm, and decreased satisfaction with sexual relations.[1,6]
According to Sarz Maxwell, MD, research director at the Center for Addictive Problems (CAP), Chicago, virtually 100% of patients coming into her clinic for treatment have some degree of SD, in that they feel their drug abuse has negatively affected their sex lives. "This age of Viagra has awakened professionals and patients alike to the possibilities of alleviating sexual problems," she told AT Forum in an interview, "and patients in addiction treatment deserve therapy for those maladies just like anybody else."
While in MMT programs, up to 22% of patients experience SD, according to past research. Reported dysfunctions included diminished sex drive, impotence, abnormal menstrual periods, and/or infertility.[1,7] Many of the reported SDs may be ascribed to medical problems resulting from prior opioid addiction, abuse of drugs while in treatment, or delayed acclimation to optimum methadone dosage.[1]
Looking Beyond Opioids
In addition to opioids, all other substances of abuse seem to have potential for creating SD. Long-term alcohol effects can include decreased sexual desire, suppression of ovulation, irregular menstrual cycles or complete cessation, premature menopause, enlarged breasts (in men also), impotence, low sperm counts, and testicular atrophy.[8-10]
Many persons believe stimulants, such as cocaine or amphetamines, enhance sexual functioning. But, in fact, chronic stimulant use reduces sexual desire and inhibits performance in both men and women, plus these drugs may cause the same severe SDs seen with abuse of opioids or alcohol.[9,11]
Medications commonly prescribed for patients in addiction treatment also may negatively affect sexual performance. These include antidepressants, antipsychotics, sedatives, anxiolytics, anticholinergics, antihypertensives, and antiandrogens.[12] With a majority of patients coming into treatment these days being polysubstance abusers and/or having dual diagnoses (addiction plus psychopathology) for which they are prescribed diverse medications, it makes sense that SD would be commonplace, as Maxwell observed.
Hormonal Upsets
Research in animals and humans has established that opioid abuse influences SD by disrupting hormonal balance in the hypothalamus and pituitary glands. The hypothalamus, at the base of the brain, is a principal regulatory center, controlling such basic drives as sexual activity, eating, drinking, and body temperature.[13] See drawing.
One major task of the hypothalamus is regulating the release of hormones from the pituitary gland, a pea-sized structure attached by a short stalk below the hypothalamus. The pituitary produces hormones acting directly on other glands ­ the thyroid, adrenals, testes, and ovaries ­ that release hormones of their own.[13,14] Disruptions in the normal flow of hormones from the pituitary, sometimes called the "master gland," can adversely affect sexual function.
The hormone prolactin, produced in the anterior portion of the pituitary gland, is believed to be at the core of SD seen in drug addicts. Prolactin affects reproductive functions and lactation (milk production in the breasts). Several hormones from the hypothalamus control prolactin release, the most important being dopamine, which has an inhibitory effect on prolactin excretion.[14,15]
Chronic opioid abuse (and potentially other addictive substances) upsets hormonal balance by decreasing dopamine secretion from the hypothalamus. Since the pituitary is no longer being held in check by the normal flow of dopamine, it produces excess amounts of prolactin ­ a condition influencing SD called "hyperprolactinemia."[14,16-22]
(Note: Dopamine produced in the hypothalamus acts as both a neurotransmitter and a hormone, and opioids appear to suppress dopamine excretion in this gland. In other parts of the brain, opioids stimulate dopamine production, engendering analgesia, euphoria, and other "reward" effects of opioids.[10,15,23])
Any SD that may occur with chronic heroin abuse can occur with methadone, since both are opioids. However, the steady-state pharmacokinetic properties of methadone allow adaptation and normalization of endocrine and neuroendocrine function.[23] As Maxwell observes: "Optimum methadone doses tend to stabilize hormonal balances over time."
SD often vanishes or improves during ongoing MMT, as tolerance develops to the effects of methadone on hypothalamic hormones.[1,7] For example, in women, menstrual cycles that had been disrupted by intermittent use of heroin return to normal; in men, circulating concentrations of sex hormones return to normal ranges.[24,25] However, in certain patients, increased prolactin levels and associated SDs may persist.[23]
Pharmacotherapy for SD
Maxwell and her associate, Marc Shinderman, MD, conducted a 90-day non-controlled, observational investigation of bromocriptine (2.5-10.0 mg/day) prescribed for 34 MMT patients (23 males, 11 females) with complaints of persistent SD. Average tenure of these patients in MMT was 46 months.[5]
Bromocriptine, an ergot-derived dopamine agonist, has been widely used in treating hyperprolactinemia in both men and women because it increases dopaminergic tone and inhibits prolactin release from the anterior pituitary.[14,21,25] However, adverse effects of the medication are common, including fatigue, sedation, nausea, vomiting, dizziness, and hypotension.[14,26]
The Maxwell/Shinderman study found that 65% of males and 26% of females had positive responses to bromocriptine therapy. The fact that more males than females responded is typical of SD therapy in general.[18]
Responders tended to be taking higher doses of methadone and/or ancillary medications with dopaminergic activity. Limited data also suggested that patients with higher prolactin levels at the outset were better responders to bromocriptine.
Although bromocriptine appeared efficacious, acceptability by patients was rather low. All of the non-responders dropped out of the study prematurely. There also was a high attrition rate among responders due to sedation effects and high cost of the medication.
Maxwell suggests, however, that bromocriptine is not the only dopaminergic agonist available and her clinic is having good response to two dopaminergic medications commonly used in psychiatric treatment of opioid- dependent patients ­ bupropion and methylphenidate. Other researchers have recommended pemoline,[12] amantadine,[12,26] cabergoline,[26,27] or pergolide[28] as effective alternatives for treating hyperprolactinemia.
The Duress of Stress
Research has demonstrated that hypothalamic-pituitary hormone imbalances engendered by drug abuse also affect the thyroid and adrenal glands. One concern is a response to ongoing stress in drug-dependent persons resulting in disruptions of cortisol and sex hormones released by the adrenal glands. These hormone imbalances may influence sexual disorders, weight gain, and other ill effects ­ e.g., insomnia, anxiety, dysphoria, or withdrawal symptoms. [7,13,24,29]
Studies have shown that injection drug abusers, in particular, have abnormal adrenal metabolism and impaired stress responses. These reactions may be due in part to an erratic crisis-laden lifestyle and the fact that every drug injection contains contaminants that must be neutralized by the body's defense systems.[29]
Complex Solutions
Further research is needed to more completely define the effects of complex hormonal imbalances seen in opioid and other drug addictions. Factors other than dopamine and hyperprolactinemia are likely to contribute to SDs in certain patients.[26]
Some authorities have recommended a sexual history-taking and function-screening for all persons entering addiction treatment. Additional clinical evaluations would be appropriate if primary or secondary SDs are discovered, especially if the problems predated drug abuse.[10,30]
Furthermore, patients and staff need education regarding the physiological and psychological impact of drug abuse on sexual and reproductive health. They should also be alerted to potential sexual side effects of medications commonly used in addiction treatment settings.[30]
1. Goldsmith DS, Hunt DE, Lipton DS, Strug DL. Methadone folklore: beliefs about side effects and their impact on treatment. Human Org. 1984;43(4):330-340.
2. Paice JA, Penn RD, Ryan WG. Altered sexual function and decreased testosterone in patients receiving intraspinal opioids. J Pain Symptom Manage. 1994;9(2):126-131.
3. Rosen RC, Lane RM, Menza M. Effects of SSRIs on sexual function. J Clin Psychopharmacol. 1999;19:57-85.
4. Teusch L, Scherbaum N, Bohme H, Bender S, Eschmann-Mehl G, Gastpar M. Different patterns of sexual dysfunctions associated with psychiatric disorders and psychopharmacological treatment. Results of an investigation by semistructured interview. Pharmacopsychiatry. 1995;28(3):84-92.
5. Shinderman M, Maxwell S. Sexual dysfunction in methadone maintenance patients: treatment with bromocriptine. Heroin Addiction & Related Clinical Problems. On press; 2000.
6. Mejta CL. Substance abuse among women: a review of the literature. Module 2. Training Manual on Women's Substance Abuse Treatment. Springfield, IL: State of Illinois Department of Alcoholism and Substance Abuse; 1996.
7. Kreek MJ. Medical safety and side effects of methadone in tolerant individuals. J Psychoactive Drugs. 1991;23(2):665-668.
8. Smith JW. Special problems of the elderly. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:833-855.
9. Blume SB. Understanding addictive disorders in women. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:1173-1190.
10. McCann MJ, Rawson RA, Obert JL, Hasson AJ. Treatment of Opiate Addiction with Methadone. Technical Assistance Publication (TAP) Series 7. Rockville, MD: U.S. Department of Health and Human Services; Center for Substance Abuse Treatment;1994:52-53. DHHS Pub# (SMA) 95-2061.
11. Rawson RA (chair). Treatment for Stimulant Use Disorders. Treatment Improvement Protocol (TIP) Series 33. Rockville, MD: U.S. Department of Health and Human Services; Center for Substance Abuse Treatment;1999:98-99. DHHS Pub# (SMA) 99-3296.
12. Moore BE, Rothschild AJ. Treatment of antidepressant-induced sexual dysfunction. Hosp Prac. January 15, 1999:89-96.
13. Dowling JE. Creating Mind: How the Brain Works. New York: WW Norton; 1998.
14. Hardman JG, Limbird LE (eds in chief). Section XIII: Hormones and hormone antagonists. Goodman & Gilman's The Pharmacological Basis of Therapeutics [book on CD-ROM]. New York, NY: McGraw-Hill; 1996.
15. Hiller-Sturmhöfel S, Bartke A. The endocrine system: an overview. Alcohol World. 1998;22(3):153-177.
16. Delitala G, Grossman A, Besser M. Differential effects of opiate peptides and alkaloids on anterior pituitary hormone secretion. Neuroendocrinology. 1983;37(4):275-279.
17. Grossman A. Brain opiates and neuroendocrine function. Clin Endocrinol Metab. 1983;12(3):725-746.
18. Laumann EO, Oaik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281:537-544.
19. Pende A, Musso NR, Montaldi ML, Pastorino G, Arzese M, Devilla L. Evaluation of the effects induced by four opiate drugs, with different affinities to opioid receptor subtypes, on anterior pituitary LH, TSH, PRL and GH secretion. Biomed Pharmacother. 1986;40(5):178-183.
20. Tolis G, Dent R, Guyda H. Opiates, prolactin, and the dopamine receptor. J Clin Endocrinol Metab. 1978;47(1):200-203.
21. Vescovi PP, Pezzarossa A, Ceresini G, Rastelli G, Valenti G, Gerra G. Effects of dopamine receptor stimulation on opiate-induced modifications of pituitary-gonadal function. Horm Res. 1985;21(3):155-159.
22. Willenbring ML, Morley JE, Krahn DD, Carlson GA, Levine AS, Shafer RB. Psychoneuroendocrine effects of methadone maintenance. Psychoneuroendocrinology. 1989;14(5):371-391.
23. Martin J, Payte JT, Zweben JE. Methadone maintenance treatment: a primer for physicians. J Psychoactive Drugs. 1991;23(2):165-176.
24. Hardman JG, Limbird LE (eds in chief). Section III: Drugs acting on the central nervous system. Goodman & Gilman's The Pharmacological Basis of Therapeutics [book on CD-ROM]. New York, NY: McGraw-Hill; 1996.
25. Coppola A, Cuomo MA. Prolactinoma in the male: physiopathological, clinical, and therapeutic features. Minerva Endocrinol. 1998;23(1):7-16.
26. Hyperprolactinaemia associated with effective antipsychotic treatment no longer inevitable. Drug & Ther Perspect. 1999;14(1):11-14.
27. DeRosa M, Colao A, DiSarno A, et al. Cabergoline treatment rapidly improves gonadal function in hyperprolactinemic males: a comparison with bromocryptine. Eur J Endocrinol. 1998;138(3):286-293.
28. Lamberts SW, Quick RF. A comparison of the efficacy and safety of pergolide and bromocriptine in the treatment of hyperprolactinemia. J Clin Endocrinol Metab. 1991;72(3):635-641.
29. Tennant F, Shannon JA, Nork JG, Sagherian A, Berman M. Abnormal adrenal gland metabolism in opioid addicts: implications for clinical treatment. J Psychoactive Drugs. 1991;23(2):135-149.
30. Smith DE, Moser C, Wesson DR, et al. A clinical guide to the diagnosis and treatment of heroin-related sexual dysfunction. J Psychoactive Drugs. 1982;14(1-2):91-99.
[Disclosure: This article was sponsored by an educational grant from Mallinckrodt Inc, a manufacturer of methadone.]

 

Survey Results ­ Patients Battling Stigma & Prejudice

An article in the Fall 1999 edition of AT Forum ­ "MMT Patients Battle Prejudice" ­ focused on the stigma and prejudice faced by patients in methadone maintenance treatment (MMT). Research conducted at several clinics in Arizona by Nancy Nieman, MA, CPC, found that patients faced difficult challenges in all aspects of their lives: social, employment, and interactions with health care professionals.
Surprisingly, nearly all (96%) of the MMT patients reported physicians' refusals to treat them or denial of adequate pain medication. Two-thirds of respondents reported that their social lives were hindered to some degree, and more than 66% reported denial of employment or loss of existing jobs due to methadone-positive urine tests.
AT Forum surveyed readers to further explore these subjects and expand the scope to addiction treatment in general. There were 481 survey responses (65% from treatment staff; 35% from patients), via mail or on the Web at www.ATForum.com. Here is a summary of results:
1. Do patients face job discrimination due to their participation in addiction treatment? 68% of staff and 77% of patients (pts) answered "often" ­ 28% staff, 18% pts said "occasionally."
2. Do you believe health care professionals are prejudiced against chemically dependent persons in treatment? 63% staff and 76% pts responded "often" ­ 31% staff, 21% pts said "occasionally."
3. Do patients avoid family or social gatherings due to their being in treatment? 35% staff and 24% pts remarked "often" ­ 58% staff, 56% pts said "occasionally."
4. Do you believe the general public understands what addiction and addiction treatment are all about? 81% of staff and 84% of patients answered "no" ­ 17% staff, 13% pts said "somewhat" ­ only 2% staff, 0.5% pts said "yes." [See graph]
It is apparent from this survey that professional staff and patients hold very similar beliefs. Although patients as a group seemed to have a more "pessimistic bias" in their responses regarding job discrimination, prejudice, and public understanding. Statistical analyses were not performed to determine if these staff/patient differences were significant.
It was interesting to note that staff generally agreed with patients concerning prejudice by health care professionals against persons in addiction treatment. Staff members only may have been referring to professionals outside of their clinics, although this possibility was not explored.
Of further interest, staff members believed that patients avoided family or social gatherings to a greater extent than indicated by patients themselves. However, 13% of staff believed patients "rarely" missed such occasions due to their being treated, whereas only 6% of patients answered "rarely."
Public perceptions of addiction and addiction treatment have been a long-standing concern. The AT Forum survey suggests a very high proportion of the public lacks understanding, but this was a very general question.
Last December, the Hazelden Foundation conducted a nationwide telephone survey of 1,500 adults focusing on public opinions regarding alcoholism. To the question, "Do you think alcoholism is a disease?" 80% answered "yes."
Although this seems like a reasonably high percentage, it is actually a downward trend when compared with several surveys since 1982 conducted by the Gallup polling organization asking essentially the same question. Public perception in 1999 was practically unchanged from 17 years earlier. [See graph]
Acceptance of the disease concept of addiction ­ whether concerning alcoholism or other drug dependency ­ affects other areas, such as employment and medical insurance. Only 62% of Hazelden survey respondents believed insurance coverage for chemical dependency treatment was as important as coverage for diseases like diabetes, heart problems, etc. Other survey questions determined that employers would be reluctant to hire persons who had been treated for addiction.
Based upon all of these surveys, it appears much more education is needed to battle the prejudices and alleviate the persisting stigma surrounding addiction and addiction treatment.
The Hazelden and Gallup surveys are available at: www.hazelden.org/press_releases_detail.dbm?ID=856. Accessed May 2000.

From the Editor

Innovation for the Methadone Millennium

"Reform is necessary; change is coming," proclaimed H. Westley Clark, director of CSAT, as more than 1500 attendees from 20+ countries gathered at the American Methadone Treatment Association's 2000 Conference in San Francisco early last April.
The Conference presented an exhausting array of pre-conference sessions, 30 workshops, hot-topic roundtable discussion groups, 41 exhibits, and 20 poster sessions.
Mark Parrino, MPA, Association president, opened the Conference by noting that low cost and easy access to heroin has created a crisis in the U.S., spreading to middle-class populations. He set the tone for the Conference by revealing 3 critical policy issues facing the methadone treatment field today:
1. The transition of regulatory over-sight of methadone maintenance treatment (MMT) programs from the Department of Justice (i.e., DEA) to Health & Human Services.
2. The need for office-based opioid treatment (OBOT, also called "medical maintenance") by physicians who are trained in addiction medicine. Parrino believes 7% to 8% of current methadone patients could benefit, thus freeing slots for new patients coming into treatment.
3. The introduction of new pharmacotherapies, such as buprenorphine, along with treatment protocols for their effective use.
These vital themes were expanded upon by a dozen speakers during 3 plenary sessions addressing the needs for innovation, change, and positive action in the addiction treatment field.
Also of interest, new data shared by various presenters portrayed an easy-to-remember 20%/20% rule of thumb when it comes to the need for expanded methadone treatment:
  • There are more than 5 million "chronic drug abusers" in the U.S. (estimates range from 5.1 to 5.6 million) and little more than 2 million of those persons receive any treatment for their addictions;
  • of the 5 million, roughly 20% are hardcore opiate addicts (977,000+), and
  • only about 20% of opiate addicts are in methadone treatment programs (179,330 persons at 940+ sites, including VA hospitals, in 42 states).
Hence, as so many speakers stressed, there is a wide gap between the number of persons needing addiction treatment and treatment delivery. Here are highlights from some of those outstanding presentations
Alan Leshner, PhD
director, National Institute on Drug Abuse (NIDA) ­ stressed that NIDA is continuing its efforts to move science-based treatment into clinical practice via its National Drug Abuse Treatment Clinical Trials Network. However, Leshner lamented, there is still a "great disconnect," with currently held perceptions and the realities of addiction treatment headed in 2 opposite directions. "We now have the science base to replace ideology as a foundation for dealing with the [addiction] problem," he said, but the challenge is putting that science into practice.
Leshner also told the audience that new addiction treatments do not necessarily replace older ones. Buprenorphine, for example, is a treatment alternative, not a replacement for methadone. Addiction treatment should be viewed as an array of services and some approaches, like buprenorphine, may be helpful adjuncts to current modalities in attracting new patients.
H. Westley Clark, MD, JD, MPH
director, Center for Substance Abuse Treatment (CSAT) ­ acknowledged that for more than 30 years methadone has been demonized by various politicians. He believes accreditation for MMT clinics is essential to combat ignorance and stigma associated with the treatment. The current system is based on decades-old restrictive standards that are not seen anywhere else in all of medicine.
In the new order to come, clinical judgment will be encouraged, programs will be evaluated in terms of outcomes, and patients will have rights as well as responsibilities, he said. Accreditation will help accomplish those goals, and, as of February 2000, 33 MMT clinics had successfully completed the accreditation process.
Clark stressed a theme of collaboration and cooperation leading to accreditation. There is also a need to partner with patients in their health care, as many have concurrent illness, such as HIV, HCV, and TB.
As for newer addiction treatment pharmacotherapies, he said those medications would be evaluated realistically in terms of how they can be best used in everyday medical practice and, unfortunately, misused. Physicians must be trained in their proper application, he emphasized.
Office-Based Medical Maintenance
was the main subject of one plenary session titled "Enhancing the Mainstream," which also included an international perspective:
James Bell, MD, from Australia, noted that a third of all addicts in his country are engaged in treatment, with 24,000 receiving MMT. Methadone is presented as a medical treatment, with many patients seeing primary care physicians (i.e., medical maintenance) for prescribing and then being administered daily methadone at local pharmacies. Bell cautioned that, since MMT is still a stigmatized practice of medicine, there is absolutely no place for low standards of care.
Mark Reisinger, MD, from Belgium, said that of 25,000 heroin addicts in his country, about 5,000 to 10,000 are in MMT. He observed that MMT is unhindered by government regulation and, since such treatment is readily available, the price of methadone is low and there is no black market for the drug. Treatment entry requirements, dosing levels, and take-home doses are guided entirely by clinical discretion. He stated, "The only regulation should be that the supply of methadone should match demand."
Edwin Salsitz, MD, was a pioneer of medical maintenance in the U.S. (at Beth Israel Medical Center in New York), beginning in 1983. Patients must have 4 years of prior MMT and see him every 4 weeks to receive medical care and 28-day take-home methadone doses ­ cost is $110/month. He observed that 90% of patients legitimately need dose increases when they come into medical maintenance. Salsitz exhorted the audience to abandon all use of stigmatizing slang ­ e.g., "dirty urines," "junkie" ­ as a way of professionalizing the field and respecting patients who are physically dependent on methadone, but not "addicted" to it.
Beverly Malone, PhD, RN
deputy assistant secretary for health, Department of Health and Human Services ­ stressed that, "We need to manage change in the addiction treatment field, so that it doesn't manage us." In a very passionate and energetic presentation, she reminded the audience that obstacles and challenges are not new to the field. "We must raise the bar to assure quality," she said, "and then fit MMT into the mainstream of health care services." However, she warned the group, "A vision of quality without action is an hallucination."
Malone said that the MMT clinic accreditation process has required collaboration among many government agencies. These agencies are interested in helping clinics become accredited and in building capacity so more patients can be served as part of a comprehensive system of holistic care. Still, for a clinic, the nicest part about the accreditation process is getting it successfully over with, she conceded.
Barry McCaffrey
director, Office of National Drug Control Policy ­ made his second personal appearance at an AMTA gathering, and was conferred the Association's "Friend of the Field Award," which recognizes extraordinary contributions to the field of methadone treatment. In a powerful presentation, McCaffrey suggested a broader vision for the Association, going beyond methadone: "There needs to be a 'package' behind the treatment of opiate addiction," he said.
"Stigma and denial are holding the field back," he continued. "They make successes invisible and are principal causes of irrational drug policies in America." He asserted that there is a need to get addiction treatment regulation away from bureaucrats and the supervision of policing agencies such as the DEA. However, he warned, there is also a need to recognize the potential for abuse in an accredited system with fewer restraints. "Methadone treatment must be moved into the mainstream of medicine, but we must be cautious of incompetence ­ practitioner training will be essential."
McCaffrey suggested that health insurers should cover addiction treatment hand-in-hand with mental health treatment. "One of the main reasons for higher outlays in public spending is limited coverage by private insurers. The lack of coverage and recent changes in payment structures affect attitudes, resources, and treatment plans. Private and public insurers are not working collaboratively; thus, more public resources are utilized, and government funds ­ which were intended to be a safety net ­ have become a primary option for many individuals."
He acknowledged that, "Restrictive regulations, incomplete knowledge of best practices, resistance to treatment on the part of certain populations in need, and limited information about treatment at the state and local levels all contribute to the current state of affairs."
"Restricting methadone erects unnecessary barriers to recovery," he concluded. "Methadone must be accepted in every state addiction is a relapsing brain disease [and] there is no reason why this ailment should be isolated from other types of care. Expanding the availability of treatment is our most important goal."
St. Louis Next
This was our 4th American Methadone Treatment Association Conference and each gets better than the one before. Mark your calendars now for the next Conference, October 7-10, 2001, and meet us in St. Louis, Missouri.
Survey ­ Addiction Treatment & Sexual Disorders
As a follow-up to our article on sexual dysfunction and addiction treatment in this issue, please respond to the following questions:
  • What percentage of patients do you estimate experience sexual disorders before coming into treatment for addiction, ____% during treatment, ____% after treatment, ____%
  • Are you responding as a patient p ? or, as a staff member p ? (Check only one.)
  • Which drug(s) are most patients addicted to before treatment at your clinic: _________________ (e.g., heroin, cocaine, alcohol, etc.)
We are continuing our survey from the last issue of AT Forum on the challenges faced by patients in addiction treatment programs. There are several ways to respond: A. Provide your answers on the postage-free feedback card in this issue; B. Write or fax us [see info below]; or C. Visit our Web site to respond online. As always, your written comments will also help us discuss the results in our next issue.
Stewart B. Leavitt, PhD, Editor
stew202@aol.com
Addiction Treatment Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
FAX: 847-413-0526
Internet: http://www.atforum.com

Events to Note

For additional postings & information, see: www.atforum.com

July 2000
41st Institute on Addiction Studies
July 9-13, 2000
Barrie, Ontario, Canada
Contact Nancy Bradshaw: 416-293-3400; info@concerns.ca
Rutgers Summer School of Alcohol & Drug Studies
July 9-14, 2000
Piscataway, NJ
Contact: 732-445-4317
August 2000
Prevention Think Tank Summit 2000
August 6-9, 2000
Chicago, IL
Contact Barbara Jacobi: 860-610-4600
bjacobi@etpinc.org
29th Ann. UCSD Institute in Addiction Studies
August 7-10, 2000
Univ. of Calif., San Diego
Contact Kathy Gorham: 858-551-1326
kgorham@ucsd.edu
Medical Review Officer Training
August 18-20, 2000
New York, NY
Contact Cindy Ferrell: 800-489-1839
cferrell@mindspring.com
September 2000
15th Ann. Conference on Addictions
September 17-20, 2000
Indianapolis, IN
Contact Dennis Miller: 317-283-8315
dsmiller@greatlakesconference.org
October 2000
National Alliance of Methadone Advocates Consumer Group
October 21-25, 2000
Miami, FL
Contact Suzie Ko: 212-213-6376 x31
suzie@harmreduction.org
ASAM Review Course in Addiction Medicine
October 26-28, 2000
Chicago, IL
Contact: 301-656-3920; email@asam.org

[To post your event announcement in A.T. Forum and/or our Web site, fax the information to: 847/413-0526 or submit it via e-mail from http://www.atforum.com]

Brainstorm: Spiritual Road to Recovery ­ Part 4

"As it is not proper to cure the eyes without the head, nor the head without the body, so neither is it proper
to cure the body without the soul." ­ Socrates
"Came to believe that a Power greater than ourselves could restore us to sanity." ­ Step Two
The concept of spirituality may be the greatest stumbling block for practitioners and patients alike in the course of addiction treatment. The importance of the human soul on the road to recovery challenges scientific validation, contravenes clinical practice protocols, and conjures a moralistic specter of religion.
However, addictionologist John Chappel has proposed that addiction medicine cannot ignore spiritual issues. "If former patients are asked about the factors leading to long-term recovery from alcohol or other drug addictions, a large number mention spiritual experiences."[1]
Yet, there remain two crucial questions: Does spirituality have a legitimate place in addiction medicine? Does belief in a higher power play a critical role in recovery?
Reborn Interest
Chappel observed that, in general, health care professionals have not afforded spiritual issues in clinical practice the attention warranted by the prominence of these beliefs in human experience.[1] Polls consistently show that about 95% of people in the U.S. believe in God or a higher power,[2] although only 50% regularly attend religious services or pray.[3] Yet, 75% of Americans believe prayer for a loved one can speed recovery from illness.[2]
Surveys also have noted that 50% to 65% of patients would want their physicians to pray with them. However, roughly 70% said their doctors never discussed religious beliefs.[2,4]
Medical training, even psychiatry, has typically ignored spiritual issues, preferring to focus on biopsychosocial models of health and illness.[1] Most health care professionals simply do not know how to integrate spirituality with medical practice.[4]
Fortunately, throughout medicine, there is increased interest in how the realm of the spirit interacts with body and mind in the management of and recovery from various illnesses. The number of medical schools offering programs in spirituality and medicine soared from just 3 in 1993 to 63 in 1999.[5]
The 13,000-member Christian Medical & Dental Society seeks to change medical practice by recognizing that patients' attitudes toward spirituality have great impact on their health. Other organizations also blend religion and medicine: e.g., Catholic Medical Association, Islamic Medical Association, and the American Physicians Fellowship for Medicine (Jewish).[4]
Little Ado About Religion
There are many misunderstandings of spirituality. Chappel noted that it simply may be defined as the relationship between an individual and a transcendent or higher being or force in the universe.[1] Booth described spirituality as "an inner attitude that emphasizes energy, creative choice, and a powerful force for living."[6]
Spirituality does not necessarily require or involve religious affiliation. Mahoney and Graci observed that many persons consider themselves spiritual but not religious.[7]
Spirituality is the backbone of recovery in 12-step programs such as Alcoholics Anonymous (AA). Founded in 1935 by two alcoholics, a stockbroker (Bill Wilson) and a physician (Bob Smith), AA quickly evolved philosophically from the religion-based Oxford Movement; retaining many of the Movement's fundamental principles but emphasizing spiritual conversion involving "deflation at depth" and surrender to a higher power as leading to recovery.[8]
AA remains strictly unaffiliated with any religious sect or denomination, yet misperceptions persist. For example, Galanter compared AA's climate of shared beliefs and group cohesiveness to religious cults.[9] Others also have compared AA to a cult or religion, further saying that it goes against scientific research and denies personal self-efficacy.[10]
In actuality, shortly after AA's founding, Bill Wilson recognized that a religious approach did not work ­ that most addicts, for various reasons, have fundamental difficulties accepting formal religion. Wilson shifted the focus to each member's unique experience with a higher power as it is personally understood.[8,11]
Pragmatic AA members like to say, "Religion is for people who are afraid of going to hell; spirituality is for those of us who have already been there." Or, as one put it, "People go to church to save their souls; I came into AA to save my ass."[8]
Still, there are more similarities with nonsectarian religion in AA than members readily concede; and, there is much more freedom of personal belief in AA than outsiders perceive.[8]
Offshoot Groups
The AA spiritual principles of recovery have been adopted by other mutual-help organizations in dealing with various addictions: e.g., Cocaine Anonymous, Narcotics Anonymous, Methadone Anonymous, Nicotine Anonymous, and others.[8] Chappel stressed that, "The Twelve Step approach to spiritual experience is one that specialists in addiction medicine should understand, clinically support and communicate to their colleagues who care for alcohol- and other drug-addicted patients."[1]
In the interest of fair balance, it should be noted that certain groups derived from or related to AA have adopted clearly religious contexts: e.g., JACS (Jewish), CALIX (Catholic), Alcoholics Victorious (Christian), and others. There also are distinct alternatives to the 12-step program approach that do not encompass spiritual principles: e.g., SMART (Self-Management And Recovery Training) Recovery, SOS (Secular Organizations for Sobriety), Rational Recovery, and more.[12]
Spiritual Qualities
For the addict, intolerance, grandiosity, anxiety, impulsiveness, isolationism, and defiance all boil to the surface of daily life as dishonesty, fear, egocentricity, and resentment. Spirituality serves as an antidote ­ the recovering addict "lets go" of being "general manager of the universe" and surrenders to the direction of an all-powerful spiritual force.[13] Step 2 of 12-step programs promises that belief in a higher power can restore sanity; i.e., "soundness of mind."[11]
The vital spiritual experiences of persons in recovery lead to emotional displacements and rearrangements; hence, a completely new set of ideas, emotions, and attitudes appears to dominate. Once the person lays aside prejudice and expresses a willingness to believe in a higher power, the change process begins.[14]
For the recovering addict, spirituality bestows a "lifestyle transplant" and a revitalizing release from social isolation ­ of feeling like a stranger in a strange land.[8,13] Themes commonly mentioned in association with spiritual enlightenment are inner strength, honesty, humility, charity, compassion, forgiveness, connectedness, hope, meaning, purpose, gratitude, and love.[1,7]
The Science of Faith
Spirituality's role in modern medicine, and addiction treatment, has been controversial. Anyone can pray; what matters clinically are results.
Scientific studies have demonstrated that spiritual faith and prayer can be helpful in preventing and treating illness, recovering from surgery, reducing hypertension, minimizing pain, improving quality of life, and even prolonging life.[3,15-18] Persons with strong spiritual faith are likely to overcome depression 70% faster and live longer than their nonspiritual peers.[5,19]
Two randomized, controlled clinical trials have even demonstrated benefits of other peoples' prayers on behalf of patients who were unaware that they were recipients of such appeals ­ called "intercessory prayer" or "distant healing." In the first study, critically ill patients receiving intercessory prayers had significantly fewer [P < 0.0001] cases of congestive heart failure, heart attacks, and pneumonia.[20] In a recent investigation, patients in a coronary care unit receiving intercessory prayers had significantly better [P < 0.04] overall clinical outcomes.[21]
Unfortunately, a pilot study of the effects of intercessory prayer on 40 recovering alcoholics reported no clinical benefits. And, patients who knew that a friend or family member was praying for them drank more than other patients in the same program. However, patients who themselves prayed exhibited less drinking during early months of recovery.[22] Apparently, when it comes to addiction recovery, benefitting from the power of prayer is an "inside job" that only the patient can bring about.
Research by Carter examined recovering addicts and found a direct relationship between spiritual practices and long-term recovery.[23] Another study observed that the risk for alcoholism is 60% higher among drinkers with no religious affiliation.[24] Separate studies including more than 700 adolescents found that religion was the single most significant factor in reducing alcohol, cocaine, and other drug abuse.[25,26]
Humphreys has proposed that treatment professionals can greatly influence patients' affiliations with 12-step groups, producing results comparable to cognitive behavioral therapy and even somewhat more effective in promoting abstinence.[27] One study found that patients attending at least one 12-step meeting per week achieved nearly 80% greater abstinence from drugs and alcohol than those participating less frequently or not at all. The researchers concluded that 12-step programs are a useful and inexpensive aftercare resource, helping many patients maintain long-term abstinence.[28]
Nevertheless, some authorities remain skeptical about the benefits of spirituality in medicine. Richard Sloan and colleagues at Columbia University have faulted many of the research studies on methodological grounds. They commented: "Even in the best studies, the evidence of an association between religion, spirituality, and health is weak and inconsistent. It is premature to promote faith and religion as adjunctive medical treatments."[29]
Rocky Road
In the final analysis, the validation of spiritual faith may begin and end on one's knees ­ and in one's heart ­ rather than by science. Medicine still remains intellectually entrenched in empiricism and there have been arguments against the inclusion of spiritual issues in addiction treatment.
However, it may be intellectually arrogant to presume that spirituality has no legitimate place in recovery programs. The experiences of countless recovering alcoholics and other drug-dependent persons cannot be ignored.
Social prohibitions make discussions of spirituality in therapeutic consultations difficult. Whereas peer-led 12-step groups, by valuing each member's experience, strength, and hope ­ and eschewing criticism of each other ­ create forums where people can openly discuss spiritual beliefs.
Sulmasy suggests that health care professionals can better prepare themselves to meet the spiritual needs of patients by deepening their own spiritual lives. They should intensify their own commitments to spiritual beliefs and begin "to talk with each other about spiritual issues that arise in the practice of medicine."[30]
There is great potential for spirituality to strengthen traditional addiction medicine. However, it must be recognized that the spiritual road to recovery is never ending. And, it is forever under construction.
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2. Condor B. Doctors finding that prayer is good medicine. Chicago Tribune. April 4, 1999:sec 13,3.
3. Health and spirituality: medicine ponders how the two may interact. Mayo Clinic Health Letter. November 15, 1996.
4. Veach M. True believers; faith-based medical societies strive to return compassion to medicine. Amer Med News. February 22, 1999.
5. Kloehn S. Doctors of a mind to treat a patient's spirit too. Chicago Tribune. March 22, 1999:sec 2,1.
6. Booth L. When God Becomes a Drug: Breaking the Chains of Religious Addiction and Abuse. New York: Tarcher/Perigee; 1991.
7. Mahoney MJ, Graci GM. The meanings and correlates of spirituality: suggestions from an exploratory survey of experts. Death Stud. 1999;23(6):521-528.
8. Leavitt S. Social Uses and Communication of Myth in a Rescue Organization: Alcoholics Anonymous [doctoral dissertation]. Evanston, IL: Northwestern University; 1974.
9. Galanter M. Cults and zealous self-help movements: A psychiatric perspective. Am J Psychiatry. 1990;147(5):543-551.
10. Schaler JA. Addiction is a Choice. Chicago IL: Open Court; 2000.
11. Twelve Steps and Twelve Traditions. New York, NY: Alcoholics Anonymous World Services; 1952.
12. Gerstein J. Rational recovery, SMART recovery and non-twelve step recovery programs. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:719-723.
13. Alcoholism and the AA program; by a doctor in AA. Chicago, IL: Chicago Area Alcoholics Anonymous Service Office; [undated pamphlet].
14. Alcoholics Anonymous. 3rd Ed. New York: Alcoholics Anonymous World Services; 1976.
15. Matthews DA. Prayer and spirituality. Rheum Dis Clin North Am. 2000;26(1):177-187.
16. Koenig HG, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DG. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med. 1998;28(2):189-213.
17. Hummer RA, Rogers RG, Nam CB, Ellison CG. Religious involvement and U.S. adult mortality. Demography. 1999;36(2):273-285.
18. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient's spirituality and health experiences. Fam Med. 1998;30(2):122-126.
19. Koenig HG, Cohen HJ, Blazer DG, et al. Reliious coping and depression among elderly, hospitalized medically ill men. Am J Psychiatry. 1992;149(12):1693-1700.
20. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J. 1988;81:826-829.
21. Harris WS, Gowda M, Kolb JW, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Int Med. 1999; 159:2273-2278.
22. Walker SR, Tonigan JS, Miller WR, Corner S, Kahlich L. Intercessory prayer in the treatment of alcohol abuse and dependence: a pilot investigation. Altern Ther Health Med. 1997;3(6):79-86.
23. Carter TM. The effects of spiritual practices on recovery from substance abuse. J Psychiatr Ment Health Nurs. 1998;5(5):409-413.
24. Drug dependency drops with spiritual spark. US Newswire. February 17, 1999.
25. Yarnold BM. Cocaine use among Miami's public school students, 1992: religion versus peers and availability. J Health Soc Policy. 1999;11(2):69-84.
26. Pullen L, Modrcin-Talbott MA, West WR, Muenchen R. Spiritual high vs high on spirits: is religiosity related to adolescent alcohol and drug abuse? J Psychiatr Ment Health Nurs. 1999;6(1):3-8.
27. Humphreys K. Professional interventions that facilitate 12-step self-help group involvement. Alcohol Res & Health. 1999;23(2):93-98.
28. Mathias R. Adding more counseling sessions and 12-step programs can boost drug abuse treatment effectiveness. NIDA Notes. 1999;14(5):6-7.
29. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet. 1999;353(9153):664-667.
30. Sulmasy DP. Is medicine a spiritual practice? Acad Med. 1999;74(9):1002-1005.
Where to Get Info
Internet links to the Web sites of 12-step, religious, and secular groups mentioned in this article, and many more, may be found at www.onlinerecovery.org. Access checked May 2000.