Benzodiazepine Tapering, BIND, and Deprescribing

We have had our share of celebrity guests and experts on the show to talk about addiction treatment and recovery. Yet, our primary goal is to shed light on alternate ways of thinking about addiction, addiction medicine, and treatment.

Much of the focus in those years was on the opioid epidemic and how to help people to overcome opioid addiction. In fact, since a significant portion of my practice at the time focused on medication-assisted treatment for opioid addiction, I did start out with the intent of this program being a Suboxone podcast.

My goal was initially to educate people on Suboxone, buprenorphine and how medication is an important part of reversing the opioid crisis. However, as I started to speak with various guests, I realized that there were many spaces to explore, discover, and learn about with respect to addiction and addiction treatment.

Suboxone treatment was only the beginning. Early on, when a guest shared their personal story about trauma and family dynamics, I realized that there were many perspectives to be considered.

I made it a point to be open-minded.

My intent in interviewing podcast guests is to be open-minded, honest, and willing to listen and learn about what my guest has to say. In one episode, my guest and I discuss the 12 steps of Alcoholics Anonymous and Narcotics Anonymous, and the spiritual component of the recovery process.

I have gone through periods where I thought every addiction patient needed the 12 steps. And, I have gone to the opposite extreme in believing that they are not the best solution for many of my patients.

The fact is that it is not about me or my beliefs at all. My opinions on programs such as alcoholics anonymous or narcotics anonymous are irrelevant. We all have opinions, and, hopefully, our understanding grows over time by being open-minded and listening to what others have to say.

There is no one-size-fits-all solution.

When the time comes to do something about an addiction challenge, whether it be opioid addiction, food addiction, alcohol addiction, nicotine addiction, cocaine addiction, or meth addiction, you or your loved ones may feel a sense of urgency and desperation. Where should you turn to when you are looking for help?

From my perspective as an osteopathic physician, I might first recommend visiting an addiction specialist who is highly trained in the field of addiction medicine. Alternatively, there are people who might recommend an extended stay in rehab, where group therapy and addiction counseling are the primary starting points in the recovery process.

There are people in favor of complete abstinence from drugs and medications who are against prescription drugs as part of a treatment program. And, you will find that other people have differing views on the role of medication in traditional treatment for substance abuse.

Alcohol is a drug.

Alcoholism and the field of alcohol treatment provide an excellent example of the clash between experts on how things should be done. Is inpatient treatment required, or can a “little pill” do the heavy lifting in helping a problem drinker to reduce their craving and avoid the intense feelings of alcohol deprivation?

There are those people who believe that alcohol dependency is primarily an issue of endorphin reinforcement, requiring medical treatment focused on pharmacological extinction. And, there are those who are more focused on overcoming the learned behavior of alcohol use with spiritual methods and counseling.

Most importantly, we must accept that alcohol is a drug like any other drug. Many people have control over their alcohol consumption, but for many others, alcohol addiction is a serious issue.

If I were to decide to start a separate alcohol podcast, focusing primarily on the challenges of achieving sobriety, it would still be essentially an addiction podcast. There is no doubt that alcohol is an addictive drug.

Nicotine is a drug.

While I had focused on issues facing people with opioid addiction and people with alcohol addiction, at the time I also planned to cover nicotine and tobacco addiction.

It has been said that nicotine is the most addictive drug on the planet. The reinforcing effects of nicotine as it stimulates the nicotine receptors, leading to increases in dopamine, are powerful. Tobacco users may feel helpless when attempting smoking cessation.

Unfortunately, tobacco is legal, with politically powerful corporations behind it, always finding new and creative ways to market their deadly products. Yet, doctors are pressured by their state medical boards, and by the federal government, to combat cigarette smoking in their patients.

Why not put the pressure on the tobacco industry? Why don’t we shut down it down altogether? No one needs a cigarette. In the long run, they would not be missed at all.

So far, the solutions to helping tobacco users included replacement therapy, with nicotine patches or nicotine gum, and medication-assisted treatment. Varenicline (once sold as Chantix) and bupropion (Zyban) are the main prescription options. Like any medication they have side effects, which are worth going over with a doctor first.

Another option, not an approved quit-smoking aid, is switching to e-cigarettes. Some people have used them to stop smoking, but their long-term effects on the lungs are still not known.

Acamprosate, or Campral, and naltrexone are approved for treating alcohol use disorder. Neither is an approved or proven treatment for quitting smoking.

Is The Sinclair Method hype or harm reduction?

How do doctors approach alcohol abuse and gray area drinking? Do they have a blanket order to send everyone with an alcohol problem to AA or rehab? What if a patient says they cannot put down the booze, and they refuse to get help?

The Sinclair Method (TSM) is an alternative method of treating alcohol use disorder. Essentially, patients continue drinking while on naltrexone. TSM may appeal to the sober curious person who is in the first stage of confronting their addiction and is not ready to quit.

So, while proponents of TSM have claimed that it is the cure for alcoholism and the best way to provide alcohol treatment, there are those on the side of traditional rehab who are against any treatment that does not involve abstinence. But, what about harm reduction? If a patient will not put down the beer, wine, whiskey, or cocktail, why not offer them something that may help with controlled drinking to reduce alcohol intake?

Harm reduction, or the approach of meeting an addicted person where they are at right now in order to protect their health and safety, is not always well-received in the US. Harm reduction, when it comes to alcohol treatment may involve helping someone to cut back on heavy drinking and binge drinking.

Of course, the ultimate goal is to help the person to achieve sobriety and to become a sober person. Naltrexone treatment is medication assisted treatment for alcohol dependency, and, it can be a form of harm reduction.

Why are we so much against harm reduction?

Harm reduction is an approach that can help to save lives. And, it can start now, right at home. For example, if you find that a loved one in your home is using heroin, what is the right thing to do?

Do you kick them out and change the locks? Is tough love the answer? Or, do you keep the opioid overdose reversal drug, naloxone, or Narcan, in the house?

Is allowing a person who is actively addicted to street opioids to stay in your home a good idea? It may be the best way to keep them alive and safe until they are ready to get help.

In the US, there has been a backlash against harm reduction, particularly when it comes to opioid dependence treatment. Local sheriffs have come out and stated publicly that they will not allow their deputies to administer Narcan to the same person multiple times. Life-saving clean needle exchanges and supervised injection sites have been blocked from opening in the communities that need them most.

In other countries, there has been a more pragmatic approach to harm reduction. From medical heroin to biometric drug dispensing machines, to supervised consumption sites, they are finding success in getting more people safely into recovery.

The primary way that this works is not by giving in to their addiction, but by forming and maintaining close relationships with the victim of addiction. The goal is to keep people safe until they are ready to take the next step in moving away from active addiction.

What about alternative medicine and integrative medicine?

This podcast is not simply a Suboxone podcast or a Sinclair Method Podcast. While these topics may have been the focus of more than one episode each, the idea is to be open-minded about all approaches to addiction therapy.

To take the integrative approach means to look at everything that is available now, or may become available in the future, and see how it might fit in for specific individuals. It is all about thinking outside the box and taking on new perspectives.

In one episode, I interview an expert on dietary supplements for improving brain health. Overcoming addiction has a lot to do with giving the brain a chance to recover. My guest made the case that nutrition supports that recovery, though the evidence for specific supplements is limited and those choices are best made with a doctor.

Conventional medicine may often overlook the significance of nutrition and how it relates to wellness and healing. In addition to nutrition, we also have tools available to help with such alternative therapies as guided imagery, mindfulness, and meditation.

Another episode focuses specifically on work addiction. However, the guest, the top expert in the world on work addiction, provides a method for getting started right away with mindfulness and meditation.

By taking this tool that he provided in our brief 30-minute interview, we can apply its use to helping with other addictions, or even as an overall life-enhancing, performance tool. Interestingly, many methods that are helpful in addiction treatment are also helpful in the lives of people who do not suffer from drug addiction.

In another podcast episode that was primarily about overcoming food addiction and binge eating, my guest discussed the importance of self-respect and setting boundaries. She stated that people can learn to not be everyone’s “welcome mat” to be stepped on and disrespected. This is good advice to consider, even for people who do not have an issue with overeating or drug addiction.

Taking it all apart and putting it all together again.

My intention for this addictions podcast was never for it to be all about sending everyone to rehab for 12-step facilitation and cognitive behavioral therapy. While I could have produced episode after episode of me sitting down with rehab therapists and administrators to have the same conversations over and over again, I never wanted The Rehab Podcast to be so limited in its scope.

Not only has my intention been to educate and expand the horizons of my listeners, but also my own understanding of what it means to be addicted and how we can creatively bring many elements together and come up with new ideas to help individuals.

As I have stated many times in blog posts and in podcast episodes, I believe that the people who struggle with addiction the most are the people with the greatest potential for success in life. They are often misunderstood creative geniuses who have been sidelined by their predisposition to addiction.

Whether the cause of their addiction was trauma, emotional abuse, depression, self-medication, or even boredom, it is the people gifted with intelligence, creativity, and empathy, who find it most difficult to overcome active addiction. In order to address their unique needs and specific addiction issues, we must be open-minded and see things from an integrative perspective.

Looking to the future of addiction treatment.

It has been said that what we need in the future to help more people to overcome addiction is more of what we already have. The tools that we have to fight addiction, including medication-assisted treatment drugs, are underutilized. We must still overcome significant stigma.

In addition to making better use of medications, such as Suboxone, naloxone, naltrexone, and methadone, as well as drugs to help with smoking addiction and eating disorders, there are new treatments on the horizon that are being researched today.

Other drugs being looked at include psychedelic drugs, such as psilocybin, DMT, and MDMA. In other countries, the psychedelic drug, ibogaine, is being used, though there are significant safety concerns with that treatment.

In addition to novel drug therapies, there are also technological advancements, such as AI-assisted diagnosis and assessment of addiction and other mental health conditions. There are prescription digital therapeutics (PDT) that use smart phone apps to provide therapy and a real time connection between patient, doctor, and therapist.

While we have some of these technological tools available today, they will only improve with time. We are now in an age of accelerated change and advancement where we will see major developments appear faster than ever.

Possibly, with the combination of advanced machine learning and artificial intelligence, tools such as sound therapy, PDT, and others, will become more effective than we ever imagined. We may find that digital therapy has the potential to work as well as or better than medication-assisted treatment, even with the promise of new pharmaceutical agents.

So, my goal, as a podcaster in the field of addiction treatment and recovery, is to have conversations with experts in the field, and people who have thought deeply about these subjects. I want to help myself and others to see the problems of addiction treatment from different perspectives.

Rather than repetitively applying the same old therapies over and over again, expecting different results, we must see our patients as unique people. Addiction is a complex problem that affects many regions of the brain. By improving our understanding of the science of addiction, and meeting at the intersection of science, medicine, art, and technology, we can work together to find a new hope in helping our loved ones to overcome their addictions.

The Rehab Podcast is a place for deep conversations where we explore important questions about our understanding of the many philosophies and disciplines in addiction treatment and wellness care in general. I hope that you will join us here regularly to listen in on The Rehab Podcast!