The Need for Medications and Psychotherapy in Treatment

“I said I will never work for anyone who just makes you throw pills at the wall and see what sticks,” said Hans Watson, DO, who is chief medical officer of Recovery Ways, a treatment program in Murray, Utah. Speaking at the Cape Cod Symposium on Addictive Disorders (CCSAD) Sept. 10, Dr. Watson is trained as a psychiatrist. When he went to work for Recovery Ways, he wanted to make it clear that in addition to medications, he insists on counseling for patients. And it’s not always easy.

“I have patients who love me and the facility, and some who hate me,” said Dr. Watson, whose plenary presentation was entitled “Restoring Neurobiology through Addiction Treatment” — a topic well known to opioid treatment program (OTP) providers. And he says he knows who will love him right away – “if you’re coming in and say I’m ready to fix this, I’m ready to work.” But it’s the other patients – those who are “looking for a place to be shielded from the world” – who hate the facility at first. And these are, in the end, the patients who can be the most rewarding to help.

PTSD and Anxiety

Most of his patients with addiction also have anxiety and post traumatic stress disorder (PTSD), said Dr. Watson, speaking to a group of many clinicians who were eager to learn about the biology of all three disorders. “You need to understand how therapy, behavioral interventions, and medications affect certain brain areas.”

Theories that explain addiction haven’t always been correct, he said. He recalled the Vietnam War, which resulted in “rampant” substance use – opioids and alcohol – among drafted individuals. “They weren’t there because they wanted to be there,” said Watson. “They were struggling.” And the belief was that when they came home, they would still be using heroin. “People thought that once you take an opioid in non-pharmacological form, you will have chemical hooks in you.” In fact, this wasn’t the case – more than 80% of those who were physically addicted to heroin in Vietnam didn’t touch heroin again when they got home.

But some did continue their opioid addiction.

The Brain

In an oversimplified but scientifically accurate depiction of the brain, Dr. Watson explained what the unconscious is. “Some people say they don’t think it exists, so I do a test, what keeps you alive? It’s not your brain. It’s your heart beating and your lungs breathing. “What part of your brain keeps the heart and lungs going? A part that nobody thinks about – the unconscious.

“Raise your hand if you’ve consciously released hormones,” Watson told the room of 500 or so attendees. Nobody did.

The frontal lobe is the part of the brain which is conscious. “If you’re aware of a thought, it’s in the frontal lobe.”

But another part of the brain, the amygdala, is the emotional part of the brain. People do not have the conscious ability to control their emotions, said Watson. “We can choose activities that are more likely to result in certain emotions,” he said. “But you don’t get to choose your emotions, anymore than you get to choose your heartbeat.”

The biggest group of positive emotions comes from feeling connected to others, and patients who are fearful, sad, and feel unloved all have feelings generated from the amygdala.

The amygdala also tells the frontal lobe when there’s a threat, and it doesn’t distinguish between an emotional threat and a physical one, said Watson. This is where PTSD comes in.

The amygdala can prompt the release of the hormone adrenaline, in response to a threat. Adrenaline is to help the individual survive by increasing the heart rate and breathing faster, in the “fight or flight” response. The conscious part of the brain stops thinking about anything other than survival. The body’s muscles tense up to prepare to fight, for example.

The Lie: Anxiety

The amygdala’s signals tell the individual what Watson calls “the lie”: “Anxiety means I am in real danger.” It’s not true, because the danger is only potential. “If you believe the lie, you you will believe it is a real threat.”

This is why PTSD is so tied in with hypervigilance and avoiding places. One of Watson’s patients, a veteran of Afghanistan, was in Walmart buying laundry detergent, when a group of female senior citizens carrying canes came in. His heart started racing, he couldn’t catch his breath, he felt the aisles closing in, and he had the feeling that he was in danger and had to get out of the store. But because of his therapy with Watson, he remained and analyzed his feelings, realizing that he was associating the canes with being ambushed by soldiers with guns in Afghanistan. He recognized that it was not the smart part of his brain telling him there was danger. So he made himself stay in that aisle for two minutes. The next day he went back and stayed for five minutes. It was insight into what was causing his problem – and the “lie” that the amygdala was telling him (elderly women with canes were the same as soldiers with guns) – that resulted in his being able to get better.

The same is true for substance use disorder (SUD) treatment, said Dr. Watson. Patients with SUD “have to be able to think about things, including things that are painful,” he said. “We need to teach our patients that they aren’t in danger, that it’s a lie.” The underlying reasons for addiction can never be ignored, even though medications can help treat the physiological dependence and restore brain balance. Often psychotherapy involves another part of the brain – the hippocampus – where memories are stored. As Dr. Watson said, counseling can be hard, but it’s worth it to patients and their families. Medication alone isn’t enough.

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