This week, you will assess a research article on psychotherapy for clients with addictive disorders. You also examine therapies for treating these clients and consider potential outcomes

Commentary: Elders, Others and Addiction: Do They Care and Want to Understand

Edward J. Khantzian, MD

I decided to write the following piece after I lectured to a group of senior citizen. It turned out to be a remarkably gratifying experience for the audience and for myself. In part I think it was successful because I touched on a nerve of the attendees, one that is of concern to so many these days, given the tragic scourge of addiction that has cut such a wide swath throughout our society. I covered a lot, namely the scope and reasons for the epidemic, the psychodynamics of addiction, and the challenges we face politically, socially, and the price tag to address the needed remedies. Admittedly my audience of lay people was at least upper-middle class and well educated, but I still worried if my perspective and some of the clinical issues I raised would miss the mark because they would not be aligned with their interests, concerns and priorities. It turned out they were deeply engaged, including a keen interest in the extent and nature of addiction problems and what it would entail to !x them. Although it was likely not a person there was not on Medicare, their questions and comments revealed, beyond their lot in life, that their concerns about addiction issues touched most of them, either personally, their families or friends.

I was recently asked to speak to a group of seniors. I was much surprised by the turnout of 250 citizens. The group sponsoring the lecture is committed to life-long learning for seniors andmy lecturewas one of a series to address “hot-button issues.” I had planned to speak aboutmy experience, spanning 5 decades, of working with individuals who had succumbed to addictive disorders focusing on the theme of “why some individuals aremore vulnerable than others.”But the day before and the day of my presentation I began to panic about my audience and what the scope of my presentation should be.

This talk is generally well received, especially given the mounting concerns about the scourge of addiction throughout our society, and usually consists of clinicians, counselors and educators. My audience this day was different—the seniors. So I panicked a bit—wouldmy audience be responsive to or be interested in my psychodynamic and psychiatric perspective on vulnerability to addiction? Beyond the usual issues I cover in this talk, I realized for it to be meaningful for this audience I had to at least make reference to social, cultural, and biological

contexts of addiction, and not least of all was the epidemic of addiction and the role of opiate drugs. Also, I wondered whether I should avoid or tone down technical issues about addiction and the psychodynamics of addictive vulnerability to which I usually refer. To put it less tactfully, should I “dumb-down” my talk? About this last concern—no need to worry, I diluted little from my usual presentation and they were with me all the way.

So I started by referring to some of my own daunting concerns about the magnitude of the addictions scourge, to which I quickly sensed my audience resonated. I cited a recent New York Times article indicating that more than a thousand young people were dying in our country eachweek from opiate overdoses. In passing I mentioned that the President just that week had declared we had a “public health emergency” with the epidemic. I mischievously made an aside that if he had called it the National crisis that it was, public funds and Federal support would follow as a remedy. Most of the audience caught the irony and chuckled. Next I wanted to make reference to the context of the social, psychological and addictive issues that are involved with the development of this disorder. I continued with the following prefacing remarks:

! Human unhappiness and sadness is an inescapable part of life. Some of us handle it better that others

! We were living in a time in our country where there was more unhappiness and misery as evidenced by divisive rancor played out in our political discourse with each other

! I contrasted the sense of feeling “less-than” in under privileged sectors of our society, versus the enormous stress and strain that the more privileged experience, especially among the young to compete and excel

! That there were counter-productive polarized contentious concepts approaches to what addiction was and what to do about it, albeit the contention not as bad as it used to be

! That one of the best kept secrets in medicine was that addiction was treatable. Namely there were options that worked, such as self-help (eg, AA and NA), talking treatments (eg, individual and/or group treatments), and when combined with each other and with medication assisted treatments (MATs—methadone, buprenorphine, naltrexone, etc.) were extremely bene!cial and often life savingReceived January 7, 2018; accepted March 3, 2018.

The American Journal on Addictions, 27: 161–162, 2018 Copyright © 2018 American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12706

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! I reminded my audience that suffering was not the worst fate; suffering alone was the worse fate, and that the combination of these treatments was an extraordinary antidote to the isolation, stigma, suffering and chaos, associated with addiction

! I made reference to the down-side of all the illuminating breakthroughs by the neurosciences how addictive drugs affected the brain over the past 3–4 decades; but too often they minimized, overshadowed or detracted from a better understanding and appreciation of the human psychological vulnerabilities that pre-dispose to addiction.

! And !nally, by way of background I reviewed how the changes in the way which drugs are dispensed andmarketed can affect and produce unanticipated problems and tragic consequences. For example, taking the acetaminophen out or Percocet1, and taking aspirin out of Percodan1, each of which contain only 5mgms of oxycodone allowed dispens- ing of large amounts of oxycodone. The original reason for the removal of the acetaminophen and the aspirin was that excessive amount of either could be toxic, the former wrecking the liver and the latter wrecking the gut. Unfortunately the removals allowed huge doses (eg, 100– 500mgms) of the opiate making addiction more likely. I then shifted to the main focus of my talk, namely why

some of us are more vulnerable than others to become addicted. I stressed the fact that despite the purported seductive and captivating nature of addictive substances, millions of individual consume and use these drugs, but only 10% or less become addicted. This is the case whether it is prescribed by a physician, or whether it is in the case of adolescent experimentation and use. That is, these drugs are not universally appealing. I stressed the life challenges of regulating our emotions, self-esteem, relationships and self- care, and how the properties of addictive drugs interact with the discomfort and suffering so many of us experience with these self-regulation challenges. Namely susceptible individ- uals, affected by troubled and traumatic life experiences dating back to childhood, and/or individuals with co-occurring psychiatric conditions, discover that addictive drugs short term relieve, change, or make more bearable the unending suffering associated with their self-regulation dif!culties.

I then went on to explain that in my 5 decades of treating and studyingaddictivedisorders Ihadbecomeconvinced that suffering is at the root of addictive disorders, and not old and new ideas and theories of addiction that emphasize pleasure seeking or self- destructive motives. I spoke of the idea or theory of self- medication, a hypothesis of addiction that I originated and published in 1985. I de!ned the theory of self-medication, namely that addictive drugs (i) short term relieve psychological suffering; and (ii) that there is a considerable degree of preference, or

self-selection in an individual’s drug of choice. I described the action of each class of drug, namely the effects of opiates, depressants (especially alcohol), and stimulants respectively, and how each class of drugs interact with and or ameliorate particular distressful states of feelings and suffering. I stressed that certain people have enduring painful states of subjective distress, not necessarily psychiatric disorders, but that some do suffer with psychiatric conditions (I listed and described a number of the conditions) which are exceedingly distressful, wherein particular painful feelings predominate. Short-term these conditions are relieved by one class or another of these addictive drugs.

In my concluding remarks, I reemphasized that more than anything addiction has to do with suffering. It has little to do with pleasure seeking, and addiction is not motivated by self- destructive motives. States of persistent psychological suffer- ing, distress, or co-occurring psychiatric disorders make it more likely that a person might be prone to develop a dependence on addictive drugs, and that the idea or theory of self-medication is a valuable, humanistic way to understand and treat addictive disorders. In addition, it is an important model to counter the stigma and prejudices associated with addictive behavior. The idea of self-medication helps to understand and accept, rather that to condemn and reject, individuals with these disorders. And understanding that addiction is rooted in suffering can and does effectively guide our group, individual, and medication assisted treatments of addictive disorders.

I guess my talk was a great success. More than usual, so many in the audience connected with my talk and ideas, as was evident with the astute questions they asked, their attentive- ness and the surprising number of seniors who effusively thanked me for my talk as they were leaving.

I realized from their reactions I should extend my talk or “conversation” to my colleagues and the broader community.

There are so many critical issues that need to be addressed and are in need of change to better deal with the staggering challenges in our society of addictive disorders. We should stop unproductive arguments with each other about the nature of addiction and how to treat it. We should be better communicating with each other about different approaches and strategies for intervention and treatments, and combining and integrating empirically proven programs that work. We need more certi!ed well trained addiction counselors, clinicians and practitioners to address, diagnose, and treat addictive disorders

And !nally we need the political will and public support to assure adequate funding to address the social, psychiatric and psychodynamic conditions that co-occur with and are intimately associated with addictive disorders.

162 April 2018

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