I was invited to read and review The Craving Brain: Science, Spirituality and the Road to Recovery recently. Unfortunately I am unable to do so at this time, but I was so intrigued by the title and book summary that I wanted to share a Q & A with one of the books co-authors, Dr. Anderson Spickard, Jr.
Dr. Anderson Spickard, Jr. is an emeritus professor of medicine and psychiatry at Vanderbilt University Medical Center who has been active in the practice and teaching of internal medicine for more than 45 years. Dr. Spickard is a nationally recognized expert in the areas of substance abuse and addiction having served as a certified addictionologist, founding director of the Vanderbilt Institute for Treatment of Addiction, founder of the Center for Professional Health at Vanderbilt, national program director of the Robert Wood Johnson “Fighting Back” program and leader in the Association for Medical Education and Research in Substance Abuse. His books include, Dying for a Drink: What You and Your Family Should Know About Alcoholism, Stay With Me, and The Craving Brain: Science, Spirituality and the Road to Recovery.
Over your 45 years working in addiction treatment, what has changed the most about the approach physicians take in working with people struggling with substance abuse?
Protocols for detoxification from alcohol addiction provide medications to help the individual become symptom free in about five days. Other medications like naltrexone help to control alcohol craving and suboxone used in the treatment of opioid dependence can be lifesaving.
The most important discovery has been the research that has defined addiction as a disease of the brain and the hijacking of the brain’s reward system by dopamine, the neurotransmitter of the addictive process that produces negative behaviors in all addicts (craving, denial, anger, minimization, etc.).
The most impressive result of treatment (80%-85% recovery) is seen in addicted physicians who are treated in a program for four months or more and who are under a five-year contract not to use their substances of addiction and are monitored by regular observed urine screens. If their contract is broken by using, they are at risk of losing their license to practice medicine and their professional position in a hospital or clinic. This close observation and monitoring of addicted prisoners on parole has also been reported as effective.
Barbara Thompson and I began this journey of writing about addiction after I founded the Vanderbilt Institute for Treatment of Addiction in 1984. She and I co-authored our first book, “Dying for a Drink – What You and Your Family Should Know about Alcoholism” published by Word Books. The revision in 2005 was published by Thomas Nelson. There are seven foreign translations. The Russian translation has been distributed to the treatment centers in Moscow.
What role does spirituality play in substance abuse and recovery?
The underlying spiritual issues of the addict are the guilt and shame of their addiction- guilt, about what they have done while addicted and shame about who they are and have become. The power and love of God as the individual knows Him in the 12 Steps of Alcoholics Anonymous and Narcotics Anonymous will lead the addict to a spiritual awakening that will sustain the person as they “work the steps” daily with a sponsor and a home group of other addicts who are working to break the bonds of addiction. The family members who attend Alanon and Naranon and work the steps also can have amazing peace and understanding of their loved ones illness. The Serenity Prayer prayed by all the addicts and their families is a spiritual healing prayer.
How has the opioid crisis influenced your work?
The tragedy of the opioid crisis has reinforced the urgency I feel to distribute “The Craving Brain” to everyone who will read it. In addition to that commitment, I have reactivated my membership in the Association for Medical Education and Research in Substance Abuse so that my colleagues and I, who teach in our nation’s medical and nursing schools, will expand and accelerate teaching of the early diagnosis and referral for treatment protocols for patients with abuse and addiction to all addictive substances.
Tell us about your connection to James B. and his role in writing this book with you.
James B. was an acquaintance of Barbara Thompson, the writer of the book, and she asked him if we could use his story in the book. His detailed description for us about the importance of the addict working each of the 12 Steps, having a sponsor and home group was critical for me since in our treatment unit at Vanderbilt we could only finish the first three steps. I have used James’ method of the addicted person working each step thoroughly to make a new questionnaire for all the steps. This has become the document I use in teaching addicts in a homeless shelter, Matthew 25, in Nashville. The spiritual awakening in about half of the men is wonderful to see. I am hopeful that this process will reinforce their commitment to sobriety when they are discharged to a job and drug- and alcohol-free housing. James’ testimony about his illness, the recovery process and his present state of continued sobriety is a wonderful story.
How has writing a book with a recovering addict influenced your perspective in conveying ideas to the public?
I believe that working and writing with James B. has reinforced my excitement about the disease of addiction and its effect on individuals. I know from our joint presentation at the Southern Festival of Books this fall that being on the podium together was a profound experience for both of us. If we had more opportunities to be together in a teaching environment, we could present an impressive program. Both of us are Christians and we could be very helpful to a group of Christians struggling with addiction issues in themselves or their families.
What has surprised you most about working in addiction, either scientifically or emotionally?
The most wonderful surprise has been the understanding of the brain changes that defines addiction as a disease of the brain. Everyone who deals with addicted persons just couldn’t understand why they couldn’t stop drinking, snorting cocaine, taking opioids, etc. When the research uncovered the presence of dopamine as the neurotransmitter in the brain’s reward system that hijacked this system and kept it moving on its own and causing these strange uncontrolled behaviors seen in the addict, it became clear that the addict wouldn’t stop because they couldn’t stop using. This is the most “AHA!” moment in my professional life.
The other part of this story is that the neurons participating in this brain injury by the substances begin to repair themselves once the use of the substance stops and recovery begins. Those neurons that are not destroyed start to regenerate themselves and in some cases restore the damaged brain.
Finally, it has been shown that parts of the neuron involved in the addictive process can remain poised to become stimulated again if the person starts to use again even years after they completed their recovery program years before. There may be similar processes in the person’s brain who has a father or grandfather who is an addict and the person inherits that susceptibility to become an addict too. These principles of addiction make teaching about addiction more scientifically established and exciting. Medications that block the neurotransmitter process in the reward system could lead to blocking craving completely. Even now naltrexone given by mouth daily and by injection (Vivatrol) once a month controls much of the craving seen in alcoholics.
What aspect of addiction recovery do you find the most interesting to study?
At Vanderbilt, we have researchers who are experts in studying the reward system, and I will keep up to date by observing their work. My particular interest now is using the 12 Step questionnaire I created to teach homeless addicted men about their addiction and the way out of it.
What new research have you seen lately on addiction, and how do you think the future of substance abuse recovery seems to be unfolding?
The research on the effect of medications on craving, denial, etc. from the reward system hijacked by dopamine will be the most exciting result of present day research labs. The importance of detailed and comprehensive reviews of the 12 Steps in homeless populations will be another fertile field of study. I haven’t mentioned yet the value of a comprehensive program of prevention in communities and especially on our college campuses. We are hoping to begin such a program at Vanderbilt.
What led you to become so involved in working with people battling problems with alcohol and drugs?
I was trained in the usual complications of alcoholism in medical school but was totally surprised when a physician colleague who was my patient committed suicide during a drinking binge. This event became the wake-up call for me to learn what addiction is and what I could have known to prevent this tragic event and the other behaviors of alcoholics that I should have learned in medical school and residency. Absolutely no training in medical school and residency at Vanderbilt and Johns Hopkins prepared me for this moment. I tell people this was God’s call to me to learn as much as I could and teach the medical students under my leadership that this disease can be treated and we can know what to do when confronted with this strange behavior. The leader of the psychiatry department at Vanderbilt at the time, believed alcoholism was a “bad habit.” I knew that wasn’t right so I started the journey, beginning at St. Mary’s rehabilitation center in Minneapolis, MN, to learn what alcoholism and drug addiction is and what can be done about it. The books “Dying for a Drink-What You and Your Family Should Know about Alcoholism” and “The Craving Brain-Science, Spirituality and the Road to Recovery” contain all that I have learned in the last 40 years about addiction.
What is on the horizon that gives you hope?
Medications for treating addiction to alcohol, opioids and tobacco have been available now for some time. Naltrexone is one of them and has demonstrated effects on reducing craving in severe alcoholics. Naloxone is a rapid acting medication that reverses the effects of opioid overdoses. The pressure of craving that drives the compulsion to drink alcohol or take addictive drugs is being intensely studied by researchers. An emerging molecular imaging technique using PET scans and (CT) computerized tomography of the brain have allowed researchers to study the craving of alcoholics and perhaps develop new medications to block their compulsive desire to continue taking the addictive substance.
What kinds of collaborations would you like to see among those in this field to better serve those with addictions?
Programs to prevent use, abuse and addiction to alcohol and drugs in high school students are in place now that demonstrate effective strategies. The program STARS (Students Taking a Right Stand) that is in place in many high schools and middle schools of Tennessee that has shown positive results. The principles of STARS translated into colleges and universities provides ideal approaches to reducing the tragic consequences of binge drinking experienced now on our college and university campuses. Also, community organizations in most of our states, organized by the Community Anti-Drug Coalitions of America (CADCA), have successfully approached the abuse and addiction problems in each community and provide blueprints for successful prevention strategies.
What has your work with men experiencing both homelessness and addiction taught you?
The addicted homeless men that I have taught at Matthew 25, a local homeless shelter, are a group of addicted men that respond as well to the usual detoxification procedures and medications as other patients in treatment centers. The problem of relapse prevention though is complicated by their lack of resources that would enable them to live in a drug and alcohol free environment, being provided medications for co-occuring medical illness and having a good paying job at discharge. I have added to the relapse prevention program for the Matthew 25 men a detailed questionnaire about each of the 12 Steps of Alcoholics Anonymous and Narcotics Anonymous. The men review each Step, write out their answers and discuss their answers with their group members. We urge them to attend AA and NA meetings, have a sponsor and continue their spiritual program after discharge. We hope they will finish the questionnaire and build a strong spiritual backup for their recovery program.
What do we as a society need to be doing that we are not?
The most effective strategy that I think is important for our country is strong leadership about the issue of addiction as a public health problem underlying many of our social ills. The issues of addiction prevention and treatment are becoming clearer as each day passes. The work by the researchers at the National Institutes of Drug Abuse (NIDA) and other federal facilities uncover additional medications for preventing craving.
The recent publication of the Surgeon General’s Report is an excellent document to use as a blueprint for action. Leadership by our elected officials will be required to put the recommendations into action.