Child of an Alcoholic – a Legacy of Untreated Secondhand Drinking-Related ACEs

Each April since 1987, the National Council on Alcoholism and Drug Dependence, Inc. (NCADD) has sponsored Alcohol Awareness Month to increase public awareness and understanding, reduce stigma and encourage local communities to focus on alcoholism and alcohol-related issues. This year’s theme is “Connecting the Dots: Opportunities for Recovery.”

In honor of this year’s theme, I’d like to connect a dot that is often overlooked in my opinion — the Legacy of Untreated Secondhand Drinking-Related ACEs and the role it can play in developing alcoholism and frustrating one’s attempts to recover.

As I shared in my post of the same name appearing on ACEs Connection

I am the Child of an Alcoholic

My mom didn’t stop drinking until age 79. She died at 84. There was no warning, no lingering illness. She died two days after an unsuccessful emergency surgery. But we had five years during which she did not drink, after forty-five years during which she did.

You see, my mom knew she had a drinking problem. So did we, the rest of her family. There were times when she fought mightily to stop or control it. There were times when the rest of us fought mightily to help her. She even succeeded in cutting back or not drinking for periods of time, which convinced her and us that she really wasn’t an alcoholic(1). None of us knew alcoholism(1) was a developmental brain disease; a chronic, often relapsing brain disease. None of us knew one of the key risk factors for developing the disease is childhood trauma. None of her primary care doctors who saw her over the four+ decades her disease marched on ever diagnosed it.

Ironically, my mom was also a 17-year cancer survivor when she died. She knew to do (and did) self-breast exams. She found a lump and immediately contacted her doctor; her doctor immediately ordered a biopsy; and she was diagnosed with breast cancer in 2000. She had a mastectomy, went through chemotherapy, lost her hair, and showed such courage and grace in her battle to recover. (If you’ve ever witnessed someone recovering from cancer, you know what I mean by “battle.”)

But cancer was a disease people and their doctors understood. Symptoms and having the disease were openly talked about and medical protocols were routine. There was no denial, secrecy, lying or self-judgment.

This was not the case with my mom’s other disease – alcoholism.

The opportunity for an earlier recovery from alcoholism for my mom would have been:

  • understanding and treating her adverse childhood experiences (unknowable at the time because the ACEs Study had yet to be done)
  • knowing that alcoholism is a developmental brain disease (unknowable at the time because the science was not, yet, available)
  • understanding the legacy of untreated secondhand drinking (SHD)-related ACEs.

Preventing an Alcohol Use Disorder – one of the Legacies of Untreated Secondhand Drinking-Related ACEs

Child of an Alcoholic - a Legacy of Untreated Secondhand Drinking-Related ACEsUnderstanding the connection between ACEs and SHD and their connection as possible risk factors for developing addiction (alcoholism) can help a family prevent alcohol use disorders going forward.

It was this connection and finally understanding that alcoholism (addiction) is a brain disease that set my mom free. She could embrace the fact that she didn’t “choose” to become an alcoholic just as she didn’t “choose” to have breast cancer; nor was she weak-willed, immoral, uncaring or any of the other adjectives used to label persons with this particular disease.

 

Breaking The Cycles – Changing the Conversations

To close this post I want to share one of my mom’s greatest gifts to breaking the cycles of untreated SHD-related ACEs and untreated ACEs in general. It happened during one of our phone calls.

She said to me, with deep emotion, “Lisa – please – please use my story – our story – to help others.”

And so I am.

There wasn’t enough time for my mom to heal from her ACEs, nor for she and I to develop the mother/daughter relationship I now have with my two daughters. Our experience is so different because of the healing work the three of us were able to do to change the legacy.

But my mom started her process by breaking the denial, secrecy, lies, and self-judgment about her alcoholism and its root causes. And it is the four of us together – my mom, myself, and my two daughters – who have now changed the legacy in our family. As such, we pass forward not lies but the truth, not self-judgment but self-compassion, not secrecy but openness, not denial but seeking awareness. Something I didn’t even understand let alone could have imagined possible just fourteen years ago.

To read the full article, please click The Legacy of Untreated Secondhand Drinking-Related ACEs.

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Endnote:

(1) Current terminology defines any drinking pattern that exceeds “low-risk” limits as an alcohol use disorder (AUD). In other words, the more commonly used terms most people are familiar with — binge drinking, heavy social drinking, alcohol abuse and alcoholism — are all considered alcohol use disorders (AUDs). Alcoholism is the most severe of the AUDs. 

Additionally, a person with the most severe AUD is no longer referred to as an alcoholic. Rather s/he is referred to as a person with an alcohol use disorder. I like this distinction. It allows us to see the person with an AUD as a person, first, and then second, as a person with an AUD.

When referring to alcoholism, it is also currently correct to use the term Substance Use Disorder (SUD). A substance use disorder is either alcohol or other drug misuse.

How Do You Know if Someone’s Drinking is a Problem

How do you know if someone’s drinking is a problem? Short answer: “If you are talking or concerned about it.” What do I mean?

The only reason a person would be worried about another person’s drinking is because that other person’s behaviors change when they drink. Their behavioral changes are called drinking behaviors.

Drinking behaviors occur when a person consumes more alcohol, thus more ethyl alcohol chemicals, than their liver can metabolize. When this happens, the ethyl alcohol chemicals interrupt the chemical portion of the brain’s cell-to-cell communications. This suppresses normal neural network functioning responsible for judgment, memory, pleasure/reward, emotions, breathing…. In other words, it changes a person’s thoughts, feelings, and behaviors.

How Do You Know if Someone's Drinking is a Problem

How Do You Know if Someone’s Drinking is a Problem

Contrary to popular belief, it’s not just the drinking pattern of alcoholism that causes these behavioral changes, although alcoholism is certainly one. Binge drinking, heavy social drinking, and alcohol abuse (terms now grouped together as alcohol misuse and/or alcohol use disorders) also cause drinking behaviors. Some of the drinking behaviors include:

  • crazy, convoluted accusations and illogical arguments
  • verbal, physical and/or emotional abuse
  • bullying; neglect
  • driving while impaired
  • domestic violence.

Why Does Knowing Whether a Person’s Drinking is a Problem Matter

Short answer: “There is a direct impact – a second-hand effect – on the people confronted and/or coping with drinking behaviors.” These second-hand effects include:

  • being on the receiving end of drinking-related verbal, physical or emotional abuse; neglect; bullying and believing it’s the “real” person coming out, not understanding the behaviors are the consequence of chemical changes in the brain
  • being seriously injured by an impaired driver
  • feelings of anxiousness, hopelessness, walking on egg shells because of the uncertainty, worry, fear, anger, concern triggered when in the sphere of an impaired person’s drinking behaviors
  • being on the receiving end of domestic violence or a sexual assault by a person whose brain functioning has changed under the influence of alcohol.

Moms, dads, husbands, wives, brothers, sisters, children, grandchildren, grandparents, boyfriends, and girlfriends exposed to and/or coping with these sorts of drinking behaviors experience physical, emotional and quality of life impacts because the drinking behaviors trigger their stress response system. When this system is repeatedly activated, their stress becomes toxic, and they experience many of the following stress-related symptoms:

  • stomach ailments
  • insomnia
  • anxiety, depression, frequent or wild mood swings
  • chronic neck and/or shoulder pain
  • frequent headaches, migraines
  • chest pain, palpitations, rapid pulse
  • increased anger, frustration, hostility
  • feeling overloaded, overwhelmed, helpless, hopeless

I call this second-hand effect secondhand drinking (SHD). For more on this, check out “The Fight-or-Flight Stress Response – Secondhand Drinking Connection.

Now… back to the original question, “How do you know if drinking is problem?” If you’ve agreed with my short answer, “You’re talking about and/or concerned about it,” then you’ve seen some of the drinking behaviors I mentioned above. And that is your answer. Drinking really is a problem because it’s not “normal” to change behaviors when drinking. And that’s because staying within low-risk or moderate drinking limits typically keeps a person from exhibiting drinking behaviors.

Definition of “Moderate” or “Low-Risk” Drinking Limits

For Women:  No more than 7 standard drinks in a week, nor 3 of the 7 in a day
For Men:  No more than 14 standard drinks in a week, nor 4 of the 14 in a day.
A standard drink is defined as 5 ounces of table wine, 12 ounces of beer or 1.5 ounces of liquor (e.g., vodka). Often “drinks” served at  parties or in bars or restaurants  contain more than one standard drink.

Lisa Frederiksen explains the three stages of substance misuseWhat Knowing Low-Risk Drinking Limits Can Do For You

1. Helps you understand when your loved one’s brain is likely changed by the ethyl alcohol chemicals in alcoholic beverages, thus their behavioral changes are not their “normal” (unless that’s how they behave when they’re not drinking).

2. Helps you avoid the unnecessary, unproductive and down right destructive exchanges that can occur when you try to make sense out of the actions and behaviors of someone who has exceeded low-risk drinking limits — especially the “per day” limit.

This 2nd reason can be especially important and makes more sense when you understand the next section.

Blood Alcohol Content Explained

Alcohol is not digested like other foods and liquids. It bypasses the digestive system and enters the bloodstream through the walls of the small intestine. Because alcohol dissolves in water, the bloodstream carries it throughout the body (which is 60-70%) water, where it is absorbed into body tissue high in water concentration (like the brain) and highly vascularized (meaning, lots of blood vessels – like the brain).

The ethyl alcohol chemicals in alcoholic beverages are metabolized by specific enzymes produced in the liver. This is the process by which ethyl alcohol chemicals leave the body. The liver can only metabolize a certain amount of ethyl alcohol per hour, which means it leaves the bloodstream more slowly than it enters. Because the brain controls everything we think, feel, say and do, ethyl alcohol chemicals “sitting” in the brain until the liver can metabolize them changes the chemical portion of the brain’s electro-chemical signaling process (in other words, how brain cells talk to one another, aka neural networks). This in turn changes neural networks (cell-to-cell communications) responsible for a person’s thoughts, feelings, and behaviors.

A very GENERAL rule of thumb is that it takes about one hour for the liver to metabolize one standard drink. A standard drink is defined as 5 ounces of table wine, 12 ounces of beer or 1.5 ounces of hard liquor. Using this very GENERAL rule of thumb, it will take four hours to metabolize four standard drinks — even if the drinks were consumed back-to-back, and it’s been over an hour.

BUT, no two people will necessarily metabolize alcohol in the same manner. Drink for drink, people who weigh less, for example, will have more alcohol concentration in their system than someone who weighs more. People who have lower amounts of the liver enzymes that metabolize ethyl alcohol chemicals will take longer to metabolize the same amount of alcohol as someone else. Additionally, genetics, whether taking medications, having a mental disorder, and stage of brain development will also have an influence on how one person’s liver metabolizes and/or their brain responds to ethyl alcohol chemicals. [See related post for more on this stage of brain development concept, “Underage Drinking – How Teens Can Become Alcoholics Before Age 21.”]

The key message is the liver can only metabolize a certain amount of alcohol per hour. Until the alcohol is metabolized, a person still has ethyl alcohol chemicals in their bloodstream, which means their brain’s electro-chemical signaling processes are still being changed. Hence a person’s decision-making capabilities are being changed, as well. In this manner, a person who’s had too much to drink may actually “choose” to drink and drive, or to keep drinking because “they feel fine,” or engage in any number of other destructive behaviors because of the convoluted “thinking” caused by ethyl alcohol chemicals’ impacts on electro-chemical signaling processes.

Knowing that it is a person’s exceeding low-risk drinking limits – especially the per day limits – that is causing the drinking behaviors is what can help you avoid a whole lot of endless, pointless talk or angst about nothing you have any control over — namely, the drinking behaviors. When a person drinks more than their brain and body can processes, they affect the very areas of their brain needed to think straight and act responsibly.

By keeping this in mind, you will know that as a person exceeds low-risk drinking limits, there is…

  • no point in having a ‘serious’ discussion,
  • no point getting into a fight about their drinking behaviors, and
  • definitely every reason not to get in the car with them (yes, a woman consuming 3 or a man consuming 4 drinks in a two hour period will likely register a .08 BAC).

For more information on drinking patterns…

check out NIAAA’s website, “Rethinking Drinking.” Another resource to check out is the World Health Organization’s Alcohol Use Disorders Test (AUDIT). To see how a clinician might interpret the test results, check out the WHO AUDIT PDF, pgs. 19-20.

 

 

Tough Love – Harmful or Helpful?

Tough love – does it hurt or help a person with an addiction, aka substance use disorder (SUD), get the help they need?

I regularly get some form of this question – generally because there’s so much confusion about what it means. Unfortunately, there is no single definition of tough love applicable to addiction.

For some family members, it's difficult to forgive and forget a loved one - even after years of sobriety.Some experts believe tough love means to cut off all support and contact in order to help a loved one hit their bottom and thus seek help. Others believe there is some middle ground, such as paying their rent or car payment so they have housing and transportation to and from a job (when they get one). And still others believe it’s staying in contact, expressing your love and support and willingness to help when your loved one reaches out for help with seeking treatment.

For a majority of family members, some or all of these approaches are tried at one time or another. And for some, there’s no other answer than, “I’ll do anything I can because not to could mean they’ll get worse, or worse, yet, they’ll die.”

To help those with whom I work as a family addiction education consultant and/or recovery coach, I ask the following questions, and in our work together, we answer them. I say, “in our work together,” because there is no one nor right way to support or help a loved one with addiction, aka substance use disorder, but there are some common road blocks to success no matter where a person falls on the “tough love” continuum.

What do you think addiction is?

Answers vary from poor choices, lack of willpower, it’s a disease (but I don’t see why it’s considered a disease), to name a few.

The “correct” answer is, “Addiction is a developmental, chronic, often relapsing brain disease.” Whew! That’s a mouthful, I know, but it’s a complicated disease, as are most chronic diseases, for you see, disease, by it’s simplest definition is something that changes cells in a negative way. When you change cells in a body organ, you change the health and functioning of that organ. Addiction changes cells in the brain — the organ that controls everything a person thinks, feels, says, and does. Check out the National Institute on Drug Abuse (NIDA) > “The Science of Drug Abuse and Addiction: The Basics.”

Does your loved one have any of the five key risk factors for developing addiction?

These risk factors influence how a person’s brain develops — in other words, how their brain cells talk to one another and map repeatedly used neural networks as their “go-to” thoughts, feelings and behaviors. These are important concepts to understand because addiction is a developmental brain disease. The key risk factors include:

  • genetics (are there persons in the immediate or extended family with addiction (substance use disorder?)
  • early use (did they misuse the substance(s) during adolescence and/or early adulthood?)
  • childhood trauma, aka ACEs — adverse childhood experiences — (did the person experience verbal, physical, emotional abuse; neglect; parental divorce; parental substance misuse?)
  • mental illness (does the person have bipolar, depression, anxiety, or ADHD, as examples?)
  • social environment (what was the home/social environment like; how were substances used by others in the family?)

Understanding these helps a person appreciate that treating/changing the treatable risk factors (e.g., childhood trauma, mental illness, social environment) is critical to relapse prevention and success in long-term recovery.

Do you understand the characteristics of addiction – what makes it addiction vs substance abuse?

The four key characteristics of addiction include: tolerance, loss of control, cravings, and physical dependence. Understanding these helps a person appreciate why anti-craving medications, behavioral modification therapy, and medically supervised detox may be necessary to successfully treat addiction.

Are you familiar with the concept of “setting boundaries?”

You’ll likely have heard this expression and perhaps told you need to set better boundaries. If you’re not familiar with it or are having trouble setting boundaries with your loved one, check out my post, “Setting Boundaries YOU Can Live With.”

Are you aware of the many methods of effective addiction treatment?

In other words — there is no one size fits all. For more on this, check out NIDA’s Principles of Effective Treatment.

Tough Love - Harmful or Helpful?For more information on the above and other related concepts…

…consider my Quick Guide to Addiction Recovery: What Helps, What Doesn’t.

No one can answer the tough love question – “Is it helpful or harmful?” – for you, but answering these kinds of questions is a start towards answering the question for yourself. Additionally, critical to helping you answer this question is recognizing how deeply you’ve been affected and appreciating that you need support and help, as well. Unfortunately, to address what that might look like is beyond the scope of this blog post.

Always feel free to contact me at 650-362-3026 (PST). There is no charge for the initial call.

Using Brain Science to Change Your Mind

Brain science is a powerful tool one can use to change their thoughts, feelings or behaviors – seriously!

For followers of my blog, you know my enthusiasm for one of the most profound discoveries I’ve learned which is how the brain wires, develops and maps. And it is this understanding that has helped me and those with whom I work or who read my blog actually re-wire their brains, creating new brain maps to heal their brains and change their thoughts, feelings and behaviors around substance use disorders, mental disorders, co-occurring disorders, and secondhand drinking-related stress impacts.

One of the authors who also embraces this science and whose work I admire greatly is Debbie Hampton, author of Sex, Serotonin, and Suicideand founder of The Best Brain Possible. “After decades of depression, a serious suicide attempt and resulting brain injury, I not only survived, but went on to thrive by discovering the super power we all have to build a better brain and joyful life. If I can do it, you can too. Let me inspire and inform you to do the same. No brain injury required,” she says.

Using Brain Science to Change Your Mind

Author Debbie Hampton, founder of The Best Brain Possible

So I want to share Debbie’s perspective on this by highlighting a few concepts she shared in her February 14, 2016, post, “How Your Mind Shapes Your Brain,” appearing on her blog, The Best Brain Possible:

Every second of your life, every single thing of which you are aware – sounds, sights, thoughts, feelings – and even that of which you’re not aware – unconscious mental and physical processes – can be directly mapped to what’s happening in your brain. Over time, patterns emerge and actually shape your brain’s form and function. What you do, experience, think, hope, and imagine physically changes your brain through what’s called experience-dependent neuroplasticity.

Every minute of every day, you are literally shaping your brain.

How Neuroplasticity Physically Happens
What you pay attention to, think, feel, and want, and how you react and behave contribute to shaping your brain because of the specific ways your brain is activated over and over again in each activity.  Neuroplasticity is physically accomplished as follows:

  • Active brain regions get more blood flow, since they need more oxygen and glucose.
  • The genes inside neurons get more or less active depending on the frequency with which the neuron fires.
  • Neural connections that aren’t active weaken and wither. Use it or lose it.
  • The synapses, connections between neurons, get more sensitive when routinely activated simultaneously, and new neurons are formed, producing thicker neural layers, in busy regions. Neurons that fire together, wire together.

The same principles that apply to physical exercise modifying your body work for neuroplasticity. A single yoga class or running three miles one time isn’t going to get noticeable results – except some brutal soreness. But months of practicing yoga or lacing up your running shoes will gradually have lasting effects on your body.

To read more of Debbie’s article and learn how to turn on neuroplasticity and make it work for you, click here.

The Craving Brain – Q & A with Author Dr Anderson Spickard

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?

The Craving Brain - Q & A with Author Dr Anderson Spickard

Dr. Anderson Spickard answers questions about his newly released book, “The Craving Brain: Science, Spirituality and the Road to Recovery.”

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.