Dr. Christopher Holden, M.D., is a Visiting Assistant Professor of Clinical Psychiatry at the University Of Illinois College Of Medicine. He works as the Director of Addiction Services in the Department of Psychiatry at the university, and also as the Medical Director of the Substance Abuse Residential Rehabilitation Treatment Program at the Jesse Brown VA. He is one of relatively few psychiatrists who is board certified in addiction psychiatry. After giving an excellent talk at our program “The Science of Addiction” earlier this year (see the trailer HERE, and the full video HERE), I caught up with him to ask some followup questions.
C2ST: Is there anything that you didn’t get to say at the program that you didn’t get to talk about?
Dr. Christopher Holden: Not that comes to mind.
C2ST: One of the things that caught my attention during the program was that you talked about mild, moderate and severe forms of substance use disorders. That was the first time I had heard anybody talk about it in those terms. I think most people tend to think about it as two categorical states where either you are healthy or you have an addiction. I wonder if you could talk a little bit more about that, and what it means for people, and how it impacts treatment.
CH: Sure. The issue raises a lot more questions than it answers. Traditionally addiction —alcoholism, alcohol use disorders, substance use disorders—were viewed in this binary sort of way, either you have it or you don’t, and this would often be in contrast to how people saw themselves. For instance, a lot of times someone who is struggling with substance use issues looks at someone else with a substance use disorder and sees that they have what seems to be a worse disease, and they say to themselves, “well, I’m not that bad.” While that can sometimes be the truth, that maybe the severity of their substance use disorder is less, there also is the possibility of denial, that maybe the person is misperceiving their own use, that it’s not to be as bad as it is, so it’s complicated in that regard. There’s all sorts of other complicating factors as well. In general, at least traditionally, by the time people are seeking treatment for substance use disorders, they are often times severe, so we don’t see people that are on the mild or moderate spectrum seeking treatment. That can be unfortunate because a lot of times mild and moderate can progress to severe, and if you treat something sooner when it’s less severe in these earlier stages, the hope is it might be more readily responsive to treatment, and lead to less suffering overall. So the thinking is that as time progresses, hopefully doctors and other healthcare providers and the public in general will be better at detecting substance use disorders and seeking out treatment sooner rather than later, thus leading to better outcomes in that regard. Also along those lines of binary, “all or nothing” is the idea—at least historically—that there’s a one-size-fits-all approach to substance use disorder treatment. Traditionally, particularly back in the 80s and into the 90s, anyone with an addiction needed to go to rehab, to a 28 day program—there was this magical number of 28 days. Whereas the truth is that the amount of treatment people need exists along a continuum. For some people it’s one on one counseling once a week for a short period of time, maybe even a few sessions, maybe even in their primary care doctor’s office. For some people it involves going to an outpatient program a few days a week for a month or two, and it goes on and on and up to people needing long-term, residential treatment, for instance. In addition to amount of treatment, different people may do better with different types and combinations of treatment- cognitive behavioral therapy, medication, and other types as well.
C2ST: Would it also be accurate to say that there is this continuum of clinical levels of substance use disorders, but is there also a continuum leading up to that of subclinical traits? Is there a continuum from a perfectly healthy brain to severe substance use disorder?
CH: Absolutely. For example- a way that researchers, clinicians, and public policy experts think about alcohol use is a sort of pyramid, and at the base of the pyramid and most of the way up are people who either don’t drink at all or are light or moderate drinkers, and then as you go higher up you get to heavy drinkers and problem drinkers, and then at the very tip of the pyramid are people who have alcohol use disorders—mild, moderate and severe. One of the big ideas behind it is that these people that are in the bottom 70-80% of the pyramid, whose drinking isn’t problematic, when they see their doctor or other healthcare provider they can be screened for that and then advised what their safe drinking levels are and to keep it that way. People who are at-risk drinkers or heavy drinkers, which vastly outnumber the people who have alcohol use disorders, can get some brief counseling from their healthcare providers or even just advice that their drinking is above what is considered safe and get some recommendations. And what’s been found is that even just brief advice like that can have huge impacts, because there is such a large number of people who are in that range that just brief advice can have a huge impact for overall public health.
C2ST: So this brings up another big question that I had. You mentioned in your talk that it can sometimes be hard to accurately diagnose the different levels of severity of a substance use disorder because, as you said, people might not be accurately what’s going on to their healthcare provider. This is, from what I understand, a problem with diagnosing all kinds of psychological maladies that it’s all based on self-reports. Whereas with something like type II diabetes, you do a urine test or blood test or whatever, and you can put a number on the severity of the condition you have. It seems like a more objective test would be very beneficial for this kind of treatment. Is anybody working on anything like that?
CH: For certain. Like you said, it’s a big question in all of psychiatry. It’s kind of the holy grail, in fact — compared to the rest of medicine, we don’t have good, objective testing. Ideally, one way to come up with a test is to use animal models, and say for instance is there a blood test for animals that you’ve made to be addicted or to appear addicted to substances. One issue in research is that there isn’t a firm, universally agreed upon definition as to what exactly addiction is.. That’s not to say that there isn’t plenty that’s agreed upon and accepted. But rather-at what point is the brain addicted, versus somebody just misusing substances, for instance. There is some brain imaging research involving fMRI and what have you that show that addicted brains look and respond differently, but this is all at the research level. As of now, there aren’t any tests that can be done, clinically speaking, that can guide clinical decision making. But it certainly is a big area of research and is something that people are striving towards. Moreover, the idea being that there is genetic vulnerability to addiction. In general, addiction risk is about 50% genetic or inherited and 50% environmental, so it would be very helpful to have genetic testing to perhaps counsel people on if they have an increased risk of developing addiction if they use or if they use problematically. But we are not at the “biomarker” stage of addiction diagnosis yet.
C2ST: I know this is an unanswerable question, but how far away from that do you think we are?
CH: I really don’t know, and I don’t want to sound like a scientific skeptic, but it seems like a bit of a moving target. I’m relatively new to the field—I went to medical school in the early 00s—and it seems about as far away as ever. It’s one of those things where it seems like the more we know, the more it seems like we don’t know. To be clear- we have made enormous progress in particular in recent years, and understand far more about addiction than we once did. The brain is so complex, complex human behaviors are so hard to reduce. The 1990s were the decade of the brain, and I think in the 90s people had a lot of excitement that we would have this figured out by now, or at least better than we do by now, so that’s the down side. The plus side is that it shows how complicated we are, and how sophisticated our brains are.
C2ST: I haven’t even gotten my flying car yet, so…
CH: Exactly. And hover boards, right?
C2ST: There was a lot of talk about pharmacotherapy for substance use disorders at the program, and we know that there is a pretty strong comorbidity between addiction and other mental health disorders like anxiety and depression, for example, so to what extent is pharmacotherapy complicated by these other co-occurring or commonly co-occurring mental health issues.
CH: What seems to be coming out is that good evidence-based pharmacotherapy seems to work quite well with people who have co-occurring disorders. For instance, and there are all sorts of different examples of this, there is a medication called topiramate or Topimax which has shown some efficacy in treating PTSD and a lot of efficacy in treating alcohol use disorders. They published a clinical trial that showed that it works very well in treating both disorders when they exist within the same person, if somebody has alcohol use disorder and PTSD. There are all sorts of examples of this. There is a study where they looked at people who had alcohol use disorders and depression, and they did a trial where they divided people into four groups: one group got an antidepressant and an anticraving medication, one group got the antidepressant medication, one group got the anticraving medication, and one group just got placebo. What they found was that the group that got both medications had the best outcomes—had the most improvement in their depression symptoms, had the most improvement in their problematic drinking—and it worked better than either of the two medications on their own, and certainly worked better than the placebo group. There is certainly a lot more to know, but it seems like good pharmacotherapy does exist and more will exist for patients with co-occurring disorders.
C2ST: Related to treatment, you talked during the program about the different levels of qualification for people who treat substance use disorders. Could you talk about the utility of each different level of qualification, if any?
CH: There are so many different certifications and I believe they vary from state to state, that I can’t speak particularly intelligently about that.
C2ST: If you were recommending treatment for someone, would you recommend any less than a psychiatrist with an addiction specialty or a clinical psychologist with the same specialty?
CH: What I think is important is that addiction is a chronic disease and that healthcare specializes in the treatment of disease, both acute and chronic. So a treatment facility, be it a residential program, be it a program in the community, would ideally have some oversight that has a medical director that’s informed by medical decision making. That doesn’t mean that everyone has to be treated by an MD who specializes in addiction treatment. Certainly, having some link to healthcare, and not only that but healthcare professionals that have addiction training is certainly the ideal. With that said, I do not mean to disparage the efforts, abilities, and services that addiction treatment providers who do amazing work and work outside the conventional medical system.
C2ST: What should someone do if they suspect that someone they know has a substance use problem?
CH: It depends on so many different factors. One thing that doesn’t seem to work is to confront or argue with somebody while they are under the influence of a substance. I think in general it should start with a conversation, or an attempt at a conversation, under circumstance that are not volatile, where the person hopefully isn’t under the influence or withdrawing from the substance, and to try to have a discussion rather than an argument to try to get the person to tap into any kind of intrinsic or internal motivation. Barring that, something else that can help is discussions with the person’s healthcare provider, informing someone’s physician, provided that they have one. I think those are good places to start.
C2ST: The common lore that is in the culture is that someone won’t get better until they hit rock bottom. Is there any truth to that?
CH: That’s the traditional idea- that they only enter treatment when they hit rock bottom, and if they aren’t ready for treatment, they need to have more bad things happen to them until they hit their bottom. The more modern conceptualization of it is that people can change at any point, and they don’t have to hit rock bottom. What seems to be most important in driving change is motivation, and motivation is something that doesn’t just involve a horrendous amount of bad things happening. People can have all sorts of reasons to become motivated, both internal reasons and external reasons, positive reasons, and consequences. That’s something that good counseling can involve. Sometimes a brief intervention from doctors can help people tap into their own intrinsic motivation to change. Certainly the idea that people just need to hit rock bottom and we as clinicians should just wait for that, that that’s when treatment can start, is anachronistic. The majority of people who enter treatment now are either pre-contemplative or contemplative about stopping their use. People don’t necessarily enter treatment having already stopped, or being firmly committed to stopping.
C2ST: Whether it’s wise or not, we have many millions of Americans who enjoy the use of both legal or illegal drugs which are addictive, including both alcohol and nicotine. Take someone who drinks alcohol but it isn’t a problem. How would you go about making sure that doesn’t become a problem?
CH: There are pretty good guidelines. Anyone under the age of 21 should not consume alcohol. That’s pretty safe to say. If someone is an adult who doesn’t have a history of alcohol use disorders themselves or a history of other addictions or any medical reason not to drink, men have recommendations for how much they can drink in a day and in a week, and there are similar recommendations for women, as well. For men, we recommend that they have no more than 4 drinks in a day, and no more than 14 drinks in a week, and with women we recommend no more than 3 drinks in a day and no more than 7 drinks in a week. That’s what’s considered safe drinking parameters.
C2ST: Without any changes in knowledge or technology, what could we do right now to improve addiction treatment or prevention?
CH: That’s a great question. As a physician, as a psychiatrist, as a prescriber of medication and proponent of evidence based counselling, I certainly put an emphasis on science, neuroscience, pharmacotherapy, and advancing research. That said, my belief is that a lot of the major gains to be made in terms of people recovering and the rates of addiction going down are going to be much more on a social basis. Increasing access to care, increasing awareness about addiction as a disease, decreasing stigma so people aren’t shunned and aren’t ashamed, and that it’s something that they recognize as something they can seek treatment for, and it not being a moral failure. These sorts of things are what make the biggest difference.
C2ST: One final, very quick question: do you have any recommendations for people who want to learn more about this? Books or articles or anything like that?
CH: The national institutes of drug abuse (NIDA; https://www.drugabuse.gov/) has a lot of stuff for the public. NIDA’s website is www.drugabuse.gov — they have a lot of stuff there. What’s called SAMHSA also does — that’s the Substance Abuse and Mental Health Services Administration (samhsa.gov). Their websites are set up in such a way that are designed for the public to access and make use of. They’re good for healthcare providers and treatment providers to access as well.
C2ST: Thank you so much for talking with me.
CH: Thank you very much for the opportunity.