Individuals struggling with addiction need a great deal of support. The families that struggle alongside them do as well. They are exposed to immense pain, grief and heartache. Loved ones of people with addiction may suffer a degree of caregiver fatigue and stress that has brought them to the end of their rope. Here are some common experiences:

• They have watched their loved one spiral into the darkness of addiction.
• They’ve argued with the addicted loved one, tried to stop them and sought help via any means possible but nothing has helped or the person relapsed repeatedly.
• In the process they’ve been drained emotionally and, often, their finances have also been drained in an effort to battle the addiction.
• They may be dealing with longtime family addiction issues with more than one relative in more than one generation affected.
• They unintentionally enable the person by giving them money, driving them to get drugs or allowing them to use addictive substances in the house, believing it will keep their loved one safer.
• They live in a state of terror that their loved one will overdose, get hurt or lose their life to addiction.

As a result of these experiences and others, families can suffer from cumulative trauma, on top of existing family trauma and personal trauma. Often, there is an intergenerational history of addiction, so there have been issues with other family members that have started to wear at the fabric of the family structure.

A colleague of mine, Clinical Strategist and Crisis Intervention Specialist Jane Eigner Mintz, MA, LPC, of Realife Intervention Solutions, explains it this way: “Family fatigue is systemic in that it has been going on for years. It has not only worn out their relationship with the individual, but it’s started to fracture marriages, deplete resources and there are usually significant legal problems.”

Many families have been beaten down by threats from loved ones, including threats of suicide and overdosing, and they are constantly pushed toward behaviors that enable the addict. “There’s a lot of poor decision-making that goes along with this and it’s based on terror,” says Eigner Mintz. “They’re terrified to do anything. They’re literally hostage to fear, feeling this is going to be on their head if something happens to the individual. That kind of manipulation happens all the time.”

It wears away at them over time until family members are as trapped in the addiction as the identified patient.

Bringing Hope to the Hopeless

For many families, a professional intervention is the only way to make progress with the addicted loved one. But by then they are so emotionally exhausted that they don’t think they have the strength to go through with it. An intervention has to be set up for the best outcome for the addict, and that also helps the family.

“Almost 100% of families say, ‘We just don’t even know if we have the energy to do this,’” says Eigner Mintz. “They have years of history, of individual attempts, group attempts, failed attempts, and by the time they get to me, usually people have had several different intervention attempts happen, so the families are very fractured. They’re feeling pretty hopeless. They’ve been burned through money and goodwill, and they’re terrified.”

However, interventionists are trained to walk into seemingly hopeless situations and mobilize families so that they are organized. The interventionist helps them send the correct messages to somebody that’s very reactive and reluctant to get into treatment. They offer professional support so that the family effort can create a turning point for the addict.

An addiction intervention is a strategy for getting families and loved ones to mobilize reluctant, resistant people out of a pattern of addiction for a few moments so they can begin treatment. Then the treatment teams take over and help the client find their own reasons for making changes in their life. The family is relieved that they’ve done everything they can do to help the addict, and they can begin the work they need to do for their own healing.

Assessing the Whole Family

It’s extremely important that the whole family is treated once the addicted person is safely in rehab. “Most families are deeply traumatized, and as a result of sustained trauma, there are fractures and fissures within the family, both with the identified patient and also within the family system,” says Eigner Mintz. “Brothers and sisters don’t speak to each other anymore. Mothers and fathers are at war with each other. It goes on and on.”

“It’s incumbent on the interventionist to make sure that everybody in the family has some kind of connection to services,” she says. Some of the following approaches help in getting family members the support and healing they need:

• Working with addiction recovery programs that have robust family programs
• Sending a family member on a brief retreat for emotional recovery
• Recommending the family get involved with Al-Anon and other support groups
• Attending family therapy to help work through trauma
• Coaching for families during and after the intervention process

A responsible, clinically driven interventionist is going to focus on the person that’s at the highest risk, which is the identified addict. They will get them into care and then turn their attention back to the family and discuss strategies for individual and collective growth.

“You have to look at the family as a group, but the family is made up of individuals,” says Eigner Mintz. “And each one of those individuals has an effect on the others. So the trick to untangling family systems is to look to see who needs what and why, and then enact a plan that’s going to set off a chain reaction.”

As a result of a raging opioid epidemic, many people have become aware of the dangers of prescription painkillers like hydrocodone (Vicodin) and oxycodone (OxyContin). But there are several other medicines commonly found in the medicine cabinet that also pose a risk of addiction for your family and anyone else who might be shopping around in your medicine cabinet. Are any of these in your medicine cabinet?

Anxiety

Benzodiazepines. These sedative-hypnotic drugs are typically prescribed for general anxiety disorder and panic disorder, as well as insomnia and epilepsy. Brand names include Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam) and Klonopin (clonazepam). They can be habit-forming with long-term use.

Sleep

Hypnotic medicines. Also known as soporifics, these are used to treat sleeping problems such as insomnia. Brand names include Ambien (zolpidem), Sonata (zaleplon), Lunesta (eszopiclone), Rozerem (ramelteon) and Restoril (temazepam). These medicines can be habit-forming but they are not as addictive as benzodiazepines, which are also sometimes prescribed as a sleep aid.

Pain

Opiates. These narcotics are used for their analgesic effect (for pain), as well as for their sedative, tranquilizing and soporific properties. They change the way the nervous system experiences pain. Prescribed opiates are controlled substances that can be addictive and should be used as sparingly as possible. Research shows that prescription opiate abuse can lead to heroin use, as well as the street drug version of fentanyl, which has an extremely high incidence of overdose. These medications are known to cause respiratory distress when taken in high doses or when combined with certain other substances, especially alcohol. There are many varieties of prescription painkillers, including:

• Codeine, which is used for pain and to treat coughs
• Oxycodone (OxyContin) as well as the shorter acting forms like Percocet and Percodan
• Vicodin, Lortab and Lorcet which contain a mix of hydrocodone and the non-opioid pain reliever acetaminophen
• Demerol (meperidine) in pill form
• Fentanyl transdermal patches to relieve severe pain, which may be prescribed for people who cannot be treated with other medications
• Morphine, which is sometimes administered post-surgically and prescribed for cancer patients
• Methadone for chronic pain

Musculoskeletal Conditions

Muscle relaxants. These are prescribed for muscle spasms and acute musculoskeletal conditions such as severe back pain. They have sedative and relaxant properties that work on the central nervous system. They are meant for short-term use and are often recommended along with physical therapy. Brand names include Rodaxin (methocarbamol), Soma (carisoprodol), Flexeril (cyclobenzaprine) and Lorzone (chlorzoxazone).

Seizures

Gabapentin. This is a medication with sedating effects that is approved for seizures and shingles, as well as nerve pain. Historically it was thought to have low abuse potential, but recent research suggests more significant addiction risk. Combined with other drugs, such as marijuana, cocaine or amphetamines, it can be dangerous. Brand names include Neurontin, Gralise and Horizant.

Stimulants

ADHD drugs. In recent years there has been a proliferation of prescriptions for attention deficit hyperactivity disorder (ADHD) medication for children and adults. While these medications can help people legitimately diagnosed with ADHD, they are also used by people to study and get an edge on the competition in the workplace much in the way steroids have been used in sports. Some people also use these drugs to get high, so the abuse potential is significant. These medicines are well-known by their brand names:

• Ritalin – Largely prescribed for children and young adults with attention deficits and behavioral issues, this medication is also known as methylphenidate. The challenge is many of the young people who are prescribed Ritalin don’t like the way it makes them feel so they’re unlikely to abuse it themselves but they end up selling it to young people who want the amphetamine-like high.

• Adderall – This is increasingly prescribed for adult ADHD and is also used for narcolepsy, which affects an estimated 1 in every 2,000 people in the U.S. Adderall is a stimulant that contains amphetamine and dextroamphetamine. It can improve attention, focus, and organization and listening skills. The problem is that people without ADHD obtain prescriptions or get them illegally, without recognizing that misuse can lead to addiction.

Antihistamines

Dextromethorphan. This is an ingredient in over-the-counter allergy or cold treatments or cough syrups. With street names like DXM, CCC, Triple C, Skittles, Robo and Poor Man’s PC, it is sometimes used in combination with pseudoephedrine. It’s a high school favorite because teens can find it in the family medicine cabinet or in a pharmacy.

Depression

Antidepressants. Medications to treat depression have low potential for abuse, but consumers should be aware of potentially dangerous drug interactions. For example, taking them with opiates, sedative-hypnotics, benzodiazepines or alcohol can be harmful. A number of antidepressants slow metabolism so if someone takes one of these other medicines it could significantly increase the risk of overdose. In addition, benzodiazepines can reduce the effects of antidepressants.

How to Safeguard Your Medicine Cabinet

• Understand the dangers. Sometimes an individual drug is not the problem. The danger often lies in the amount taken or the combinations with other drugs. For example, many of the opioid overdoses we are seeing today are related to combining opioids with benzodiazepines. Take medication as prescribed by your doctor and ask questions to be sure you understand if you truly need it and how to take it safely.

• Take inventory. Look at the medicines you have on hand. Are they still needed? Studies show that most people keep unused medication lying around and about 20% share leftover pills with friends and family. If there is a potentially dangerous drug in your cabinet that has expired or you no longer need, dispose of it properly or find a drug disposal program in your community.

• Remove temptation. If there is someone in your household or that visits your home who may be at risk for medication misuse, lock potentially addictive medicines in a secure location.

Doctors overprescribe potentially addictive medications, but patients play a part too. About half of people who abuse prescription painkillers get them from a friend or family member. Taking steps to safeguard your medicine cabinet can help ensure that you’re part of the solution to our nation’s prescription drug addiction epidemic.

Nothing shakes us to the core like a school shooting. More often than not, follow-up investigations show that the person who pulled the trigger was suffering from a mental illness. But the narrative that often follows in media is that all mentally ill people are dangerous and capable of causing the violent deaths of innocent people.

This is simply not accurate. It’s like lumping together your grandmother who is mildly depressed, a 5-year-old with ADHD and Charles Manson. Mental illness is not a one-size-fits-all label. Yet when a tragedy the magnitude of a school shooting happens, there is a tendency to cast mental illness as the villain when, in fact, violence is not a characteristic of the vast majority of people with mental disorders.

More Likely to Cause Self-Harm

A bigger problem among people with mental illness is violence towards themselves. It’s far more common for them to commit suicide than to harm another person.

Other common consequences of chronic mental illness are poverty, homelessness and criminal involvement due to drug or alcohol use. It’s not typically the kind of violence that has sadly been witnessed in school shootings. However, when these incidents occur, it’s often at the hands of people who have longstanding mental disorders. Violence then becomes linked as a part of mental illness, which adds to the stigma that mentally ill people face and that often prevents them from seeking help.

We Can’t Predict Violence in Advance

After a school shooting or other act of violence, there is often discussion about how people may have missed the signs that a person was potentially dangerous. They wonder how a violent attack was not predicted, especially when classmates, teachers and police may have had problematic interactions with the person responsible for mass violence before the fact.

Even with the best police work and awareness of mental disorders, identifying someone who may perpetrate such a crime is like searching for a needle in a haystack. A psychiatric diagnosis cannot predict a gun crime. The single best predictor of violence is someone who says, “I’ve bought a gun and I’m going to do something violent.” Beyond that, it is difficult to predict for the following reasons:

1. There is no accurate test. Even with all the psychological testing at our disposal and research into the psychological state of people who carry out mass violence, there is no test that predicts that someone will purchase weapons and show up at a school and begin shooting. You can’t pinpoint where or when, or if, a person will act out in that way.
2. The pool of people is too large. Nearly one in five Americans, or 43.8 million people, has a mental illness in a given year, but having a disorder is not predictive of violence. Looking under the generalized umbrella of people with mental disorders would focus on a group much larger than the group likely to ever become violent.
3. Childhood trauma is not always an indicator. While people involved in shootings may have had troubled pasts, not everyone becomes mentally ill or violent from early trauma. There are many children who have been abused but do not develop post-traumatic stress disorder, addiction, personality disorders, depression, bipolar disorder or schizophrenia. Even though they have the risk of that exposure, they don’t have the susceptibility or there may have been other protective factors that kept them from developing those issues.
4. Not everyone who meets the profile acts on violent urges. Many of the characteristics associated with people who subsequently become violent are seen in a large group of people with mental disorders, and probably a substantial portion of the general population. So these characteristics are not accurate predictors of violence. People who have been bullied, publicly disruptive or have shown violent tendencies toward people or animals may be troubled, but they are not necessarily going to carry out a violent act of this magnitude.
5. Schizophrenia does not always cause violence. It is especially damaging to assume everyone with schizophrenia is a danger. The proportion of violent crimes attributable to schizophrenia is consistently a small fraction of all the crimes committed. This means that the vast majority of crimes aren’t going to be explained by a serious mental disorder, and that finding the person who is going to commit a violent crime is going to be very difficult.

Universal Plans for School Safety and Mental Illness

There was a time in history when blood was collected without the use of latex gloves and the used needles were tossed into a trash bin. This was before we knew how dangerous it could be if someone’s disease-infected blood was transferred onto the person drawing the blood. Once the dangers were identified, a universal system for blood collection was put into place and it is followed around the world.

This is what is needed in this new age of school violence. Now that we know the danger to students and staff, schools need to develop a universal way of preventing violence; for example, through advances in security systems and designs that can keep out intruders.

Mental illness needs a universal system too – not because of a threat of violence, but because we know all the problems that can occur for individuals, families and communities when mental health goes undiagnosed and untreated. From homelessness and unemployment to medical and substance abuse issues, we know the devastation mental illness causes but we don’t put enough resources into treating it.

School shootings are tragedies on so many levels, but mental illness is not the culprit for every problem in society. Blaming mental illness alone is going to sweep many more people into the fold than should be, and won’t get us closer to the real roots of the problem.

I’ve been involved in addiction medicine for 40 years and have seen many innovations, but mindfulness remains one of my favorite tools for helping people with addiction as well as their families. It might surprise people to learn that one of the greatest sources of mindful inspiration may already live in your household ― your dog.

Our Bassett Hound, Charlie, has been in our family for 11 years and he continues to inspire us. I like to call Charlie “The Mindfulness Bassett,” but any breed can teach valuable lessons. Noticing their approach to everyday living can have a profound effect if you look at problems the way a dog may view them. Here are some of the lessons families of addicts can learn from our canine companions:

1. Take care of yourself.

Dogs have strong survival instincts. They need their human family to do the things they cannot, like open food containers and refill the water dish, but they fend for themselves and don’t hesitate to defend their turf and beloved owners. Family members often focus so much attention on their addicted loved one that they forget to set boundaries and take care of their own physical, emotional and financial needs. Dogs teach us that self-care is key to survival.

2. Live in the moment.

Dogs live only in the present. People who live in addicted families are often held back by unresolved trauma. They may ruminate and get stuck in the past, try to self-soothe to avoid pain in the present, or worry about the future. One man whose alcoholic father had abused him got triggered at family dinners. He’d overeat and drink heavily to “survive” because he felt like he was being pulled back into his childhood. Mindfulness of the present moment helped him realize he was no longer that child but an adult who could walk into another room and enjoy himself talking with other family members.

3. Learn to let go.

While they can be traumatized by abuse, dogs generally don’t remember the time they chewed your favorite shoe and made you mad. And they don’t carry it around as a secret shame. They are masters of letting go. Given all the turmoil they’re facing, families of addicted loved ones can become overwhelmed by negative emotions, but research shows that learning to let go of the smaller stuff and release negative thoughts can help you come back to difficult situations with fresh eyes.

4. Say what’s on your mind.

Dogs bark their heads off when someone disrespects their turf or they need to get your attention. And if you forget to feed them or put them in a room and close the door, you may hear loud whining. Dogs let you know their needs and they don’t politely decline to speak up just because other people don’t want to hear. If you’ve kept things bottled inside for fear of upsetting others, try to discover your voice and use your bark when needed.

5. Rest up.

Dogs are master sleepers. There can be all sorts of activity around them, but they’ll plop down and rest if needed. When was the last time you took a nap, or put your feet up and sipped tea? Living with addiction puts people on high alert and stresses their nervous system. Dogs are on high alert too, and they’re built to be alert to the smallest noise, but they rest in between. Practicing mindfulness can help you sleep and improve the quality of your rest, which can enhance your ability to cope.

6. Stop and smell the flowers.

When dogs go for a walk they enjoy the smorgasbord of things to sniff out in the world. And they want to stop and smell everything! How often do you stop and smell the aroma of coffee brewing in the morning or the scent of food before you eat it? Many of us, and especially families of addicts, spend a lot of time rushing from one moment to the next, dealing with one crisis after another. Addiction in the family can lead to compassion fatigue, but if you blend moments to meditate, or just breathe, you can counteract some of the stress. Whenever things get overwhelming, go for a mindful walk with your dog. Look at the flowers and things around you. You may notice beauty despite the difficulties you’re facing and feel a greater connection to the world.

7. Find the positive.

Left alone by day dogs may get lonely, but when you come to the door they jump and yelp with joy. The tail wags and the long day is suddenly behind them. Life is filled with challenges and dealing with an addicted family member makes it even more so. That’s why it’s so important to embrace those moments that are joyful and find more of them every day. Like a dog that delights in discovering a ball or a bone in the backyard, find the things that give you joy.

8. Love unconditionally.

It can be difficult to unconditionally love someone who has hurt you or brought destruction to your family. Sometimes it is even harder to love ourselves. But this is something dogs do brilliantly. They love and are loyal to us no matter what. They accept us for all our imperfections. If you can find it in your heart to love your addicted loved one without condition, recognizing that they are battling a disease, it will help your healing as well as theirs.

Mindfulness is a powerful tool for anyone, especially families facing a crisis like addiction. To learn more about starting a mindfulness practice, check out these resources:

Mindful Magazine

The Mindfulness Summit

All It Takes Is Ten Mindful Minutes

Mindfulness-Based Stress Reduction Course

In recent weeks the government has taken positive actions to combat the opioid epidemic. The President announced steps to prevent opioid addiction and also to appropriately treat the 3.3 million Americans who already have opiate addiction. The Centers for Disease Control and Prevention (CDC) released new opioid prescribing guidelines based on studies showing opioid painkillers work best for relieving cancer-related pain and acute pain during the first few days after an injury or a surgical procedure. Beyond that, opioid medications are not necessarily more effective at relieving pain than non-addictive or non-medication alternatives.

It will be impossible to stop the opioid crisis without assistance from government, and I hope the President’s passion for this cause galvanizes a national effort that turns the tide. However, much of the power to reduce the number of people becoming addicted and increase the number of people getting help exists within the family.

We know that the initial call to an addiction treatment center often comes from the family. We also know that strong family support helps keep a person in treatment for the duration of their rehab program, giving them a better chance for recovery.

The Best Position to Help

Part of our effort to combat the opioid epidemic should be to help people understand what they can do within their own families to help prevent addiction. Family members have a role to play in making sure loved ones don’t fall into addiction and, if they do, family members are often in the best position to recognize it and do something about it. Here are five things families can do to help:

#1 Educate Yourself and Your Loved Ones About Addiction

Get educated about the biochemical processes of addiction and how physical dependency develops and can escalate to addiction. Talk about the dangers of prescription painkillers as well as effective pain management alternatives.

To the greatest extent possible, keep prescription painkillers out of the house and properly dispose of any unused medication. Studies show that 53% of opioid users obtain the medication from friends, family or the medicine cabinet, not a doctor. Many people addicted to opiates like heroin and fentanyl got their first exposure via prescription opioids found in the home medicine cabinet.

#2 Learn How to Spot Opioid Addiction

Learn about the signs of opiate addiction so you know when to step in and help. These include:

• Changes in habits such as poor hygiene or withdrawal from favorite social activities
• Increased drowsiness or sedation during waking hours (nodding off)
• Elated mood (high) and/or changing moods
• Confusion
• Constricted (small) pupils
• Constipation
• Slowed breathing (inhibited respiration is often the cause of opioid overdose)
• Withdrawal symptoms when a prescription runs out, such as increased pain and/or flu-like symptoms such as headache, nausea/vomiting, diarrhea, sweating, fatigue, anxiety and insomnia

#3 Take Action as Early as Possible

If you see signs of addiction in a loved one, don’t wait to do something. It is time to slay the myth that an addict must hit “rock bottom” before getting help. Most people with addiction are in denial, and it often takes some time in treatment to recognize that they have a problem.

The family can help get the addict into treatment and keep them on the recovery path long-term. Loved ones can:

• Have an honest conversation with the addicted person about their drug use and how it is affecting them and the rest of the family.
• Help them choose an addiction treatment program, and be ready to do some footwork. Since an addicted person is typically in denial or not in a state of mind to explore treatment options, facilitate the process by researching programs, finding out if they accept your insurance plan and getting them safely into treatment.
• Once a loved one is in treatment, participate in any family days or family-focused sessions the program offers to show your support and willingness to be involved in the healing process.
• Do what you can to facilitate your loved one’s adherence to their aftercare plan, including long-term therapy or pursuing resources that can help resolve financial and employment problems.

#4 Be an Ongoing Source of Support

A common misconception is that when a person completes an addiction treatment program they are cured. The truth is that recovery is a long, hard road, and rehab is the beginning of the process. You can participate in treatment and support your loved one through rehab, but the work continues after they leave the structure of the rehab center. This is when they need additional support from family and a sober community to help them cope with triggers for relapse and learn how to effectively manage pain without prescription painkillers.

It is estimated that 62% of the 10.6 million Americans who report that they overused or misused prescription opioids in the past year were taking the medication to relieve physical pain. Family members can make life easier for a loved one who lives with pain by asking how they can help — perhaps doing the activities that exacerbate pain or injury, such as grocery shopping, housecleaning and other physical chores, and offering to take them to support group meetings and medical appointments.

Family members can join Nar-Anon and similar support programs for families of addicts to learn how to support the recovery process, avoid triggers, cope with relapses and practice good self-care.

#5 Help Prevent Other Families From Suffering

Whenever possible, be open about your family’s struggles with addiction. Sharing your story helps reduce stigma around this disease and may help someone else who is struggling in silence. Addiction can happen to anyone and in any family, even in families that don’t have a history of addiction or condone drug use. Telling others about how your family member became addicted and recovered lets others know they aren’t alone and might inspire them to get help.

So, while federal agencies and the White House focus on stopping the opioid epidemic at the national level, families can focus on tackling it at the grassroots level, beginning at home.

Childhood trauma has lasting effects that can impact us throughout adulthood and can even be transferred to our children. Exposure to various forms of abuse, violence, loss or neglect early in life has been linked to higher risks for addiction, depression, anxiety, eating disorders and other mental health conditions.

Treatment for trauma and related disorders sometimes includes getting in touch with your “wounded inner child.” Simply put, your wounded inner child is any emotional and psychological baggage you have carried from early childhood that leads to emotional or psychological problems as an adult. The term “inner child” has been popularized by writers in the self-help field, most notably John Bradshaw, who wrote the best-selling book Homecoming: Reclaiming and Championing Your Inner Child, among others.

How do you know if your adult problems are related to wounds you have carried with you since childhood? The “wounded child” archetype is usually characterized by a person who, as an adult, repeats their childhood patterns of negative experiences or dysfunctional behaviors they learned from adults in their lives. For example, a little girl who watched her mother get abused by her father may repeatedly attract abusive men as an adult.

Therapies for Recovering From Childhood Trauma

Adults who struggle with addictions and mental health issues stemming from childhood adversity can heal those wounds. There are a number of therapies that help people recognize negative patterns they learned in childhood and “re-parent” their inner child, including:

#1 Chair Work

Using an experiential approach called “the empty chair technique,” a therapist will ask you to sit across from an empty chair and imagine that someone (such as a parent or other relative) is sitting in the chair. You will have a dialogue with that “person,” telling them your feelings and thoughts — perhaps explaining what you needed from them (but didn’t get) in childhood. You might also be asked to reverse roles and assume the role of the metaphorical person in the empty chair.

Chair work can be particularly useful when important figures from the past can’t or won’t communicate with you or participate in therapy. Some of the goals of this technique are to get you in touch with feelings about the past and help you reconnect with parts of yourself that you may have denied or tried to minimize through substance abuse or other destructive behaviors. As you reconnect with feelings and memories, you also become aware of how these are linked to your current behaviors and what you can do to change them.

#2 Schema Therapy

Schema therapy can be particularly helpful for people who are challenged by social situations and relationships and/or have poor coping skills stemming from childhood trauma. Early maladaptive schemas often develop in children raised in hostile or dysfunctional environments, and these schemas — problematic coping mechanisms, memories, emotions or thoughts about oneself and others — can continue as dysfunctional responses and behaviors into adulthood.

Schema therapy is an integrative approach that draws on cognitive behavioral therapy and attachment theory, among others. Studies show that schema therapy has a high rate of success in helping to heal problems that stem from childhood experiences. Key to its success is the therapist’s use of re-parenting techniques to reach the “vulnerable child” and meet the client’s core emotional needs.

Through a variety of approaches that might include schema dialogues, diaries, role plays and skills training, schema therapy teaches you how to change the way you view yourself and others, and helps you overcome avoidance or other self-defeating responses to people and situations.

#3 EMDR

Eye Movement Desensitization and Reprocessing, or EMDR, is an information-processing technique that can help you ease distress caused by exposure to traumatic events. EMDR therapy helps diminish the effects of psychological trauma that may manifest as intrusive thoughts, flashbacks, anxiety, panic attacks, overwhelming emotions and fear.

EMDR involves tracking a stimulus with your eyes, such as the therapist’s finger movements or other sensory cues, while simultaneously focusing inward on a negative mental image, feeling, thought or physical sensation. This dual processing technique engages the left and right sides of your brain to decondition your responses to trauma. The rapid eye movements and the focus on sensory stimuli help you retrieve, process and resolve past experiences that are contributing to your current challenges.

Through these therapies and other approaches, you can find healthy ways to fulfill core needs that were unmet in childhood and keep old wounds from diminishing your quality of life today.

The human brain is constantly changing. Our gray matter is responsive to music, mayhem and medicine, adapting with exposure to these and other stimuli, including psychotherapy. Science has shown that many forms of psychotherapy, whether used in conjunction with medications or without, can actually cause physiological changes in the brain that result in better treatment outcomes for people with trauma, addiction and other mental health disorders.

Through functional neuroimaging scans, researchers involved in more than 20 scientific studies have provided evidence of structural and functional changes in the brains of patients receiving psychotherapy for conditions such as depression and anxiety. These studies show physical changes in the brain that correlate to noticeable improvements for the patient.

Additional research studies have revealed that medications and substances of abuse also cause changes within the brain, altering the wiring within its reward center, thereby impacting levels of neurotransmitters like dopamine and serotonin that are sent along the nerve pathways in the body. Studies also reveal that after cessation of medication or substance use, and with sustained abstinence supported by therapy, a person’s brain structures can eventually return to a normal state. When a client who has given up drugs in treatment starts to feel less anxious or sleeps better, it is the brain healing.

All of these studies illustrate the amazing plasticity of the human brain — a plasticity that  makes it responsive not just to the substances people abuse or the medications they take, but also to psychotherapies that modify how we think and feel about things and how we behave.

Your Brain on Psychotherapy

Psychotherapy can help people with mental health disorders change the thoughts and actions that contribute to their symptoms — and actually alter the brain areas involved in controlling related emotions and behaviors — so they can stop being hindered by their illness and begin enjoying more of life’s experiences. Here are a few examples of evidence-based therapies that can have a significant impact on common mental health disorders:

Depression

Psychodynamic Therapy (PDT) – When undertaken for 12 months or more, PDT has been shown to increase production levels of the feel-good neurotransmitters serotonin and dopamine within the midbrain, helping improve symptoms for patients with atypical depression. While PDT has not proven to be as effective in patients with major depressive disorder, research indicates that relapse rates among all depression patients treated with some type of psychotherapy are generally lower than among those treated with antidepressants alone.

How PDT Works: Psychodynamic therapy involves action. Rather than simply talking about feelings and the reasons behind those feelings, in PDT patients work on why they do things. The goal of PDT is to uncover the unconscious motivations behind our actions, with the premise that doing comes first, and if we change what we do in certain situations, we can change how we think and feel about them.

Interpersonal Therapy (IPT) – In a study conducted at Christian-Albrechts University in Kiel, Germany, researchers used brain scanning to track brain changes caused by the use of interpersonal psychotherapy in depressed patients. The findings showed that IPT was associated with changes at the brain’s cellular level, increasing the production of a brain protein involved in creating neural pathways.

How IPT Works: This therapy focuses primarily on a client’s interpersonal relationships. The approach tackles the stress the client is under, the resources the client brings to the problem, and the social context of the problem. IPT is generally used over shorter time frames, typically three or four months.

Anxiety

Cognitive Behavioral Therapy (CBT) – This widely used therapy can bring relief to people with anxiety by focusing on how we think and act, with the premise that if we change our thoughts about certain situations that challenge us, we can change the way we feel and behave around them.

Research findings from a collaborative study in Switzerland shed light on why CBT may be particularly helpful in addressing anxiety issues. It can change key brain structures involved in self-control and emotion regulation. For example, in people with social anxiety disorder, regulation of excessive anxiety by frontal and lateral brain areas is impaired. Evidence shows that putting the emotion-regulating methods of CBT into practice restores the balance between cortical and subcortical brain areas, diminishing anxious responses to previously problematic stimuli.

CBT, which includes subtypes such as exposure therapy and acceptance and commitment therapy, also is used to help resolve depression, chronic pain, eating disorders, anger issues, low self-esteem and addiction.

How CBT Works: In cognitive behavioral therapy, clients learn to apply new strategies for dealing with anxiety in various situations through the use of role plays, video recordings and observations that promote self-awareness, helping them see where they can develop new views of a situation, and new actions to take within it.

Emotional Trauma

Eye Movement Desensitization and Reprocessing (EMDR) – This approach uses a set of well-researched, standardized protocols, integrating elements from several other treatment approaches. EMDR therapy is effective for treating trauma because it helps reduce flashbacks and intrusive thoughts. Some clients report improvement after just a few sessions.

How EMDR Works: The goal of EMDR is to process traumatic experiences in new, healthy ways. This “reprocessing” happens while the client focuses on a light or other object with their eyes. EMDR usually occurs in several phases, during which the client is eased into a learning state that allows them to revisit traumatic experiences, learn only what was useful from them, and discard the rest. Old memories are processed and stored in new ways with enhanced perspective.

Studies that track clients before and after receiving EMDR therapy have demonstrated changes in the hippocampus, indicating alterations in memory storage. EEG studies have demonstrated enhanced function in several areas of the brain after EMDR and decreased activation in other areas, indicating desensitization and inhibition of trauma responses.

Borderline Personality Disorder

Transference-Focused Psychotherapy (TFP) – This form of psychodynamic treatment is designed especially for patients with borderline personality disorder (BPD), a disorder characterized by intense emotional reactivity. TFP is distinguished from other treatments for BPD by its premise that psychological structure underlies the symptoms of the disorder. Treatment focuses on a person’s unique psychological make-up, and their ways of experiencing self, others and the environment.

How TFP Works: Transference is when someone transfers feelings about one person to another. TFP works by helping people navigate these feelings and understand their reactivity (how their feelings about one person or situation don’t necessarily apply to another).

A small study of 10 women with BPD who received TFP treatment showed increased activation in brain regions associated with cognitive control and decreased activation in regions of the brain associated with emotional reactivity.

Dialectical Behavior Therapy (DBT) – This approach incorporates tools from cognitive behavioral therapy, combining them with Eastern concepts of acceptance and mindfulness, to treat borderline personality disorder (BPD) and a variety of other mental health disorders.

How DBT Works: The combined tools are used in dialectical behavior therapy to teach people with BPD emotion-regulation strategies to improve self-representation and emotional reactivity.

In a 12-month study of people with BPD, brain scanning was used to track the physiological results of participants who were receiving DBT treatment. Brain scans of the participants who received therapy showed decreased activation of the amygdala, a region of the brain that is involved in our memory of emotions, particularly fear, and our emotional behavior. The patients who had received therapy also demonstrated improved overall emotion regulation.

Changes in Gray Matter Lead to Changes in Outlook, Behavior

While it may be hard to believe that psychotherapy is capable of producing physical brain changes that can be as effective as taking medication, the proof is in the gray matter. Scientists have demonstrated that brain changes resulting from psychotherapy are enduring, and crucial for long-term recovery from mental illness.

These findings challenge a longstanding “brain bias” that exists in the field of psychiatry — the view that the brain’s physical structure is unchanging and should be the primary focus of treatment, while psychological factors are secondary. Based on this bias, some will argue that medications provide the best results. But the latest scientific revelations indicate that, for those willing to invest time in therapy, the coping strategies and behavioral tools they learn will help manage life’s slings and arrows in the short term, while the brain’s circuitry works to catch up and affect lasting change in the long term.

The take-away message? Even if you are already taking medication that helps manage your symptoms, you can complement the medicine’s therapeutic benefits with psychotherapy. Find the psychotherapy that works for you and stick with it — your brain will adapt in ways that will enhance your healing, making you feel even better over time.

Over the past few years, media reports have sounded the alarm that an opioid epidemic is sweeping the country, killing thousands of our citizens. And now new research findings reveal that the problem may be even more widespread than we had thought.

In 2015 it was reported that 33,000 people died from an opioid overdose — a historic high. However, researchers now tell us that number should have been even higher, as it is likely that thousands more opioid overdose cases went unreported due to problems with how the “cause of death” is reported in the U.S.

A new study from the U.S. Centers for Disease Control and Prevention (CDC) uncovered the fact that toxic levels of opioids had contributed to numerous deaths where infectious diseases like pneumonia were listed as the only cause of death. The misreporting is partly due to a lack of codes available for listing opioids as a causal factor on death records from state to state. The coding issue and other problems in the reporting system limit coroners from accurately recording cause-of-death details — a procedural hitch that spans the nation.

This discovery by CDC researchers indicates that the opioid epidemic is even more dire than we realized.

Drastic situations require drastic measures. A new federally backed program may give us the opportunity we need to put those measures in place.

Help From High Places: Working Together Nationwide to Save Lives

Through the Department of Health and Human Services (HHS), the Trump Administration recently issued a press release announcing it had established the President’s Commission on Combating Drug Addiction and the Opioid Crisis. With money made available through the 21st Century Cures Act, which President Obama signed in December 2016, the commission is allocating federal funding to all 50 states and the U.S. territories to ramp up addiction prevention, treatment and recovery services.

Faulty cause-of-death reporting systems notwithstanding, funding amounts for these grants were based on each state’s rate of overdose deaths and unmet need for opioid addiction treatment. Administered by the Substance Abuse and Mental Health Services Administration, every state and territory will receive funding, with the largest grants going to California ($44,749,771), Texas ($27,362,357), Florida ($27,150,403), Pennsylvania ($26,507,559), Ohio ($26,060,502), New York ($25,260,676), Michigan ($16,372,680) and North Carolina ($15,586,724).

HHS Secretary Tom Price, MD, reports that the HHS is working to ensure the funds and any new policies will support “clinically sound, effective and efficient programs.” The HHS aims to work with states to improve strategies that strengthen public health surveillance, advance the practice of pain management, improve access to treatment and recovery services, target availability and distribution of overdose-reversing drugs, and support research. In a letter to state governors, Dr. Price made an appeal for assistance in identifying best practices and key strategies that will help stem this public health crisis.

Based on recent information on the opioid crisis and my own experience in the addiction field, I propose several practices and strategies that I believe will help.

9 Things We Need to Do Now to End the Opioid Epidemic.

#1 Write only short-term prescriptions. It should be a medical standard nationwide to prescribe opioid painkillers for only three to seven days or fewer. Short-course treatment helps prevent addiction in the person who receives the pain pill prescription, and also keeps any oversupply out of home medicine cabinets — which is where kids/teens are finding them. Most youngsters with addiction say they were first introduced to opioids at home. Studies show that opioid pain pills are often the gateway to heroin addiction. Many heroin addicts have reported that once the home supply of opioid pain pills ran out and they couldn’t get more prescriptions, they sought heroin to feed their addiction to an opiate-fueled high.

#2 Prescribe only low doses, and establish a standard maximum dose for all patients. Since we know that patients receiving higher-dose prescriptions can become dependent in only two days, it makes sense to lower the dosing guidelines and cap the maximum dose … and always prescribe the lowest possible dose for pain management. In 2016, the CDC established new opioid prescription guidelines, which provide a safer template for prescribing doctors to follow.

#3 Require that all doctors check a prescription monitoring database to ensure that patients don’t doctor-shop for opioids. New Jersey and 28 other states have established laws that require doctors to consult an electronic state-managed prescription drug monitoring program (PDMP) before prescribing opioid painkillers or other controlled substances. Not all states have such laws, and sharing this information among states can be problematic. Let’s establish these laws in every state and optimize doctor access to prescription databases so the information can be shared among prescribers in different states, enabling them to grab nationwide information more efficiently.

#4 Choose alternative pain medications in every case possible. This should be a required first step before prescribing opioid pain medications. The CDC stipulates that non-opioid treatments are preferred for managing chronic pain, and opioids should be used only when the benefits outweigh the risks. Non-opioid alternatives should always be the first choice to avoid contributing to addiction — even short-acting prescription opioids such as oxycodone and hydrocodone were involved in 24% of all drug overdoses in 2015.

#5 Track and record cause of death data more rigorously. An Unexplained Death surveillance system (UNEX) was rolled out by the CDC in 1995 for use in all states, but only Minnesota maintains it. Intended to help identify cases where there is no clear explanation for death and where more testing may be warranted, UNEX needs to be revived and updated in each state so we can more closely track deaths in which drugs played a role. Further, we need to expand the cause-of-death codes for use on death certificates so that when coroners detect elevated levels of opioids, they can list them as potential contributing factors in death records.

#6 Monitor patients who receive opioid medications throughout the course of treatment (say, three to seven days maximum) via follow-up. Once a short course of opioids is completed, transition these patients to non-opioid pain medication, perhaps combined with another therapy.

#7 Alert the medical community about the addiction risks associated with opioid prescriptions. Disseminate clearer information about opioid pain medication/narcotics to all physicians, healthcare personnel and pharmacists. It has taken recent studies and countless unnecessary deaths to give us a true understanding of how addictive and harmful these medications are, and also to reveal how frequently, and even needlessly, doctors across the U.S. have been writing prescriptions for these drugs. This isn’t necessarily an issue of irresponsibility — much of the problem has been due to a lack of awareness and time to thoroughly weigh all the considerations. We need to get information to the medical community more efficiently, and facilitate ways for doctors and pharmacists to easily share information with patients. Simplified advisories would be particularly useful in clinic settings and big box retail pharmacies where people are rushed and pressed for time. There have to be educational signposts in place to help ensure that patients see, understand, and heed the warnings.

#8 Educate the public — initiate a national public awareness campaign that includes TV, radio, print messages and signage. Did you know that more people die from drug overdoses than from guns or car accidents? In fact, more people die from drug overdoses than from AIDS. This holds true even at the peak of the AIDS epidemic in 1995 when 43,115 people in the United States died from the disease. Compare that to 2015 when 52,404 people lost their lives to drug overdoses with at least 63% of those deaths involving an opioid. Educational messages must also shatter stereotypes about drug addicts. The public needs to understand that a drug addict is not just that poor guy sleeping on the street but also the well-to-do adolescent shooting up heroin in his bedroom. Statistics show that today’s drug addict is often a white, middle-class professional living in the suburbs.

#9 Change public discourse to bring more people to addiction treatment. We need to change how we talk about drug addiction — in the media, in our schools, at home and in the doctor’s office. Unless we change how we discuss drug addiction, people who develop drug dependencies will continue to feel shame, hide their addiction and avoid treatment. We must make it clear that addiction is not a moral choice. It is a disease.

It is going to take a concerted effort, but if every state works to improve each of these areas, we can turn things around.

When you think of a drug overdose victim, chances are you think of someone inexperienced with drug use who takes more than they can handle, or a person who unknowingly takes a purer strain of drug than they’re used to. Those assumptions, however, aren’t reflected in current U.S. statistics. So what is an accurate profile of a drug overdose victim?

WHO: Statistics show that the people most at risk of drug overdose are people you wouldn’t necessarily think of as drug addicts — suburban, middle-aged white men, according to a 2014 study. Although many people picture the young being hardest hit, the Centers for Disease Control and Prevention (CDC) reports that in 2015 alone, the highest death rate from drug overdose occurred in people aged 45 to 54.

WHAT: What drugs are people in the highest risk groups taking? In a word, painkillers. Prescription opioids like hydrocodone (Vicodin, Lortab) and oxycodone (OxyContin) were responsible for 24% of drug-related deaths in 2015. According to the Office of the Surgeon General, 44% of Americans say they personally know someone who is or was addicted to prescription painkillers, and 78 Americans die every day from an opioid overdose. Prescriptions for opioid medications have quadrupled since 1999.

But the problem doesn’t stop with prescription painkillers. Heroin is another drug contributing to the alarming rise in overdose deaths. In 2015, heroin was responsible for 25% of drug-related deaths. Heroin overdose deaths tripled between 2010 and 2015. The highest recorded death rate from drug overdose in the U.S. occurred in 2014, when there were 47,055 drug overdose deaths, including 28,647 people who died from an overdose involving either a prescription painkiller or heroin.

Trailing close behind heroin and pain pills, at an 18% overdose death rate, are semisynthetic opioids such as fentanyl. Typically used for sedation during medical procedures and to treat cancer pain when other painkillers have failed to provide relief, fentanyl is 50 times stronger than heroin. For illicit use, fentanyl is regularly mixed into other drugs such as heroin and cocaine, often without the user’s knowledge, making it even more dangerous.

WHEN: Many users don’t realize that once they achieve a period of abstinence, either through a drug rehab program or on their own, they are at greatest risk for drug overdose. When they haven’t been using the drug regularly their tolerance drops. If they relapse (as about half of addicts do) and return to their usual dose of the drug, they are at grave risk of overdose.

There is also a risk of overdose when people mix drugs. For example, if a person takes one form of an opiate (such as a pain pill) and within 24 hours takes another type of opiate (such as heroin), they increase the opiate’s effect in their body and, thus, their risk of overdose.

WHERE: Studies also reveal surprising information about where drug overdoses are most likely to take place. A growing number of drug overdoses are occurring not in low-economy urban areas, but in suburban and non-urban settings, and often in affluent neighborhoods. Some of the states with the highest numbers of drug overdose deaths in recent years are New Hampshire, Ohio, West Virginia and Kentucky.

WHY: Addiction to opioid painkiller medications can develop even when people are using them for legitimate medical reasons. In fact, nearly one in four patients receiving long-term opioid pain therapy in a health care setting struggles with addiction. People who struggle with underlying depression, anxiety, trauma or other issues may find that the medication they take for physical pain also helps them cope with their emotional pain. This can contribute to addiction and lead to further problems. For example, since heroin is cheaper and easier to get than prescription opioids, many painkiller addicts turn to heroin when pain pills become difficult to acquire.

Stemming the Tide of Drug Overdose

In an effort to raise public awareness about opioid addiction, the Surgeon General has launched a “Turn the Tide” campaign advising concerned Americans to take active measures to help people in their communities who are struggling with addiction. Some of these include:

• Write to local health care providers encouraging them to treat their patients’ pain appropriately
• Talk to community leaders about the practices that are most effective and the challenges that remain
• Inform policy makers, educators, law enforcement officers and others to help change how they think about substance use disorders and addiction

These measures can help address the problem at the community level, but it is also important to take action at the individual level. If you are seeking medical assistance to manage your pain, ask your doctor questions before taking an opioid prescription. Also consider alternative pain management approaches as well as medications that carry a lower risk for addiction, such as gabapentin (Neurontin, Gralise) and pregabalin (Lyrica). These are FDA-approved for pain and can be combined with other therapies for long-term use.

Finally, if you or someone you know is struggling with opiate addiction, get treatment before you become a statistic, and learn about the powerful anti-overdose tools available to you. Naloxone, a medication that can rapidly reverse opioid overdose, is easy to administer and more readily available than ever. In many states, relatives and friends can obtain prescriptions for an automated injector or nasal spray in case their loved one overdoses and in some states no prescription is required. Drug overdose is a tragedy that can be prevented by knowing who is at greatest risk, and how and when to take action.

Is there anyone left in our nation who can say they personally know no one touched by problem drug or alcohol use?

Judging by a flurry of studies released in 2016, including the first-ever report on alcohol, drugs and health by the Surgeon General, the answer is a resounding no. The new data makes clear that more and more Americans are using drugs and alcohol in ways that are hurting them and those around them, and experiencing record levels of addiction.

Yet amid all the discouraging findings, there are signs of hope. It is now up to us to find ways to use this new knowledge and build upon it so we can stop the downhill slide and maybe even reverse it.

First the bad news:

• Drug overdoses killed a record 50,000 people in 2015.
• Deaths from opioids such as heroin and prescription painkillers have quadrupled since 1999, breaking down to 91 deaths for every day in 2015.
• Heroin-related deaths now surpass gun homicides. As recently as 2007, gun homicides outnumbered heroin deaths more than 5 to 1.
• Almost 1 out of 12 people in the U.S. has substance use disorder, but only about 10% of that group receives any kind of treatment. Complicating the picture, nearly half of those with a substance use disorder also have a mental disorder but less than half are treated for either condition.
• Each year, alcohol misuse contributes to 88,000 U.S. deaths.
• Substance misuse costs society an estimated $442 billion annually in health care, lost productivity and criminal justice costs.
• Since 1980, the combined death rate from drugs, alcohol and mental disorders has almost tripled. And some areas have seen astonishing jumps. Clermont County, Ohio, for instance, which has been hit hard by the opioid epidemic, saw a 2,206% increase.
• A third of long-term prescription opioid painkiller users surveyed said they are addicted to the drugs. One in 5 said their doctor didn’t give them enough information about the addiction risks, and 6 in 10 said they weren’t advised about when and how to stop taking the drugs.

Put it all together and there is no question that ours in a nation in the throes of a drug crisis unlike anything we’ve seen before.

Now, some good news:

We are finally waking up to that trouble and the need to address it aggressively before it snowballs further out of control. For example:

• In December, Congress approved the 21st Century Cures Act, which includes $1 billion in state grants to help tackle the opioid crisis.
• Overdose deaths involving prescription opioids (such as OxyContin and Vicodin) are now rising only slightly after years of galloping to record highs, a sign that efforts to educate the public about their dangers are starting to have an effect.
• The CDC’s “Guideline for Prescribing Opioids for Chronic Pain” has begun to be implemented by the medical community, resulting in less prescribing of the drugs that have proven so addictive.
• Naloxone, a medication that can reverse the toxic effects of an opioid overdose, has become more widely distributed, is now standard equipment for most emergency responders, and is saving lives daily.
• Medication-assisted treatment, such as with buprenorphine, which blocks painful withdrawal symptoms and diminishes cravings, is becoming more accepted and more available. Recent rule changes have allowed qualified doctors to prescribe the drug to more patients than in the past (up to 275 in some cases).
• Prescription drug monitoring programs, which seek to keep patients from shopping around for doctors willing to prescribe to them as well as oversee doctors who might be tempted to operate a “pill mill” for profit, are being ramped up.
• The Affordable Care Act and parity laws have created new opportunities to receive treatment by requiring insurers to cover substance use disorders and addiction issues at the same levels as traditional medical services.
• Through drug courts and other efforts, the criminal justice system has taken steps to put non-violent drug offenders in treatment rather than behind bars. And more of those who are already behind bars are getting access to evidence-based treatment.

In the big picture, research has helped us better understand that a substance use disorder is an illness, one that changes brain circuitry and disrupts functions such as decision-making and self-control. That knowledge is slowly helping to lessen the stigma surrounding addiction.

We still need “a cultural shift in how we think about addiction,” as Surgeon General Vivek H. Murthy, MD, MBA, noted in his agency’s report, so that we can move past the old idea of addicts being simply immoral or weak-willed. But progress is being made, and that means people who are struggling with drugs or alcohol may be more willing to admit they have a problem and seek treatment. And the sooner a person gets help, the less likely they are to show up one day as a statistic.

Perhaps most crucially, the Surgeon General’s report notes that recovery from addiction is possible along a variety of paths and it is much more common than many realize. It may take time, multiple episodes of treatment, and a long-term commitment but “approximately 50 percent of adults who once met diagnostic criteria for a substance use disorder — or about 25 million people — are currently in stable remission (1 year or longer),” the report noted.

It’s a reality that we shouldn’t forget when the bad news about our nation’s substance use starts to seem overwhelming, and it’s one that I can attest to as an addiction psychiatrist. No matter the substance, the person, the circumstances, or the depth of the drug or alcohol use, there is hope.