Michigan Medicine Presents: The Science of Addiction

Almost 21 million Americans have at least one addiction. The financial impact on the US economy is staggering, but the human toll – the impact on lives and the lives of the person struggling with addiction – is immeasurable. Addiction threatens careers and destroys marriages. Even at its most basic level, any form of addiction harms a person’s health.

But most of us don’t treat addiction like other conditions that affect your health. Addiction is often stigmatized or hidden.

And that may be part of why so many of us know so little about what addiction actually is, and how it works.

The Science of Addiction talks with the experts at the U-M Addiction Treatment Services, part of the U-M Addiction Center and to help listeners better understand what we know about addiction today. 

Episode 1. Why do people do drugs?

Featuring Jonathan Morrow, M.D., Ph.D.

Episode 1 Transcript

Introduction (00:10):
Welcome to Michigan Medicine Presents, a wide ranging podcast series that will explore the progress in scientific research and innovation, historic roots, and the current state of conditions that affect us all. Join us for our first series, a three part look into the science of addiction.

Narrator (00:30):
The stats are easy enough to find online. Almost 21 million Americans have at least one addiction. The financial impact on the US economy is staggering. But the human toll, the impact on the life of the person struggling with addiction and the impact on the people around them, is immeasurable.

Addiction threatens careers and destroys marriages, and at its most basic level, any form of addiction harms a person's basic health. But most of us don't treat it like other conditions that affect your health.

Addiction is often stigmatized or hidden. And that may be part of why many of us know so little about what addiction actually is and how it works. And that's what this podcast is about. We're going to talk to the experts at University of Michigan Health and U-M Addiction Center - people whose careers are focused on better understanding addiction and how to better treat and live with addiction.

Narrator (01:28):
This is Michigan Medicine Presents, and we are talking about the science of addiction. Episode one: why do people do drugs?

Dr. Jonathan Morrow (01:38):
Well, there's many answers to that, that probably the easiest way to address that question is simply to ask people why are you using drugs? And when you do that, they'll answer many different things. They'll say, probably the most common answer is that it's fun. It's a pleasurable thing to do. But people will give other reasons like it's a way of treating their depression or relieving stress. Some people do it out of curiosity, sometimes to expand their mind, kind of open the doors of perception, or have some kind of adventure. Or learn more about themselves. And all of these reasons are probably true for various people. What they all have in common is that they're trying to reach some certain goal. The drug is supposed to do something for them that they consciously want. But there's evidence that that may not be true.

Narrator (02:41):
This is Dr. Jonathan Morrow, a psychiatrist with University of Michigan Health Addiction Treatment Services, or UMATS. Dr. Morrow also works with the U-M Addiction Center, and as he just explained, there are lots of reasons someone makes the choice to use a drug. But it is a uniquely human problem, right? Humans, the most complex form of life, we must have some very sophisticated reasoning that contribute to why we use and get addicted to drugs. After all, it's not like animals get addicted to drugs, right?

Dr. Jonathan Morrow (03:14):
Certainly some of these reasons you would have to be a conscious person, a human, really to have these kind of these kind of goals in mind. If you want to expand your self knowledge or open the doors of perception, right? That's not something a rat or a dog is going to do. But the problem with these explanations is that animals do use drugs. They use the same drugs we do. They love drugs. If you give them access to drugs in a way that they can use it, they'll do it all day. So that raises the question, are they really trying to expand their minds? I mean, do they have the same kinds of reasons for using drugs we do? It suggests that there may be a subconscious reason that's driving a lot of drug use. And if that's true for animals, it may be true for humans as well. We may not know the real reasons that we're using these substances.

Narrator (04:14):
There you have it, dogs can get addicted to drugs, just like people can. It's not just a sign of human weakness. If that's the case, how much control do we really have in whether or not we can become victim to substance abuse?

Dr. Jonathan Morrow (04:29):
We're in control and we're not in control. I mean, our brain is in control of what we're doing of drug use, just like anything else. But the question is whether we, our conscious self, how much we are in control of that behavior. So an example I like to give is just of breathing. You're breathing right now. But probably before I mention that you didn't notice that you were breathing. So you have to ask, why are you, if I asked you, why are you breathing? You might give me an answer. Well, I need to breathe so that I get oxygen into my blood and that will keep me alive. But the reality is, you weren't thinking about that before, but you were still breathing. Your brain stem was making you breathe, and all your brain stem knows is how much carbon dioxide is in your blood. It doesn't know anything about air. It doesn't know anything about oxygen. When your carbon dioxide levels get high, it just tells you to breathe and that's it.

Dr. Jonathan Morrow (05:27):
So that's not the real reason that you are breathing, but you have control over your breathing. I can breathe anytime I want. I can breathe in. I can breathe out. I can stop breathing. But the problem is, when I ask you to stop breathing for 10 minutes, you're going to have a problem. Now you're not in control. Eventually your brain stem is going to say, okay, I don't know what story you just told that says you don't have to breathe. You're going to need to tell a new story, because we're breathing.

Narrator (05:59):
We're breathing. Whether you want to or not, your body is going to kick in and take that breath. So using that reasoning, even if you know you shouldn't have a few more drinks, because you have an early morning tomorrow, is there a part of you that takes over and says, “I don't care that you have to work early. We are drinking.” Turns out there is.

Dr. Jonathan Morrow (06:19):
So dopamine is a chemical that's released into an area of the brain called the nucleus accumbens. This is part of the kind of the subconscious areas of your brain. And whenever you do something that meets some goal that is fulfilling for you, you're going to get a dopamine release into the nucleus accumbens. And what that signal is going to do is going to tell you, it's going to tell your brain anyway, do that thing again. No matter what it was, do it again. People think of it as a pleasure signal. We've known since the 1980s that it is not a pleasure signal. I'm not sure why people keep saying it's a pleasure, but it's more of a motivational signal. It tells you just do it again. And it's really whether you liked it or not. You'll get a signal to do it again if you get a dopamine release.

Narrator (07:15):
The nucleus accumbens. Now we have somewhere to direct our ire, and a worthy nemesis it is, because no matter which form of addiction we're talking about - the role of dopamine and the nucleus accumbens is universal.

Dr. Jonathan Morrow (07:29):
So one thing that we've learned from research on the neurobiology of addiction is that dopamine release in the nucleus accumbens is a key part of addiction. All drugs of abuse release dopamine into the accumbens. There's a lot of different drugs that people abuse and they have almost nothing in common chemically. Alcohol, cannabis, cocaine. They're very different molecules. The only thing they have in common is one way or another. They released dopamine in the nucleus accumbens. And really any reward that you have, any like food, sex, anything that you will pursue is also going to release dopamine in the nucleus accumbens. So a deeper question would be, what is the purpose of the nucleus accumbens? What does the nucleus accumbens do for us? And the nucleus accumbens is part of a larger circuit. It's a reward learning circuit. And the purpose of that whole circuit is to basically translate perceptions, emotions, experiences into a behavior or a response.

Narrator (08:41):
Can we turn it off? If the drug triggers the dopamine release and the dopamine is released into the nucleus accumbens, and then it starts calling the shots, against your will even, why does the nucleus accumbens have to be such a troublemaker?

Dr. Jonathan Morrow (08:55):
And so that's processed on different levels. So there's one level you just perceive the stimulus, say it's a beer bottle. Your brain recognizes that's a beer bottle. On another level, you have things like the amygdala hippocampus. Those are going to bring associations, memories, and attach that to whatever stimulus is. So the last time I saw this beer bottle, I was at a party. I was having a good time. And then the next level, you make a decision about what to do. That's where the nucleus accumbens lives. So the nucleus accumbens comes in at that decision level where you say, okay, I saw that beer bottle. Last time I saw it, I was having a good time. So now do I drink this beer bottle? Do I walk away? And then once you make that decision, it goes to another part of the brain where you actually prepare for the action and you do the movements to actually drink the beer or walk away or whatever it is.

Dr. Jonathan Morrow (09:54):
So the accumbens is making that decision. What am I going to do? And when you add dopamine to the nucleus accumbens, it's going to reinforce whatever you did. So you drink the beer, you get a dopamine surge, and that's going to say, okay, whatever sequence just happened, beer, memory, drink, we're going to make that stronger so that the next time you see the beer, you're more likely to drink.

Narrator (10:21):
You may be more likely to drink, but can you draw the line before things go too far? Lots of people enjoy drinking. With marijuana now legalized in many states, more people than ever before have access to legal marijuana. Is there a way for a person to know when they're at risk of going from regular, but casual use of a substance into addiction?

Dr. Jonathan Morrow (10:42):
So usually they don't know, because it's a subconscious process. We want to believe that we're in control all the time, even when we're not. But gradually you start to lose control and it gets to the point where you just, you can't really stop. You're making decisions that don't really fit with your larger goal. You're making a decision, for example, that it's more important to drink than it is to keep my job. Once you've gone that far down the road, I'd say you have an addiction. You've lost some level of control, because the motivation that you have is all getting funneled to the drug. Motivation that used to be for other things, is all getting funneled to the drug. Very hard to recognize from the inside. Whereas people on the outside can see, probably before you can, that your decisions are not yours anymore. It's a very tough message for people to hear.

Narrator (11:44):
It's as simple and as complicated as that. If you're in a place where all the motivation that used to go to your work, to your family, your art, your fitness is getting funneled to the drug, getting the drug, taking the drug, hiding your use of the drug, your decisions aren't really yours anymore. What kind of motivation does it take to break that cycle? How do you get to a place where you reach out for help?

Dr. Jonathan Morrow (12:10):
So some of it is just listening to other people who are probably telling you that this drug is kind of ruining your life. And it's also taking stock of the situation. And being honest with yourself about what this drug is doing. Because your conscious self is still, it's still there. You are watching this happen. So you'll have flashes of insight where you say, “Is this really what I wanted to do at this point?” If you can recognize that and give up some of the control that you believe you have, then you can get help with the addiction.

Narrator (12:57):
Do you have to get help or can you convince someone to stop? Can you trick your brain into not needing that dopamine surge, to ignoring the call of the nucleus accumbens? If you give someone enough negative consequences, can you just convince them to make the right choice?

Dr. Jonathan Morrow (13:16):
So there are ways that you can manage it. It's hard to really treat, people have tried this before where you try to have a negative experience associated with the drug use. This is the basic idea behind aversion therapy, which people still use, even though it clearly does not work. But the idea is that you have drug use and then you have a consequence to that. And the idea is that that's going to stop the drug use, because you have a bad experience. The neurobiology tells us that that won't work, because drugs release dopamine whether you have a good experience or a bad experience. You're going to want to repeat it no matter what the experience was. That's why drugs are addictive. And that's why other things are not addictive. If I eat good food and I have a pleasurable experience, I'm going to want to do that again. If I eat good food and I get sick off of it, I won't want to eat anymore, but that's not because I won't get the dopamine release. But if I have cocaine and I have a terrible experience, it will release dopamine, I will want to do it again. If I drink and I vomit all over myself, if I have legal charges, if I'm sexually assaulted, I still get a dopamine release because alcohol releases dopamine no matter what. So I'll want to do it again.

Narrator (14:44):
You want to do it again, and again. Can you become more addicted the longer you are dependent on a substance? And what other effects does prolonged substance use have on a person's body?

Dr. Jonathan Morrow (14:59):
There's the sub-cortical kind of unconscious parts of your brain, like the nucleus accumbens, and drug use will actually increase the activity in those areas of your brain. You also have prefrontal cortex in some kind of executive control areas. These are areas where your conscious self lives, where you're making your conscious decisions, and drugs, pretty much all drugs, will weaken those areas of the brain. They'll directly damage those areas. They'll weaken the connections between those kind of conscious prefrontal areas with the subconscious areas, and they will weaken your ability to control those urges over time. So, yeah, they do have long term consequences on the brain and it helps to reinforce that addiction cycle.

Narrator (15:56):
That was Dr. Jonathan Morrow in our three part series, The Science of Addiction. For more information about the University of Michigan Addiction Treatment Services, call (734) 764-0231, or visit uofmhealth.org/addiction. And don't miss the other two episodes in the series. You can find these and other Michigan Medicine podcasts at uofmhealth.org/podcasts, or by looking up the Michigan Medicine Podcast network wherever you stream your podcasts.

Episode 2. Alcohol addiction

Featuring Anne Fernandez, Ph.D.

Episode 2 Transcript

Introduction (00:08):
Welcome to Michigan Medicine Presents, a wide ranging podcast series that will explore the progress in scientific research and innovation, historic roots, and the current state of conditions that affect us all. Join us for our first series, a three part look into The Science of Addiction.

Narrator (00:27):
A lot of people think they have an idea of what addiction is, but if you peel away the stigma that surrounds addiction, if you dig deeper, you'll get to the heart of what clinicians actually define as a substance use disorder. Because addiction isn't necessarily what it seems. And that's what this podcast is about. We're going to talk to the experts at University of Michigan Health and the U-M Addiction Center. People whose careers are focused on better understanding addiction and how to better treat and live with addiction. There's a lot here that might surprise you. So, get comfortable. This is Michigan Medicine Presents, and we're going to talk about The Science of Addiction. Episode two, alcohol addiction.

Dr. Anne Fernandez (01:14):
Alcohol use is still the most common addictive behavior, addiction disorder that there is in America right now, despite the opioid epidemic. So, we still see a high proportion of alcohol cases in our clinic. And in particular, because I have a focus on liver disease, I see a particularly high proportion.

Narrator (01:33):
That's Dr. Anne Fernandez, a licensed clinical psychologist at University of Michigan Health Addiction Treatment Services, or UMATS. Dr. Fernandez also works with the U-M Addiction Center. So, addiction is her life's work, and she knows how hard living with addiction can be. Alcohol addiction has some unique challenges though. For many people, alcohol use is associated with socializing, with celebration. It's normalized. But what is normal? How much alcohol use is too much?

Dr. Anne Fernandez (02:07):
So, the warning signs for an addiction to alcohol, but actually the warning signs for an addiction to any substance, are pretty much the same. We use pretty much the same criteria for all addiction. We typically call it either an alcohol use disorder or a drug use disorder of some type. There's 11 symptoms, according to the Diagnostic Manual for Psychological Disorders. And these include things like loss of control, overuse. So people who find that they're no longer able to control, or they intend to use a certain amount, but continuously go over that amount or use more often than intended. So, that kind of thing is a big warning sign.

Dr. Anne Fernandez (02:49):
Also developing tolerance. When a person starts to spend a lot of time using the substance, especially in place of other things that they maybe previously enjoyed. And then there's also a large segment that has to do with consequences. If a person starts to notice that there's harm in their life, they're not doing activities and obligations that they normally do going to work, going to school, that can be a warning sign. In addition to physical health indicators, such as tolerance and withdrawal. So, if someone notices when they don't use the substance, they start to feel really bad in various ways. And then they need the substance to make that feeling go away, that can be a pretty big warning sign as well.

Narrator (03:29):
Knowing you may have a substance use disorder or that someone you care about does is a first step, a huge one actually. But what then? Can you just stop if you have a substance use disorder?

Dr. Anne Fernandez (03:42):
Alcohol use, and also benzodiazepines are probably the most dangerous substances to stop on your own. Alcohol use, if you stop at cold turkey and you're dependent, can actually kill you. And that has to do with neurotransmitters and the way that the alcohol interacts with the brain. And when you remove that, the overexcitement that happens in the brain when you've normally put a depressant in it can cause seizures and actually death. So, for individuals who drink even probably more than a few drinks a day, if they're drinking regularly, should really seek medical advice before stopping use to figure out if they need medications to make their detox not only safe, but more likely to be effective in the sense that they would have something to make them feel more comfortable and not go back to using, to get rid of those uncomfortable symptoms.

Narrator (04:35):
That's a key point that Dr. Fernandez wants people to know. While safety is important when you're talking about going through withdrawal, it's not the only consideration. There's another reason someone might need help withdrawing from alcohol dependence.

Dr. Anne Fernandez (04:48):
I'd say in terms of danger, alcohol and benzos, and to some extent, opioids can be a little bit risky. But the main thing with withdrawal from many substances is the discomfort that it causes, psychological discomfort and physical discomfort, that it can be so extreme that a person has trouble managing and tolerating that on their own. So, detox medications, withdrawal management can really help a person succeed. So, it's not just about danger. I think it's about comfort and likelihood of success. I think the first step would be to go and talk with someone before you embark on stopping. If you do not do that, and you find, particularly with the alcohol use, shakiness, sweating, and that's kind of a mild detox symptom, but if you start to feel extreme like seizures or extreme anxiety and restlessness, that would be a time to call someone, call for help.

Narrator (05:53):
Call for help. Take the first step towards taking control of a substance that feels like it might be controlling you. Making the decision to get help is arguably the biggest part of the battle, but where does someone begin on the road to recovery?

Dr. Anne Fernandez (06:08):
So, yes, it's definitely okay to drink around people within recovery. Some people who've been in recovery for 30 years and they're very comfortable being around alcohol and are around alcohol frequently in their lives. However, if someone is very early in recovery or they're struggling in certain ways, it may be difficult for them. So, I would say the individual also has to decide in what situations they want to put themselves.

Dr. Anne Fernandez (06:34):
So, for example, if someone is in a bar, then they're probably going to expect that alcohol use is going to be going on. So, I think for if you're a friend or a loved one, and you're wanting to know what's appropriate for someone that you care for, the most important thing, if you can, is to just ask them and try to support them in their goals. If you're not sure, but I'd say if you're in a place where alcohol use is common and the person would expect it, then it would probably be something that they would anticipate was happening. So, I don't know if that makes it okay, you could still ask, but it's something you could consider is the setting.

Dr. Anne Fernandez (07:12):
One of the things that people really struggle with when they stop using alcohol or other drugs is finding social outlets that don't involve substances. So, if your friend or loved one is in recovery and wants to stop using, if you can create social engagements or social situations where they can enjoy themselves and alcohol and drugs aren't going to be a part of it, that's something that people really want. So, as a mental health professional, as an advocate for people in recovery, I would say, try to support your friends and offer those opportunities as well.

Dr. Anne Fernandez (07:49):
Stigma is definitely a real problem in the United States around addiction and is something in research that people cite as a barrier to them seeking care. It's something that's somewhat... It's hard to move the needle for any one individual at any one time. But I think as a field and as someone who works in healthcare, I think one way that I think about this is that alcohol use or other addictive behaviors are not unlike other health-related conditions or other diseases or illnesses. There's debate about whether addiction is a disease or not, or how people like to articulate that.

Dr. Anne Fernandez (08:36):
But I would say, in general, I think thinking about alcohol and drug use in the context of health can be de-stigmatizing for people. So, considering the health impacts when someone comes into a clinic or a primary care and talking about alcohol addiction and health with them, can I think be de-stigmatizing. I think for individuals, when they think about their health and what they want in their life and their goals and whether this substance or behavior gets in the way of it is a helpful way to consider alcohol and drug use as opposed to, is this a moral failing? Is this a disease I have forever? To kind of keep it in the here and now like, is this serving me right now? What are my long-term goals? Do I want to continue doing this behavior? And to try to think of it in those contexts and then reach out. It might be uncomfortable. It might be difficult. But hopefully in a clinic setting, there's going to be less stigma and more understanding once you start talking with people who are experiencing something similar as you.

Narrator (09:47):
Dr. Fernandez's work at the University of Michigan Addiction Treatment Services is packaged in the form of a program called an IOP, an intensive outpatient program.

Dr. Anne Fernandez (09:58):
So, generally speaking, if a person is trying and failed multiple times to stop on their own, it's probably a good time to try something different. That thing that could be different could be AA, NA, or going into treatment. So, it's kind of up to the individual, but generally a healthcare professional, if you take your loved one to be evaluated, can give you recommendations based on a lot of different factors. At our clinic, we offer it three days a week for a month. So, it's a four-week program, Monday, Wednesday, and Friday. The person comes in for a group therapy from I believe it's 9:00 AM to noon. So, it's more intensive therapy than you would get if you were just seeing a one-on-one provider. So, you've got a group and you're there three days a week working and learning about addiction and in therapy for that whole time.

Dr. Anne Fernandez (10:53):
So, you get a more rich treatment experience, but you don't have to go and stay in a residential program. And typically, and ideally the person also has an individual therapist that they're also having contact with. Some programs in other places might be a little longer, or maybe it's four days a week instead of three. But essentially that's the model of an IOP. An intensive outpatient program and an AA program, or NA, which is Narcotics Anonymous, are similar in that they have the same goal, which is to help people stop using substances long term and to support them in doing so. But the programs themselves are quite different.

Dr. Anne Fernandez (11:39):
I mean, to just touch on a few of the dimensions, AA or NA is not a professional mental health, professional delivered treatment. It's a community-based 12-step program and it's free and it's also very ubiquitous. They're in so many communities nationwide. And they're run by peers. So, other people who have had alcohol or drugs in their life that are trying to stop. And you can go daily, some people have them in their community, they'll do 90 and 90. That means you go 90 meetings one a day, every day for 90 days, and then people will continue to go frequently. So, they also offer a constant and frequent source of support, but they're different because it is a peer run 12-step organization with a particular treatment philosophy.

Dr. Anne Fernandez
While an IOP may include other types of treatment philosophies. It might have some 12-step within it. It might have cognitive behavioral therapy and it's run by a therapist. So it'd bill insurance often and would have psychiatry potentially available and also a one-on-one therapist who generally has a degree in mental health or addiction treatment training.

Dr. Anne Fernandez (13:00):
So, it's definitely going to vary by individual, by gender and by age. So, even some of those guidelines around no more than a drink a day for women, and no more than two drinks a day for men are loose guidelines. That's the cutoff for "healthy versus unhealthy" alcohol use. And for older adults, for example, those numbers are even lower, so that's someone 65 or older. So there's a lot of variability, even something like a guideline is just a guideline.

Dr. Anne Fernandez (13:31):
And for any family member or individual to determine what's harmful, it's a bit complicated. I think that you can see that sometimes it's very obvious for the family. Other times it might be more ambiguous. There is something called the ASAM criteria. It's essentially a set of criteria that evaluate the severity of substance use, risk for withdrawal and a lot of different factors, including other medical issues that the person may be experiencing to essentially assess the severity of the disorder and match the person to what treatment that they may need. So, that's something that healthcare professional is really going to be in the best position to do, as opposed to someone in the lay community, looking things up on Google.

Narrator (14:20):
Whether treatment comes in the form of a 12-step program, an IOP or a residential program, getting help from an established program is essential for someone who needs help quitting. So, what keeps some people from getting the help they need?

Dr. Anne Fernandez (14:35):
I usually think of barriers as falling into two buckets. One is more about the individual's motivation, interest and the stigma. So sort of more things going on within the person. And the others are the things outside the person, the external factors, which can be where the treatment's located, whether they have insurance, whether they have childcare, whether they can get out of work. So, all of those things need different tools or skills or changes to impact, but they are surmountable and people do come into treatment, but sometimes it takes some planning and time.

Dr. Anne Fernandez (15:18):
The first step might be different for different people, depending on where they're at in their motivation and their readiness for what they want to do. There's definitely a great website, it's called findtreatment.gov. It's the Substance Abuse and Mental Health Organization of the United States that essentially puts this together. It's called SAMHSA, and they have a treatment locator. Essentially you can put in your ZIP code and find people who offer treatment for addiction and other mental health problems.

Dr. Anne Fernandez (15:54):
You can also search online for AA or NA meetings, other 12-step meetings that you could go to. They're often offered multiple times a day in a lot of communities. So, that's something someone could just do right away. They could call up a local provider's office and make an appointment. Or if they're not quite ready to jump into treatment, they could just talk to a friend or loved one about their concerns. I think voicing your problem, talking about it, considering it is also really important, even before you maybe enter treatment, or if you're not ready to enter treatment. But you don't have to kind of hide it. You can also just talk to someone, especially if it's someone you trust and can be supportive.

Narrator (16:39):
That was Dr. Anne Fernandez in our three part series, The Science of Addiction. For more information about the University of Michigan Addiction Treatment Services, call 734-764-0231, or visit uofmhealth.org/addiction. And don't miss the other two episodes in the series. You can find these and other Michigan Medicine podcasts at uofmhealth.org/podcasts, or by looking up the Michigan Medicine Podcast Network, wherever you stream your podcasts. 

Episode 3. Helping someone get help with addiction

Featuring Sarah Rollins, LMSW

Episode 3 Transcript

Introduction (00:10):
Welcome to Michigan Medicine Presents, a wide ranging podcast series that will explore the progress in scientific research and innovation, historic roots, and the current state of conditions that affect us all. Join us for our first series, a three part look into the science of addiction.

Narrator (00:29):
When your partner falls and hurts their leg, you probably don't think twice about encouraging them to get it looked at. When someone at work complains of allergy symptoms, it's not uncommon for someone to quickly jump in with a recommendation for a great allergy specialist. But when you see someone struggling with addiction, well, for many people, what to do next is unclear. Watching someone live with addiction is hard. You may feel helpless. You may feel scared. You may feel angry, but you may be able to help.

Narrator (01:02):
In this episode, we're talking with experts at University of Michigan Health, about how to help someone who is struggling with addiction. In fact, we're talking with a specialist from one of the places that provides exactly this type of help: U-M Addiction Treatment Services.
This is Michigan Medicine Presents, and we are talking about The Science of Addiction. Episode three: Helping Someone Get Help. This is a complicated topic. I think we're going to need an expert.

Sarah Rollins (01:31):
I'm an adolescent and adult therapist, and I work with individuals, groups, and families.

Narrator (01:37):
Perfect. Enter Sarah Rollins, a licensed clinical social worker at University of Michigan Health. Sarah works with adolescents and young adults who have substance use disorders. Let's start with what help looks like. When a lot of people think about helping someone with addiction, they imagine something they've seen maybe on a TV show or in a movie: interventions.

Sarah Rollins (02:00):
So in regards to interventions, I think that the typical view of interventions is like the TV show intervention, where a bunch of family members sit down, they maybe bring an outside person and they just tell the family member who's struggling with addiction, all of the bad things, and they force them to go into treatment. So that is one way, but I like to think about an intervention as a broader topic.

Sarah Rollins (02:24):
So interventions can simply be someone one-on-one sitting with their loved one and expressing their concern. So usually family members are one of the main reasons that people seek out treatment. And so we know that family involvement is really powerful. So I would recommend if you decide that you want an intervention as maybe you see on TV or that you've heard about, to look up some resources. There actually are a lot of resources on how to do a proper intervention, because we know going back to what increases motivation, is that it's kindness and support rather than criticism and yelling. And sometimes interventions, if not done in an appropriate manner can lead to actually more resistance, and people feeling as though they're not supported and their family members are all against them. And that it can actually create a bigger gap between the patient or the person wanting care.

Narrator (03:27):
Okay. Do some research first on how to structure your intervention. That's important, and stay tuned to the end of this episode, because we're going to lay out a bunch of great resources for how to do just that. But back to the intervention. So it's good to have family involved?

Sarah Rollins (03:42):
Yes, 100%. Again, we know that family involvement is one of the main reasons that people seek treatment. And if we can help people identify maybe what their struggles are. So for example, a lot of people struggle with comorbid psychiatric concerns like depression, anxiety, trauma. And so sometimes people really feel that those issues are bigger in their lives than maybe the substance use. And so sometimes starting there and saying, I see you're really struggling with depression or whatever word they describe their mental health concerns as, and then that can help link them to treatment for that, which then maybe will help motivate them to see how their substance use is playing a role.

Narrator (04:30):
So an intervention is one way to help, and it's normal to want to help, to look for different ways to support your loved one. But good intentions aren't always enough. Sometimes help can not be helpful. Sometimes what you think is help might be enabling.

Sarah Rollins (04:47):
So I really like Betty Ford Hazelden's definition of enabling. They say enabling behavior is "Behavior that shields people from experiencing the full impact and consequences of their behavior." And most people engage in enabling behavior out of really good intentions. So for example, an individual may have drove or done something dangerous under the influence, and then a family member will come and take their car away so they don't get caught. And so what happens is, is out of good intention, the family member or friend will allow the person to not have the legal consequences, but then what can happen is the person who engaged in the dangerous behavior may not see the full impact of their behavior. So enabling, as you said, is kind of a hot topic. And one of the most important things is just allowing people to have the natural consequences of their behaviors. And it is very hard. And so that's why sometimes we need supportive counseling or peer support to help us really do that.

Narrator (06:01):
It can be especially hard to know how to help someone who isn't a family member. Family members get into each other's business all the time, but a friend, someone who's not in your biological family, what can you do then?

Sarah Rollins (06:14):
Maybe approaching them in a kind and gentle way and saying, "Hey, I've been noticing that you haven't been feeling well. Would you like to talk?" And reaching out your own hand and maybe not waiting for their family members, but also knowing your own boundaries and limits because that person may just not be ready and that's okay. So really focusing on the fact that again, motivation can be grown and common ways to increase motivation are the person feeling acknowledged, getting information without pressure. So some people feel really pressured to "go to rehab" or something like that. Having different options, having reasons that make sense for them to make that change, having the cofidence to make the change and also getting positive feedback. So although you may not get them straight to where you think they need to be, it's really important that you can increase motivation by doing those things.

Narrator (07:16):
That's a really interesting point. You can help someone who isn't inclined to get help become more motivated to change?

Sarah Rollins (07:23):
Ambivalence is really normal and motivation is not a fixed trait, so it can actually be grown. And one of the ways that we really help families support their loved ones in making a decision is to help them see, from the loved one's perspective, why they might be using. It might be to help with a psychiatric problem such as depression or anxiety. It also might be to cope with trauma. So what we always encourage family members to do is to really take a step back. And this is very hard of course, to take a step back and focus on what is really going on with the individual. And to remember that we don't have to wait to rock bottom, which is a common phrase we use in addiction language, that sometimes problems are actually more treatable early on. And to help family members by responding with kindness and helping them see all their choices, rather than feeling like there's only one treatment option because there's so many, and one size does not fit all.

Narrator (08:28):
Like with so many things, one size does not fit all, but there is one treatment option a lot of people have heard about. Let's talk about 12 step programs. And they're not just for the person who is living with the addiction, are they?

Sarah Rollins (08:42):
Yes. 12 step programs, both for family members and for individuals struggling with addictions can be helpful because it's a place where people can find other people to empathize with them, to feel connected to others and feel as they're not alone. It also is a good way for self-care. We talk about the self-care process for both family members and those struggling with addiction, because it's important to take care of ourselves and focus on what we need.

Narrator (09:10):
Okay, we're going to interrupt here because Sarah made some important points about self-care. Self-care in this case is not as simple as a mani-pedi or treating yourself to something fun. Sarah's referring to a very specific type of self-care.

Sarah Rollins (09:24):
When I talk about self-care, I mean a few things. So first of all, I mean that knowing your boundaries and your limits is really helpful. And sometimes saying “no” or saying “not right now” is actually a way that we can engage in self-care. A lot of times we think about self-care as an act of doing something, like going to yoga or getting a massage, which are all great ways to take care of ourselves. But sometimes by saying no, or by setting boundaries, not to keep people away, but to keep ourselves safe and stable, we're actually able to care for ourselves better.

Sarah Rollins (10:01):
Another way I think about self-care is actually asking for help or support. We know that we can't do everything by ourselves, yet sometimes we feel like the world is on our shoulders. And so sometimes asking people who we trust and we care about to help support us. And it can be very simple ways such as, "Can you drive with me to this appointment? Or can you talk on the phone for a few minutes?" So when I think of self-care, it's not just about what we do, but about what we don't do.

Narrator (10:31):
So find what form of self-care you need to support yourself on this journey. Important for both the person living with the addiction and the person supporting them. Drawing boundaries, knowing your limits, finding the tools that work for you, and that sort of personalized approach to what works for you applies to the addiction treatment itself too.

Sarah Rollins (10:53):
So one thing that I like to mention about any 12 step recovery group is that there's a common phrase that people say, which is “Take what you like and leave the rest.” Which means that just because you hear something in a recovery meeting does not mean that you have to adopt that or that it's right for you. I always encourage people to talk to an individual counselor or someone they trust about any advice that they're not sure of that they've received in a 12 step meeting.

Narrator (11:21):
Find someone to talk to is great advice for the person living with the addiction - and anyone really, and sometimes getting help can be a family affair.

Sarah Rollins (11:31):
Yes, family therapy can be really helpful because it allows family members to speak their truth and gain information about how to best support their loved one. There is evidence that supports family therapy or family involvement improve the odds of recovery. It also helps to increase empathy of the family, which also increases communication.

Narrator (11:52):
It can be especially hard to be the child of someone living with a substance use disorder, but there are special resources for these kids too.

Sarah Rollins (12:00):
There's a great program at Brighton Center for Recovery, and it's actually a free educational healing and addiction prevention program for children aged 7 to 12. And the program is really helpful for children whose parents are struggling with addiction. And they also get to come together with other kids who are experiencing the same thing. There's also Alateen and then individual counseling that are really good resources for children.

Narrator (12:30):
All right, so say you've made some progress, your loved one is getting help. How can you help someone who's in the middle of their recovery journey?

Sarah Rollins (12:38):
The biggest thing I always say is to ask the person and to not assume. So everybody wants and needs something different, and the person may not know what they want or need. And that's okay. So typically I'll ask people, how would you like me to support you? Or would you like me to not drink around you? Or use a certain substance around you?

Sarah Rollins (12:59):
Another way to support a loved one in recovery is to really use positive reinforcement. A lot of times we just expect people to get better. And we don't remember that changing is a lot of work and sometimes it can feel worse before it gets better. And so people really respond to positive reinforcement, really good feedback, offering statements of understanding and offering to help. So even if you ask someone what they want at first and they are not sure, maybe circling back in a week or two, or a month or two and saying, "Hey, I'm still here for you. Would you need anything today? Or this week?"

Narrator (13:41):
Lots of people wonder, “Do I need to change my behaviors around someone who's in recovery?” How much of someone being able to successfully recover from a substance use disorder is about good old fashioned willpower?

Sarah Rollins (13:54):
Willpower is a concept that I really like to educate people about. When we think of willpower, we think of it as, something that we all have an infinite amount of. And if we don't have it, it means we're weak. What we really know about willpower is that we all have a finite amount of willpower, and we use willpower to do things as get out of bed, go to work, spend time with family, parents, our children. And so when people are in recovery, what happens is they still have that same amount of willpower, but then they have more to do. And so sometimes we need support from other people to help us through. So it's not really about willpower. It's about having the resources and the support to cope with a change in our lives. And again, it's really asking the individual what they would like. Some people are really offended when other people change their behaviors. And some people are very appreciative and feel supported when people ask them what they would like them to do in regards to changing their behaviors. So again, it's a really case by case basis.

Narrator (15:06):
And recovery doesn't always work for everyone on the first try. No doubt, you've heard about relapse. What should we know about relapse and addiction?
Sarah Rollins (15:15):
I encourage everybody to think about a time in their lives when they tried to make a change. It might be with their weight. It might be in a relationship. It might be with a job. And think about if you did it perfectly from the first day that you decided to make that change. And most people would say no, that along the way, there were some blips or maybe if it was with weight loss, they decided one day they really wanted to eat that cupcake. And so we want to think about sobriety in the same way. That again, making a change is really hard work, and there's also a lot of underlying psychiatric factors, societal factors and social factors that might lead to making a change be a little bit harder than maybe we anticipated. There's also withdrawal in cravings that can lead to difficulty maintaining sobriety for long periods of time.

Sarah Rollins (16:10):
The last issue that some people aren't really aware of is post acute withdrawal syndrome. It can actually take the brain about six months to two years to recalibrate after being completely sober from substances. The brain will naturally begin to produce endorphins and dopamine, but again, it can take a really long time. And so us being aware of that, especially with family members who are struggling, and maybe educating them that it's not always their fault or about willpower, the brain is really going through a lot of change that we can't always control.

Narrator (16:48):
It's clear that helping someone who is living with addiction is complicated. And we've talked about the importance of getting help, not just expecting willpower to be enough. So let's get to the resources part. Where do you start?

Sarah Rollins (17:01):
So that's a really good question. So in the Metro Detroit area, the Ann Arbor area, you can always call UMATS and you can speak to a clinician or a nurse.

Narrator (17:11):
She's talking about University of Michigan Addiction Treatment Services. They call it UMATS for short.

Sarah Rollins (17:16):
Their number here is 734-764-0231. We do work with families too, whose loved ones aren't ready to get help yet with their addiction or psychiatric problems. So it's a good resource. There's also Families Against Narcotics. There's a FANs organization in Ann Arbor, and there's also other treatment centers such as Home of New Vision and Dawn Farm that also have a lot of resources. Another really good resource is the SAMSHA website. It's S-A-M-S-H-A. They have a lot of good resources for whatever area you're in, in addition to Partnership to End Addiction at drugfree.org. And they actually have a lot of peer coaching support and other support that you might want.

Narrator (18:07):
That was Sarah Rollins in our three part series on The Science of Addiction. For more information about the University of Michigan Addiction Treatment Services, call 734-764-0231, or visit uofmhealth.org/addiction. And don't miss the other two episodes in our series. You can find these and other Michigan Medicine Podcasts at uofmhealth.org/podcasts, or by looking up the Michigan Medicine Podcast Network, wherever you stream your podcasts.

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