Spring Break is prime time for our teens to have fun and travel to places such as Mexico and Costa Rica, where alcohol and drugs are more easily accessible to  underage populations (legal drinking age in Mexico, for example is 18). As parents we are responsible for overseeing our children’s plans and monitoring their activities–covering the bases of who, what, where and when. Spring break for many teens includes travel with other families, or other organizations, with the typical teen delighting in the fact that their  parents are NOT going! As a parent we may face the tough decision of setting a boundary and saying no to a spring break trip that lacks supervision or safety we would be comfortable with. The backlash of anger, depression, despair that our teen might display certainly sways some parents into just saying yes. If we say no, it is ideal to offer another suitable spring break alternative. If or when we say yes, we do so ideally under conditions that we truly believe will keep our kids safe. As a parent I’m better equipped to make that decision if I personally know the family who will be supervising my teen. If it is a family that shares my family’s values, and respects the boundaries I set with my teens around underage and illegal (in our country) consumption of alcohol or drugs, I’m comfortable sending my teen away with them. If I don’t know the supervising adult, or if she herself drinks to excess or uses illicit drugs on vacation, I would be complicit in to some extent in sending my teen abroad with at best intermittent or impaired supervision.  I also encourage parents to pay attention to the number of teens going and the supervisor to teen ratio (keeping it in 1:3 or 1:4 neighborhood). When I’m assured that my teen will have supervision and safety on the trip, I let go and trust in the years of training my family has given her–really from in utero to now, 15-20 years depending on the age of your teens. One thing I learned in my years of practice as a psychiatrist is that kids pay much closer attention to what we do than what we say. Toddlers, tweens and young adults (old adults too) tend to practice what they’ve  learned. Their learning starts at home and in the community, with the explicit and implicit messages we send. The nonverbal messages impact us the deepest, many times at a subconscious or even unconscious level. Family and community culture impacts the beliefs and behaviors of developing young people. The way we live, the things we do and don’t do, and the things we focus our collective attention on impacts those who are dependent on us–much more profoundly than our words do. If we focus on health, self care, interdependent and mutually fulfilling relationships, balance, giving back and loving our community, the chances that our kids will follow suit are higher (not absolute, just higher). How we live on vacation as a family impacts how they will live on vacation as emerging adults. If vacation is a time to connect with family and friends, engage in nature, engage in service work, the meaning of vacation will be different than it is when vacation is a chance to be perpetually wasted. This is also a time for us to reflect on why teen do turn to alcohol and drugs to deal with uncomfortable emotions such stress, peer pressure, pain and sadness, loss or other forms of trauma. By being aware of what our teens are experiencing and feeling, we can support them in finding healthy and constructive ways to address these challenges without resorting to self-destructive behaviors. When our kids are living healthy, balanced lives where they feel loved and supported by their families and loved ones, they are significantly less likely to turn to drugs and alcohol.  In this respect, prevention really does start at home. Yet the reality is Spring Break can be a tempting time even for the most well-adjusted teens.

It’s very important to talk with our teens about drugs because:

• they may hear wrong information about drugs from their friends, the media or other adults
• they (or you) may be concerned about someone else who is using drugs
• they may be using drugs and might need help to stop

The American public willingly exists under many myths: the tooth fairy is real; love always lasts forever; one size fits all.  Belief in such myths is basically harmless.

This one is not: the myth of mental health parity.

Far too many people labor under the notion that insurance coverage for mental health issues is equal to that for problems of a physical nature. After all, wasn’t that legislated by the federal government a while ago?

Here’s the answer:  no.

Every single day, we on the outpatient side of things, fight insurance companies to provide just one more day of care for those struggling with severe depression, an eating disorder, or substance addiction with co-occurring bipolar disorder or post-traumatic stress disorder. What does this translate into in real terms? Approximately $400 at the outside. And yet, a recent patient of mine, who was also a physician, told me about a surgical procedure in which the doctor elected to use a new semi-synthetic mesh product to close a patient’s abdomen, without making a single phone call to an insurance representative. The cost: $10K.

Due to much coverage by the media lately, there is now widespread awareness of opiate addiction throughout our country. This increased awareness is extremely positive on many levels. Yet again, a severe disconnect remains in the minds and hearts of insurance companies.

A patient of mine nearly died from an opiate addiction. On his current insurance plan, the co-pay for narcotic pain medications such as vicodin, oxycodone and morphine is literally nothing; it is essentially free. However, a prescription for suboxone, a medication that actually treats opiate addiction, requires a co-pay of $80 a month. Mind you, this is only after I, as his physician, spent 15-20 minutes on the phone with the insurance company to get the authorization required to treat him with this potentially lifesaving adjunct to his treatment.

Several roadblocks already exist for those with the disease of addiction. The stigma associated with substance abuse is very real and frequently proves a huge deterrent to accessing treatment, especially for those in the military. Moreover, instead of viewing addiction as a genuine illness, too many people continue to perceive it as a moral failing. Denial, a core symptom of many mental illnesses, keeps untold numbers of individuals from treatment. Add to this, a health care system that sets up serious barriers to both the patient and the treatment professionals and you have a perfect storm in which people remain addicted until they die, often due to overdose.

All of us need to be conscious of this ongoing injustice and question it whenever we can. Additionally, we must be grateful for groups like the Kennedy Forum, NAPHS, REDC and the Parity Implementation Coalition for working specifically and diligently on this issue of lack of parity. Only through both awareness and action will we witness much-needed change.

Thanksgiving has come and gone with Christmas fast approaching. Many referred to this as the season of giving, which is certainly a fine concept. I like using this holiday as a season to intentionally practice gratitude, a practice that we may embrace right now and then continue to develop a day at a time far into the New Year.

All of us, even in our darkest times, have at least something for which we are thankful. The fact that I am writing these words and you are reading them indicates that we are far more blessed than many in the world today. We are literate, safe, warm in the winter months, and have access to food, clean water and clothing.

When I first entered recovery, gratitude was extremely difficult to find. I would try so hard each day to dig up even one thing to appreciate in my life. On very challenging days, the only thing I could consider to be grateful for was I could breathe. And some days, even that did not feel like a blessing.  That was a dark time, indeed.

Today, I can easily name two handfuls of wonderful things without even breaking a sweat! My life is rife with positive experiences, events and people. I had blessings in my darkest times as well, but I was blind to them. Like so many, I was robbed of my vision by the diseases that threatened to take my life, and the traumas that created them. I had not yet developed eyes attuned to seeing the light. Today not only do I have such vision, best of all, I get to help men and women who come to SunCloud to develop theirs. They are exactly where I was.

And there within lies one of the beautiful aspects of the power of gratitude; if given a chance, it leads to hope. By and large, we are thankful for certain things because there was a time when we didn’t have them. Years ago, I did not have my husband; I did not have my step-children or my son. My life was defined by addiction and misery.  I could not have possibly imagined a future that was not only freedom from addiction, depression and ill health, but a life experience filled with abundance.

And neither can those who walk into our treatment program.

But all of us at SunCloud can imagine it for them.  We can create and hold a positive vision of their future lives within our hearts. Essentially, we serve as holders and see-ers for our patients. We stand in a symbolic line of hope for them because they cannot stand for themselves.

We know one simple and powerful truth:  if these hurting people engage with us and allow us to help them, their bodies will heal, their minds will unwind, their souls will flourish. Hope will ignite. They will take their rightful place in that line, a line that leads to a future of health, healing, joy and abundance.

More from Dr. Kim and SCH On The Compatibility of 12-step and MAT

The initial step of any successful treatment is patient engagement, establishing trust and hope, and collaboratively designing a treatment plan that the individual buys into. The evidence base for opioid use disorders has consistently shown that opioid replacement therapy (classically referred to as “harm-reduction”) yields far better outcomes and mortality rates than so-called “abstinence-based” approaches. In part, this is due to much higher treatment retention rates when patients receive appropriate medications for the physical aspects of the illness.   Instead of being consumed by cravings and withdrawal symptoms, individuals have a better chance to form trusting relationships with treatment providers who can help them, and peers in recovery who can support them unconditionally along the way.

For as essential as medication can be for many people in treatment, it alone is usually insufficient to keep a person in long-term, sustainable recovery. There must be additional treatment components to address the myriad facets of the illness.  We must address depression, bipolar disorder, anxiety disorders, eating disorders and post-traumatic stress disorder, all of which commonly co-occur with addiction.  Evidence based-treatments targeting the emotional, social, environmental and spiritual domains of addiction include (but are not limited to) CBT, motivational interviewing, DBT, nutritional therapy, and 12-step facilitation (a topic often wrought with resistance from professionals and lay people alike).

There are many reasons why people resist going to a 12-step group; most are related to misconceptions of the fundamental tenants of the 12-step approach or a previous experience with unhealthy groups or individuals. The goal of 12 step participation is ongoing sobriety, along with sustained social, emotional and spiritual growth. The 12 steps serve as guiding principles of recovery for those with any type of addiction and the 12 traditions serve to guide the behaviors of groups as a whole.

One of the most relevant traditions with respect to MAT/12 step model controversy is the single-ness of purpose tradition, which encompasses the idea that “We have no opinion on outside issues.” Medication is considered an outside issue in healthy 12 step groups.  Sponsors are not doctors. And for those who are doctors, their role as a sponsor is simply to share their experience, strength and hope regarding one area: how they work the steps to thrive in life and remain sober. Much of the push back against medication use by some individuals in 12-step groups is predicated on the definition of sobriety.

Those opposed to MAT claim that relying on medication is simply addiction shifting; in order to be genuinely “clean [do we refer to cancer patients as clean or dirty???],” they believe medication cannot be used. The truth is, for a person with an opiate addiction, part of being sober means authorizing an expert addiction doctor to manage his or her medications rather than a drug dealer on the street.  This is no different than an individual who takes an anti-depressant to treat clinical depression. Some people will need anti-depressants for their depression regardless of how well they work all 12 steps.

Often the implication from opponents of MAT is “if you didn’t go through hell like I did, then you don’t deserve to be in this meeting with those who did.” The implicit message is that those with addiction must endure more suffering to learn their lesson and finally recover. “Inclusion based on degree of suffering”? This makes no sense. Everyone with the disease knows pain.   Additionally, at its very heart, this mindset is judgmental and stigmatizing, which is antithetical to all that 12-step recovery stands for. Meetings are intended to be a safe, accepting place where unconditional acceptance of individual differences regarding the path of recovery is paramount.

Recovery doesn’t happen in a vacuum.   ‎Recovery happens in community, not just any community, but a healthy, compassionate, accepting, and well-informed community, not one based on intolerance and judgment.

The Big Book, essentially the “bible” for Alcoholics Anonymous was first published in 1939. From that year until the present day, spirituality, in the form of developing a working relationship with a Higher Power, has been considered an essential component of addiction recovery in the 12 step program.

Bill Wilson and Dr. Bob Smith, the founders of AA, could only guess at the power of prayer, but now we know:  they were right.

“Craving” is one of the criteria that physicians use to diagnose addiction. A strong desire for alcohol or drugs can persist for years after people become clean and sober. That is why AA members continue to recite abstinence-promoting prayers that are designed to reduce cravings.

Researchers from NYU Langone Medical Center set out to explore the brain physiology in AA members, the first study of its kind. They sought to determine what transpires in these people’s brains when exposed to alcohol-craving triggers.

The researchers recruited 20 long-term AA members; each reported no cravings for alcohol during the previous seven days. The subjects were placed in MRI scanners and then shown images that involved alcohol consumption. These pictures were displayed twice: first after asking the participant to read neutral material from a newspaper, and again after the participant recited an AA prayer promoting abstinence from alcohol. All participants reported some degree of craving for alcohol after first viewing the images, yet the craving diminished after reciting an AA prayer. Importantly, the MRI data revealed that there were actual changes (increased activity) in parts of the prefrontal cortex in those who prayed. This is the region of the brain that is responsible for attention and emotion.

Whereas previous research examining the role of prayer on drinking behavior found that alcohol abusers who reported a spiritual awakening drank less after treatment for alcoholism, this study proves that physiological changes actually occur in the brain as a result of prayer.

I trust that more and more will be revealed as new research emerges on the neurobiology behind why participation in 12 step communities works for long-term sobriety. Until that time, those of us with experience helping others recover using a bio-psych-social-spiritual approach will continue to do what decades of recovery has proven works.

Finally, after all these years, the reality show “The Biggest Loser” has offered the American public something of actual value; this comes in the form of a surprising new medical discovery made by studying the 14 contestants who participated in the 2009 show. Surprising and new to everyone except those of us who work in the eating disorder field!

If you are not familiar with the show, it focuses on people who are very overweight to start with, then helps them shed many pounds. The winner is, naturally, the one who loses the most weight during the season.

Of course, what they fail to disclose to the viewing audience is how these people fare after the show wraps. Turns out, not so well. All but one out of the 14 contestants studied regained weight in the six years after the competition. In fact, four of them are heavier now than before the competition.

A casual onlooker would immediately conclude that these people were simply weak-willed and could not resist “bad” foods, and that would be incorrect.

In part, their weight gain is the result of their resting metabolism, which determines how many calories a person burns when at rest. Originally, the contestants had normal metabolisms for their size, but by season’s end, their metabolisms had slowed radically and their bodies were not burning enough calories to maintain their thinner sizes. This is a normal occurrence when vast amounts of weight are lost in short amounts of time; in other words, this transpires after the body experiences prolonged periods of starvation. But the problem is, their metabolisms never recovered. They became even slower over time, as if the body was fighting back against this weight loss.

As far as I am concerned, this study merely added to the evidence that DIETS, specifically extreme diets, are far more the problem than people being overweight.

So instead of focusing on a population of people, such as those who participate in “The Biggest Loser,” we should look at people who have lost weight in a sustainable, healthy, slow method and look at their metabolic rates over time. These would be people who have lost weight WITHOUT starving their bodies to do so. My bet is we would not see the metabolism rate differences or certainly not to the same degree as those engaging in extreme dieting.

I’m continually blown away that expert researchers can’t see this. It is just so ingrained into our medical and lay culture that if it isn’t fast it isn’t American. If you can’t lose 40 pounds in 2 months, why bother?

Sadly, the biggest offenders in this regard are medical professionals who encourage their overweight patients to go on these extreme diets, unfortunately because it is so “shameful” to be fat in our society.  It is so regrettable that it gets beaten into every doctor’s head that fat is always bad and unhealthy, which is just plain wrong.