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Unhealthy Relationships with Alcohol

April 14th, 2020

We have guest Dr. Joseph Volpicelli joining us on the show to help us understand what defines an alcohol use disorder. He’ll be telling us more about the signs when an unhealthy relationship with alcohol turns into an alcohol addiction, and what recovery options he recommends. Then, we have Rosalind Donald a Victim Services Specialist for Mothers Against Drunk Driving (MADD) in Kentucky. She’ll be tell us more about her organization and the what people need to know about the dangers of drinking and driving.


Welcome to Recovery Radio by Landmark Recovery with your host, Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields, and help navigate the road to recovery.


Now, here’s the host of Recovery Radio, Zach Crouch.


Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.


We have guest Dr. Joseph Volpicelli joining us on the show today. Dr. Volpicelli has sent the last 25 years as a pioneer in clinical research, education, and practice. He has served as an Associate Professor of Psychiatry at the University of Pennsylvania and Senior Scientist at the Pennsylvania VA Center for Research on Addictive Disorders.


He has led the way in the integration of medications and psychotherapy support to treat addictions. His research on the use of naltrexone led to the first new medication to be approved by the FDA for alcohol treatment in nearly 50 years.


Dr. Volpicelli, thank you so much for coming on the show today.


Dr. Volpicelli: Thank you for inviting me. It’s a pleasure to talk with you today.


Zach: Tell me a bit about yourself. What led you to pursue a career in medicine and more specifically, I guess addiction medicine?


Dr. Volpicelli: Sure. I first became interested in medicine because of my long-term interest in understanding the interaction between the brain and behavior. In college, I majored in biology and psychology, couldn’t decide between becoming scientist or physician. Fortunately when I got to medical school there’s a program for trained physicians to be scientists so I joined the PhD program so I could do both. I was there with the medical team when I became really passionate about victim medicine.


I met a patient at the VA hospital who had returned from Vietnam and he had symptoms of PTSD. When he returned to the States, he was drinking. He was dependent on alcohol. He told me about some of the [Inaudible][02:31]while they’re in Vietnam, he used opiates. When he came back, he stopped using opiates and started drinking alcohol. That started my passion to understand how people became addicted and how we could treat them.


Zach: From your perspective as a researcher and being in this field for a long time now, where do you think we are in terms of understanding the brain and especially how it interacts with behavior and addiction?


Dr. Volpicelli: I think we really made dramatic progress in the past 25 years or so and we have a much better understanding in how stress and receptors in the brain particularly dopamine and opiate receptors interact to produce addiction and we even have effective treatment. For me, the biggest challenge in the field is how to integrate what we learn from research and clinical practice.


Zach: Yes. You brought up something very interesting and it’s become a lot more popular. We do it in our treatment centers at Landmark. That’s the idea of almost a mindfulness, I think that it goes along with meditation and mindfulness, for that matter. Can you talk a little bit about how that has sort of helped out people who have addictions in your practice? Is that something that you regularly prescribe people to begin a regimen of meditation?


Dr. Volpicelli: I often recommend that to my patients I have. In my practice I have patients who have in addition to addiction to alcohol or opiates, they have psychological symptoms. Some of them have symptoms of panic disorder or social anxiety.


For those folks, I like to prescribe meditation. I think there’s pretty good data that that can really help to quiet the mind and help people focus and help to reduce anxiety without the need for using other medicines particularly like benzodiazepine which I try to avoid.


Zach: Yes. What I guess in your time in your practice, what specifically defines alcohol use disorder?


Dr. Volpicelli: Yes. I am really fond of the old Japanese proverb that says, “First the man takes a drink then the drink takes the drink then the drink takes the man. Addictions per alcohol use disorders as well as addictions in general, is the behavioral pattern where using the substance increases the need to use more of it.


For me, that’s the fundamental property of addiction is that doing drinking, after three or four drinks, a person has decided to have fourth and fifth drink and people who don’t have addictions don’t have that. For myself, I can understand how that sort of works. I love ravioli, but after I eat a handful or ravioli…


Zach: Me, too.


Dr. Volpicelli: You could understand that I think. After eating a few ravioli, you get full and you feel like stopping, but for my patients after they had three or four drinks they want to have the next drink even more than they wanted to have that first drink.


I should point out that even though I’m sort of unique among some people in the field that I didn’t become involved in this field because of any personal history of addiction, I do consider and empathize in one way because my relationship with corn chips has the flavor where when I start eating corn chips I have a hard time stopping right until I finish the whole bag or someone takes the bag away.


Zach: Me, too. Right.


Dr. Volpicelli: There you go. That’s what addiction is. In the field, we often define addiction by its consequences; say, if you have psychosocial problems associated with drug use back when you had a girl problem. I think that defines it too late; sort of like defining an infection by someone who has a fever, cough, and shortness of breath. Infection is when you have the virus or the bacteria in your system. That’s when you’re infected.


Zach: Right.


Dr. Volpicelli: You need to diagnose it early and if you do it early, you have a much better chance of making effective treatments, managing it easier. Sometimes I think we wait too late for folks.


Zach: Yes. I want to come back to the piece that you mentioned as well about when people go for that first drink. If you’re an alcoholic, you’re already thinking about the second and the third and the fourth. I remember when I first started in this field as a counselor.


One of the things, you brought up the Japanese proverb, one of the things that comes up for me is that people who are predisposed to having a substance use disorder, alcohol being one of those substances, they, from the first drink typically after they’ve experienced it, they’re not going just for having a drink. They’re going for the effect.


Dr. Volpicelli: Yes. Yes, that’s exactly right. It’s not to have a pleasant glass of wine with dinner. It’s to get the effect of the alcohol. I think this is important for people to understand that they wonder, “How do I know I’m at risk of becoming an alcoholic?”


Zach: Right.


Dr. Volpicelli: “My father is an alcoholic. My mother, on her side there’s some alcohol dependence. Do I have a risk for becoming dependent on alcohol?” I actually did research on this and what I found is people who have a strong family history for alcohol use disorder, they respond to alcohol differently than people who don’t have the strong family history.


I gave people, college students so they’re not currently abusing alcohol in this study, but they have a strong family history. I put people in the lab and I gave them three drinks. After three drinks, I asked people to rate how they felt. The people with the strong family history when they had three drinks they felt more energetic. They felt more euphoric. They had an alcohol high and their craving for the next drink was higher than the craving when they first came in to the study.


Zach: Yes.


Dr. Volpicelli: People without the protogene for alcohol use disorder, they, after three say they were tired. They’re not interested in having the fourth drink.


Zach: Yes.


Dr. Volpicelli: If you have a pattern where after three drinks, you’re just getting started that’s a risk factor. You better be careful.


Zach: Yes. I want to touch on a couple of things here. In my time in doing research on, since we’re talking about family histories, did you also find, too that people that are predisposed that they are born with a lower level of dopamine and serotonin in their brains versus people that are not predisposed?


Dr. Volpicelli: Yes. We’ve been looking at that in research. Again, there’s a lot of controversy about this, but the clinical factors, not so much the serotonin or dopamine but the response of the brain with the opiate system to alcohol.


When people with a strong family history drink, their levels of beta endorphins go up and then the beta endorphin in turn increases dopamine like a nuclear [Inaudible][10:22] — dependence on alcohol, endorphins, dopamine. That’s just if you could block the opiate receptor you would block the increase of dopamine and that’s pretty much what we found in our research.


Zach: Got it. I was thinking, too back to what we’re talking about with people who are predisposed, have you found also that their body processes alcohol just biologically different versus someone who doesn’t have that history?


Dr. Volpicelli: Yes. The pharmacokinetics is very similar. When people drink, they’re blood alcohol levels go up about the same as people who don’t have the family history, but their physiologic response and behavior responses are very different. People tend to get more sedated and tired if you’re not at risk for using alcohol and you don’t have a strong family history. The people who get energized, who feel high and euphoric, those are the folks who I think are more at risk.


Zach: I was doing a presentation with another professional in the treatment center in Pennsylvania and we talked a little bit about BAC limits and our levels rather, in that most people’s BAC, the most enjoyment that they feel typically is around 0.06 I think. People who are predisposed typically surpass that if they’re well into their alcoholism by a lot.


Why is it do you think that people just don’t…if the peak is at 0.06 and you’re getting a 0.18 or 0.25, why don’t people just maybe back off a little bit so they could come back to the 0.06 level?


Dr. Volpicelli: Yes, now that’s a really good question. I think the answer is that again, for people who are disposed to have problems with alcohol addiction, when they get up to a 0.06 that’s when they get that little squirt of…that’s when the endorphins go up and that little squirt of dopamine and that feels good. It’s on the ascending limb when the alcohol level is going up that people get that really good effect.


Once they stay at that level, the dopamine level starts to fall again, but now people want to get that dopamine kick. How can they do that? By re-dosing on alcohol. They have to have the next drink and the drink after that. They’re trying to get that little squirt of dopamine again.


It’s interesting because in my research, what we found was that if we took someone with a strong family history for alcohol problems and we gave them naltrexone. We block their opiate receptors with naltrexone. When they came in to the lab, they didn’t show that increase in energy anymore. They didn’t report that they felt high, euphoric and they didn’t have increased craving for alcohol. Their craving was just the same as someone who didn’t have the strong family history.


Zach: Right. Wow. I’m going to digress a little bit here because I do have a family history of alcoholism and I’ve done recovery for going on 14 years at this point. The other piece this, too is that I got kids. I got two kids, seven-year old and a one-year old. I’m curious as a parent and I’m sure that there are listeners out there who are also parents with younger kids.


You talked about how being defined by the problem is too late of an approach once you’ve got the disease and you’ve already got symptoms where there would be DUI’s or getting kicked out of school, whatever it is. What have you found to be useful or helpful for parents who do have that predisposition to have that conversation with their kids? What are some of the things that work?


Dr. Volpicelli: I think it’s really helpful to explain to children what this addiction is all about. There are so many misconceptions. People feel ashamed about their addiction. They feel like, “What’s different about me? How come my buddies, my friends go out and drink and they don’t have a problem.”


I did a study where I looked at college students. I wanted to identify who as a freshman would have problems later as senior in college based on their drinking history. What we found is that drinking levels were high across the board, family history or not. Everyone is drinking and a lot of people were drinking excessively especially a freshman.


Zach: Binge-drinking, right.


Dr. Volpicelli: Drinking actually decreased over the course of four years for some groups, but the group that had the sort of impaired control that when they drink they have a hard time controlling how many drinks; let’s say, “Tomorrow I have a test so tonight I’m just going to have one or two drinks,” and they have four or five drinks. They consistently drank more than what they intended as freshmen later had much more problems associated with their drinking as seniors.


Talk to your kids and see if they have that pattern where the craving for alcohol increases after three drinks. If their energy increases after three drinks then they’re at risk. Explain to them that, “Your friends are able to do this but their response to alcohol is different than yours. It’s not that you’re broken. It’s not that you’re bad or anything. It’s just that this is biology.”


Zach: Right.


Dr. Volpicelli: “If you start having trouble with it, let’s address it early on before it crosses all kinds of consequences for you.” Now I don’t know if you had any bad consequences associated with your drinking but you might share some of that and say, “If I knew what I knew now, I would have avoided X, Y, and Z.”


Zach: Absolutely. Yes, there were some bad consequences. I was younger. I’m 40 now. I would say by about the time I was 23 and I was, undergrad I was finished. I kind of knew. A lot of my friends were getting jobs and moving on. They’re past the party, but I’m still, I remember 22, 23 I was still living in an apartment on campus still and working at a job but still partying with some of these people.


It was a pretty tell-tale sign and I ended up getting terminated from a job because I’d shown up late time after time because I was hung over from the night before.


Dr. Volpicelli: It would have been nice to avoid some of those consequences and I’m sure all those consequences helped make you the person that you are today and you’re doing really good work.


Zach: A hundred percent.


Dr. Volpicelli: For some people, this outcome is not as good, is not as hopeful and for some people it can be devastating. If we can identify it early and then take appropriate steps early then I think there’s a better outcome. By changing our concept of addiction as its bad consequences to addiction as a pattern of behavior where using a substance increases the need to use more of it, I think we can intervene at an earlier stage and at a stage when not so much prejudice associated with it.


Zach: Yes. Listen, I don’t want to create any panic here when I ask this question but I feel kind of compelled to ask. If you have kids and you do have a family history of alcoholism, addiction, etc. and I’ll check this out with you first but is some of this when I ask this question predictive of later onset of alcoholism if they have poor impulse control as young children?


Dr. Volpicelli: Yes, there’s pretty good data that poor impulse control is a risk factor. This is how I like to explain it to folks and hell, I like people to conceptualize it. Human beings have basically two basic brains. One part of our brain is our rational, thinking brain that’s looking out for long-term consequences. The other brain is more interested in emotions, feelings, and is more interested in immediate consequences.


At each moment our behavior is determined by which part of the brain is sending out the strongest signal. When you think about what do I want to be doing next week generally your logical brain has a stronger pull, but when you think about what do I want to do now often the impulsive brain or the I call the limbic brain, the emotional brain has a stronger vote.


Some people are really good at with the delaying gratification because I’m going to get a bigger reward if I wait. You can even do studies with children and at what age that part of the brain kicks in.


Zach: Yes.


Dr. Volpicelli: Other people are less good at that. It looks like the people that are interested in immediate consequences are more at risk for having problems with drugs because they’re listening to more the emotional brain than the rational, logical brain.


Zach: There was you mentioned studies with kids. I can’t think of the author, but wasn’t the study that was done where the teacher shows up and tells the kids, “You know if you are able to wait ten minutes,” I think it’s an undisclosed amount of time, “I’ll give you a cookie right now. You can eat it right now or if you wait, when I come back I’ll give you another cookie or two cookies,” or something like that?


Dr. Volpicelli: Yes.


Zach: There were kids that couldn’t wait, I think it was pretty predictive of later problems that they would have with substances.


Dr. Volpicelli: That’s right, yes. I don’t remember if those were cookies or mushrooms; not mushrooms, marshmallows.


Zach: Marshmallows, that’s what it was.


Dr. Volpicelli: Marshmallows, I think it was marshmallows. Yes, exactly.


Zach: Yes. Let’s talk a little bit about some of the signs and what are they when an unhealthy relationship with alcohol turns into an alcohol addiction. What are they?


Dr. Volpicelli: It’s a variety of, for the medico-biological signs, psychological signs and social signs. In general they all conspire to increase the need to use more alcohol.


For example, from a biological or medical perspective is that people who drink excessively for a long period of time, your brain sorts of adapts to the alcohol because alcohol has sedative effects so in addition to reinforcing effects it has sedative effects that mostly involves the GABA system and the leudemic system. When the brain sees alcohol for a long period of time it adapts to the alcohol and has compensatory changes and that’s what gives you tolerance to the alcohol. Instead of being drunk on five drinks it now takes ten drinks.


The problem is it’s sort of like if you’re driving a car and drinking alcohol is putting your foot on the brake, your body compensates by putting its foot on the gas and so you’re still going the same speed, but then if someone was to stop drinking, your foot is still on the gas so the car goes too fast. There’s a rebound withdrawal that increase the need to continue drinking.


I think some people wind up being hooked on alcohol, not so much even at this point to get high anymore, but to avoid the withdrawal and I see this from my patients addicted to opiates really clearly that they stop getting the euphoria from using heroin or other opiates but they are still stuck in that pattern where they have to keep using to avoid the withdrawal. That’s one of the biological consequences and that’s a real important thing that helps to maintain the addiction.


There are other medical consequences to the liver, to the nerve cells. I remember doing research where I found that alcohol affects virtually every organ in the body except the ears. I don’t know for some reason they don’t seem to affect the ears, but virtually every other organ in the body it has bad effects. It affects immune system so it makes you more prone to infection, to cancers, hepatitis, pancreatitis, peripheral neuropathy. Chronic alcohol use can cause dementia in patients. It can cause a variety of serious medical consequences.


Zach: What I’m just thinking about now are we are in a country with this COVID, coronavirus; people who have chronic alcohol problems are probably more at risk.


Dr. Volpicelli: They’re more at risk I bet. I bet if you look at folks who wind up having a worse outcome, I wouldn’t be surprised if alcohol use contributes to that. That’s the medical side.


The psychological side as some of the stories sometimes people drink alcohol to reduce anxiety or simply like social anxiety. They have a couple of drinks before going out for a social function. It looks like it works initially but then your body gets used to it and then if you don’t have the alcohol the social anxiety comes back stronger than it was there before. The alcohol drinking creates the need for more alcohol drinking.


I have a patient who I saw his mother for a long time then she was worried about her son because he was showing some signs of having problems with alcohol. He had really bad social anxiety. He felt that when he was anxious he had to drink and it seemed to work initially, but as the alcohol wore off his anxiety came back stronger than before so he was stuck in a terrible vicious cycle.


It’s sort of like borrowing money from the bank at high interest rate. You know you can pay your bills but eventually you have to pay the bank back and usually at a higher cost than having the money to begin with. Fortunately he’s been in treatment with me. I put him on acamprosate, naltrexone and he stopped drinking and the social anxiety went away. Now he’s living with his girlfriend in the city.


Zach: Okay, cool.


Dr. Volpicelli: He’s doing great. That’s the psychological side.


The social side, people who are lonely, who lack good social connections could probably be at risk for having problems with alcohol. The fact that when they become dependent on alcohol, that further deteriorates their social relationships so again the drinking creates the condition to drink. That’s why I think it’s so important that part of treatment include re-establishing social connections.


Zach: I’m curious with your thoughts, too on we talk a lot with our patients; obviously getting through that really critical first, we’ll call it week or two weeks of acute withdrawal it’s so important, medically to get someone stabilized. Can you share a little bit about your experience on how the post-acute withdrawal can be as much of a factor in people’s relapses, anything or any other thoughts?


Dr. Volpicelli: Yes. That’s a good point. A lot of people think detox is just created when you’re done. In a fair percent of my patients particularly those who have anxiety disorders, even after after they go through the acute detoxification phase they have another period that can last months in which they’re jumping. They’re anxious. They’re irritable. That provides a condition for them to want to go back and drink because after they drink they feel better temporarily. I think that’s really important to address.


Zach: Right.


Dr. Volpicelli: I’ve been trying some different medicines to see if we can help with that. There are probably some medicines that are helpful but understanding that going back to drinking is not going to help. They’re just really calling for your brain to heal.


Zach: Does naltrexone help out with any of that, Dr. Volpicelli?


Dr. Volpicelli: No, not so much. Naltrexone is much better for losing craving and the pleasures associated with drinking. I’ll use more medicines like nirantum o tegritox to help with acute withdrawal symptoms.


Zach: Tell me about your experience in working with patients in how trauma plays into all of this treating of people?


Dr. Volpicelli: I know a bit. Trauma was thing that really got me interested in the alcohol problem because I was a graduate student when I went to graduate school to get my MD PhD. I was really initially interested in the relationship between trauma and illness. I worked in a laboratory with Marty Sullivan where we looked at how people with trauma could lead to depression.


I was in his lab. I was working with rats. We actually did a study were we showed uncontrollable trauma on rats increased the risk of dying from tumours so we did that study. I was thinking working with the vets from Vietnam maybe the uncontrollable trauma has something to do with why the vets have increased risk for alcohol. That’s what got me started in this whole career.


I did a study in rats; it was interesting where I gave them uncontrollable trauma. They had five days of that. On weekends I just went in and measured their alcohol and water bottles. I didn’t work on the weekends but even though I was an ambitious MD PhD scientist I wanted to have my weekends off and I wouldn’t have to put the rats in the chuck boxes on the weekends. I gave them the weekends off. I gave weekends off.


Zach: That was nice of you.


Dr. Volpicelli: Anyway, I was surprised to find that most of the alcohol drinking occurred not during the week when I gave them the trauma, when I gave them the uncontrollable stress but on the weekends. I was trying to figure out why was that the case.


It looks like when organisms, humans, rats are exposed to uncontrollable trauma yes, you have the familiar fight or flight response where your body releases ACTH which increases cortisol and there’s higher sympathetic activity, everyone’s aware of that response to blood flow to muscles and unfortunately away from the GI tract and your thinking brain.


The other part of the fight or flight response is it releases endorphins. I know this because there have been times; I remember one time I was late to see a patient and I was running across the field and I actually broke my foot. I broke the fifth metatarsal on my foot but I was able to sit down and treat a patient and it wasn’t until the next day that, “Oh my God, my foot hurt.”


Under times of stress your body releases these endogenous opiates. During the week when I was stressing the rats, probably their endorphin levels were high, but on the weekends…


Zach: They’re high, right.


Dr. Volpicelli: That’s it.


Zach: Wow.


Dr. Volpicelli: The endorphin levels are high during the week, but during the weekend they will start to drop. Since alcohol can release endogenous opiates, the alcohol I think was consumed to take away the withdrawal from their own endogenous opiates. That would sort of give them a re-down that would help correct the deficiency in endorphin activity. I said, “If that’s true then I should be able to block post-stress drinking by blocking the opiate receptors and I did that experiment and that’s what I found. That’s what I did for my dissertation.


Zach: That was what led to the FDA approval of naltrexone?


Dr. Volpicelli: I did a study in humans at the VA hospital where I gave them naltrexone and it blocked relapse to drinking in humans and then yes they did a study in Yale which showed the same results. We went to the FDA and they approve naltrexone to treat alcohol use disorders.


Zach: When was that, Dr. Volpicelli? When did the FDA approve that?


Dr. Volpicelli: I believe that was 1994. My goodness. Look at that. 1994 and still people don’t use it very much. People I think still don’t understand how effective it can be. I think part of the problem is that this naltrexone works really great in some people but not so great in other people. When I looked at my research trying to understand that, I think some people drink alcohol not so much for the endorphin effect but because of alcohol sedative effect.


They drink alcohol to sleep which reduce anxiety. Its affects to increase the GABA system as opposed to the dopamine and endorphin system. When I did the research, for a lot of people it didn’t work because they weren’t consistent with taking the naltrexone. They would stop the naltrexone on the weekends so they could drink and go get high. That led me to figure out strategies to how to prevent that sort of thing. Medication, non-compliance turned out to be a real issue in terms of getting effective results.


Zach: Have you found the use of Vivitrol has helped somewhat curtail that?


Dr. Volpicelli: Yes. Part of the answer to that was in a study getting people the option of taking a pill every day. We will give them an injection of the long-acting naltrexone, Vivitrol. They would only have to make the decision once a month. Do I want to be on naltrexone? They will come in on a Monday. By the time Friday came around they might stop the oral naltrexone but they couldn’t stop the Vivitrol. That’s why it works better in many folks.


It’s, again we have that conflict between the thinking brain and the emotional brain. When you’re thinking about drinking on the weekend, if it’s Monday, the cognitive brain has a stronger vote. When it’s the weekend and the effects are immediate, sometimes the emotional brain has a stronger vote. We get around that by having people decide on a Monday to come in and get the shot and then they don’t give themselves the option of stopping naltrexone for the weekend.


Zach: You can probably speak to this, but I’ve heard if you try to get into a fight — the thinking brain against the emotional brain, the emotional brain’s going to win just about every time.


Dr. Volpicelli: Yes. There are certain rules that we can use. I take my cue from looking at Ulysses. Ulysses is the captain of the boat who wanted to sail past the island of Crete where the sirens will sing. When the sirens would sing people would direct their boats to the coast and the boats would crash up against the rocks. He knew ahead of time how people responded.


What he did was he had the crew tie him to the mast of the ship and he made sure the crew put wax in their ears so they couldn’t hear the singing. He told the crew, “Until we get past this island, ignore any orders that I give.” He did that and he was able to have the ship go past the island. He could hear the singing and he didn’t crash the boat.


That’s how it is with dealing sometimes with the emotional brain or the limbic brain. We do think ahead of time so we’re not at risk later when we know we’re going to be more at risk.


Zach: I don’t want to spend too much more time on this, but I think it’s a pertinent question. The people that you’ve treated, do you often find more often than not that it’s really a reservation for relapse most often when people just, when you know that it’s going to be effective when they refuse to take the naltrexone as a preventive measure?


Dr. Volpicelli: Yes, I’m afraid so. People often when they start treatment are ambivalent about treatment.


Zach: That’s a good word, yes.


Dr. Volpicelli: What I do is I try to work on the ambivalence. One of the things I did was when I realized that medication non-adherence turned out to be a significant problem with naltrexone, I went back to the drawing board and I actually designed a psychosocial program that I call the BRENDA Approach with the design to get people to initiate treatment and stay in treatment.


BRENDA was basically derived from motivation interviewing and it was designed for the people without PhD’s in Psychology could use this approach. It’s really designed to help people to engage in treatment. We’ve used that and that’s worked very well.


In my program now where we use Vivitrol I look at the data to see what percent of folks wind up getting the second shot, the sixth shot, the twelfth shot and often in clinical practice people get one shot and they don’t come in for the second shot where they drop out early. The folks who get the Brenda plus the Vivitrol they have like 80 percent success rate. They do really well.


Zach: That’s a big difference right there. One of the pieces that at least at your center the Volpicelli Center, you mentioned that ambulatory detoxification, medication and psychosocial support are all key elements to your services that you offer. How important is psychosocial support especially for people after they complete primary treatment at a place like Landmark, like primary detox and residential treatment?


Dr. Volpicelli: It makes all the difference. For many people, they don’t start treatment until again relatively late in their recovery and the effects of the alcohol has affected their brain. You have acute withdrawal symptoms. You have other medical problems but has impaired relationships with other people so it has social consequences and sometimes it’s impaired feelings about themselves. If you don’t address those issues, the chance or relapse is very high.


For example, sometimes I have patients who have been on Vivitrol for a year and say, “Is it okay for me to stop?” For me I ask, “How are you doing in terms of your relationships with the people? Are you getting along with others? Are you getting along with your family? Do you have good friends? How are you doing professionally? Do you have a job that you enjoy, that you’re successful at? How are you feeling emotionally? Do you feel anxiety, guilt, shame?”


For people who still have those symptoms, psychological or social consequences I say it’s not time to stop the Vivitrol. Those issues have to be addressed. What I find is when you stop the Vivitrol before these issues are addressed they’re likely to relapse. It’s really important to repair relationships. It’s really important for people to be connected to other people. I think that’s maybe one of the best predictors for long-term success. People who have a loving, supportive family and feel productive in their career choice, those are the people that are much less likely to go back to using drugs or alcohol.


Zach: You mentioned connection being a big piece of people’s recovery and one of the questions that we ask on the front-end of our admission processes around the ACE study, the ACE score and how important that piece is to understand clinically for people coming in to a facility like ours, as an example because so often, as you already know with ACE score, if you’re high on ACE score you’ve had a lot of failed relationships throughout your life.


I think that long-term what you’re talking about especially around forming those relationships. You brought up the piece around naltrexone. I think the meat and potatoes for people in recovery processes is really all about that. It’s about relationships and having successful relationships.


Dr. Volpicelli: Yes, exactly. It’s interesting because it’s the addiction itself that impairs those relationships. The very thing they need to get better is the thing that interferes with the addiction. Again, it’s that vicious cycle where the addiction creates the need for more of the alcohol because the very thing that’s going to help your recovery from that you’ll lose.


Zach: Let’s talk a little bit about some alternative options to recovery that you recommend beyond abstinence programs. What would you say to that?


Dr. Volpicelli: I’m just a great believer in using a variety of options. I actually wrote a book called Recovery Options. I highlighted the various options that people have for recovery. There are a couple of things that I think are really important. You need to make sure you address people’s psychological distress. That’s important. It’s important to have the counseling to address that. You need to address their occupational functioning, their social functioning. Those need to be addressed.


I think you need to include medications for treatment — medications to help detox people; medications to help with the post-acute withdrawal symptoms. Medications like naltrexone to help reduce cravings. If they do have a slip, it doesn’t turn into full blown relapse so all that. The easiest way to get there is not to get re-engaged in that cycle of addiction so abstinence makes good sense if you can do that.


Some people can’t do that. I just want to say to folks that if you can’t do that, that’s not necessarily a failure. That’s not necessarily mean you’re a terrible person. You’re not using your willpower. You’re not working the program, that sort of thing. The nature of the disease in general is to go back and slip. I tend not to blame people so much for slips and if they go back to using. I recommend abstinence but I don’t make that the only criteria of success.


Zach: Sure.


Dr. Volpicelli: In terms of peer support, there are various options that are not so abstinence-oriented and that may work for some people. I think the A number one priority is to get people engaged in treatment. That’s what I tell the people who work with me. The number one priority is to get the person to come back again. If they do that over time they’re going to get better. If we make hard and fast rules and say, “If you do this, you’re fired,” I’m not sure we’ve done very much to help the patient.


Zach: Amen. Yes. There’s a really big push these past couple of years here locally in Louisville, Kentucky. It’s been controversial for a lot of people in the community. It’s this idea of having needle exchange programs locally. We’ve seen from our facility and my friends in recovery there are a lot of people who will get access to treatment that way. I don’t know if you have something similar in Philadelphia or not.


Dr. Volpicelli: Yes.


Zach: It’s been great.


Dr. Volpicelli: We do the needle exchange. There’s even talk about having not just needle exchange but an injection site where people can come safely inject themselves. Of course they also get a lot of material to say, “If you want to quit, here’s a strategy you can use to quit.” Again, to engage people in treatment, to keep people in treatment, that’s the highest priority I think of any addiction treatment program.


Zach: 100 percent because if you lose them after the first session then I think that there’s a picture that’s been painted for some people even if it’s a defense mechanism to not have to dig in to their own recovery process, back to what we’re saying it’s about the relationship.


Dr. Volpicelli: My goal is for people not to go back using drugs and to have an enhanced psychosocial functioning. That’s for me the A number one priority that people are doing well with purpose in their life in terms of relationships. That’s where I want people to be. If I want to get there, the chance to going back using drugs is much less. That’s the A number one priority. While abstinence is a good goal, for me the critical thing is keeping people in treatment and looking to see how well they’re functioning.


Zach: Got it. I guess last question from my end: how long do you typically see patients? Is there a typical time frame that you’ve…months, weeks, years does your typical patient come in? What does that look like?


Dr. Volpicelli: In our program now, I sort of modeled our program based on what we did on our research studies. Again, in the research studies we are finding a very high percent of people getting better and in clinical practice a really high relapse rate. I said, “What happens if we took what we do in research and design a clinical program around that?”


The clinical program I have now when you come in, basically we assess to see if you need to be detoxified from alcohol or other drugs. If you do you need to come in every day. We give you some medicine to help alleviate the withdrawal symptoms. After that then the next 12 weeks is going to be a more acute recovery phase, if you will. During that time we’ll oftne recommend that you take naltrexone or Vivitrol. We do once-a-week individual counseling and get people peer support.


After three months if people are doing well, they could come in every other week. If they’re doing well another three months after that, six months into treatment they can come in once a month. For some people that works fine. For some people they have more needs – maybe the addiction is under more control but they’re still dealing with social anxiety or depression or bipolar disorder so we’ll have to see them more frequently. We individualize treatment depending on what the needs of the patient are.


Zach: I think there’s a lot that can be learned from that because as we become almost sort of a cliché this idea of individualized treatment and what that actually means it sounds to me like that’s a really nice framework for people who follow.


Dr. Volpicelli: Yes. We find that again, people who stay in treatment tend to have a good outcome.


Zach: Got it. I just want to thank you for your time today, Dr. Volpicelli.


Dr. Volpicelli: You’re welcome.


Zach: This has been great. Yes.


Dr. Volpicelli: Thank you.


Zach: Listen, if you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.


I’m Zach Crouch with Landmark Recovery Radio wishing you well.


[47:15] to [01:33:59] is just a replay of the preceding interview with Dr. Volpicelli.


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Landmark Recovery was founded with a determination to make addiction treatment accessible for all. Through our integrated treatment programs, we've helped thousands of people choose recovery over addiction and get back to life on their own terms. We're on a mission to save one million lives over the next century. We encourage all those struggling with substance use to seek professional help.

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