Appeared in The Los Angeles Psychologist September / October 2007


Ken Bachrach, Ph.D.



There have been many changes in the field of addiction in the past fifteen years.First, drugs of abuse have changed considerably.††† Methamphetamine is now the number one abused hard drug in the world, with there being more methamphetamine addicts than heroin and cocaine addicts combined.World-wide there are over 26 million methamphetamine users, with 1.4 million of them being in the United States.ďMethĒ has taken the world by storm, and researchers and treatment providers have been working hard to understand its short-term and long-term effects.There are profound psychological, cognitive, sexual, and physical effects of methamphetamine abuse, which are often not well understood by treatment providers.Knowledge of this is critical to deal effectively with methamphetamine users in various stages of recovery.For example, compared to cocaine, methamphetamine releases three to four times the amount of dopamine to the reward center of the brain.It is not surprising that sex plays a major role in the use and recovery process, and surveys of methamphetamine users, compared to users of cocaine and other drugs, document that they experience an increased sex drive, an improved sexual performance, and a greater obsession with sex.Also, they worry more about what sex will be like without methamphetamine.It has been my experience than most clients will not bring up issues around sex and drug use, and most clinicians will not inquire about the topic, which is critical to effectively work with these individuals.


Much has changed in terms of our understanding of addiction and the brain.We are now able to use brain scans to see which parts of the brain light up when we use drugs or think about using them.We can identify the parts of the brain associated with craving states, which is the precursor to relapse.Medications are being developed to damper these craving states so that the frontal lobes can take over and make more appropriate decisions for the individual.Still, these cravings can be very powerful, since they often resemble other built-in motivational systems we need for survival.In fact, the brain may be tricked into thinking we need drugs to survive, which may explain the driven state often associated with individuals addicted to substances.In addition, there is classical conditioning going on at the same time, which further drives the person to want to use and act on these impulses.


The field of addiction has entered its adolescent and is slowly maturing.There is now a consensus of treatment principles that were developed by clinicians and researchers working together.There is an emphasis on disseminating evidenced- based treatment approaches to providers, although there still is difficulty in getting providers trained to use this information.One area that seems to have been successfully disseminated is the recognition that confrontational approaches to engage individuals is often counterproductive, and the recognition that most people entering treatment for an addictive disorder are ambivalent at best.Engagement is now viewed as a separate and distinct part of the treatment process, and the failure to recognize this can lead to much lower retention rates.Motivational counseling approaches are now used regularly by treatment providers, and this is one area where mental health professionals, who generally donít work in the addiction field, can learn a thing or two.This requires assessing the state of change a person is in when they first seek treatment, since different clinical tools and skills should be used, depending on their stage of change.


Once youíve identified that a person has an addictive disorder, how do you determine the level of care they need?Over the past ten years, a patient placement criteria, developed by the American Society of Addiction Medicine, has become the national standard for determining patient placement for individuals with addictive and co-occurring psychological disorders.Most states and managed care companies use some form of this criteria, and it provides a very useful framework to both conceptualize cases and communicate oneís findings to others.There are six dimensions, with three being the usual medical necessity ones and three being more psychosocial in nature.Two individuals can be using the same amount of substances, but based on the application of these criteria may be appropriately placed at different levels of care.


A major paradigm shift occurring in the addiction field is the viewing of addiction as a chronic disease.A ground-breaking article was published in 2000 in the Journal of the American Medical Association by the well-respected researcher, Tom McLellan and colleagues, which compared compliance and relapse rates for addictive disorders to those for insulin dependent diabetes, medication dependent hypertension, and asthma.Surprisingly, relapse rates for addictive disorders looked very similar to those other chronic diseases.Yet the model of care for other chronic diseases is quite different than that provided for addictive disorders.Imagine telling a diabetic that itís their third visit to the emergency room this year, and since they donít seem to be able to manage their weight and diet, we will no longer provide care to them!Yet for substance abuse this is unfortunately how we often establish benefit plans and treatment, with lifetime limits to care, even though the total economic costs to society for addictive disorders is greater than that for cancer and heart disease. ††Studies of individuals with serious and persistent addictive disorders reveal that these individuals have a death rate 50 to 100 times the rate of the general population in the same age range, and that those who achieve one year of stable recovery, do so following three to four treatment episodes over a span of eight years.The outlook is not so dismal for all individuals, just like it is not for all people with mental disorders.Still, there is a need to examine how we provide care to people with addictive disorders and reframe addiction as a health problem.


Ken Bachrach, Ph.D. is Clinical Director of Tarzana Treatment Centers.He has been engaged in clinical practice, research, and training in the field of substance abuse and co-occurring disorders for over 20 years.Dr. Bachrach is site Principal Investigator in NIDAís Clinical Trials Network, which tests new and promising treatment protocols.Also, he is President of Professional Psych Seminars, a leading continuing education provider for psychologists and other mental health professionals.