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Clinical Perspective: EZ Does it

By Jeff Vircoe

Just as spiritual leaders like Emmet Fox and 12 Step laymen like Bill Wilson were quick to caution people to slow down and take it easy, experts in the field of addiction medicine stand solidly behind the Easy Does It mantra as well.

It seems there is plenty of therapeutic medicine to be digested in the saying.

In the 1500s, British writer John Heywood is widely saluted for coming up with the phrase “Rome wasn’t built in a day” as a translation from a French proverb. The idea is that anything of value requires patience and hard work to obtain.

At Edgewood Treatment Centre, the Romans are addicts and Easy Does It fits in with the old familiar ditty.

“One of the big things that helps them to stay grounded, especially when they’ve got a lot of personal things going on and it’s distracting them, is the Stay in Your Shoes keychain. I still give lots of those out,” says John Pynnaken, an addiction counselor who has been helping addicts for almost 22 years.

“Stay in Your Shoes is similar, it’s about focusing on where I am at presently, rather than focusing on everything else. So it’s very similar,” says Pynnaken.

When addicts in treatment are busy with outside issues, it interferes with the important work they are supposed to be doing on themselves, like learning to identify their feelings, getting and giving feedback, becoming responsible.

“It looks like they’re busy, they’re avoiding, or they’re hiding out,” says Pynnaken. “Or they’re so fixated on calling home, so busy outside of themselves. They’re getting caught up in other people’s craziness. In and outside of the treatment centre.”

Physician Gary Richardson concurs with the prescription of Easy Does It as well. With 15 years of helping addicts find their way back to health, Dr. Richardson is quick to understand the importance of some of the time-tested slogans of recovery. Easy Does It makes a lot of sense to him.

“Your addiction didn’t happen overnight,” says Richardson, “so, remember that we are dealing with a chronic illness. To expect everything to just turn around immediately is not realistic. I have used this [Easy Does It slogan] before … in terms of how long did it take you to get here? One is going to have to be patient. So, some of it, to me, means patience, but trusting that if you are doing the right things, with time, things are actually going to get better.”

To a person, all of the Edgewood staff questioned for this story felt that Easy Does It was an appropriate bit of advice for any addict trying to get healthy. Most were able to quickly name a behavior they see that could be helped by the slogan.

Joel Hughes is a counselor, as well as a business development director for the Edgewood Health Network. Working with addicts at Edgewood in inpatient and extended care since 2008, Hughes says he understands how the Easy Does It concept can be so hard for addicts to get their head around at first.

“It’s a little bit counter-intuitive,” says Hughes. “[For] a lot of things in life, we, especially in North American culture, are taught, ‘If at first you don’t succeed, try, try again.’ So try harder. Push harder. Work harder. Be stronger. Just keep putting more effort at it, more time into it.”

Going fast is not a good idea, he says.

“The idea of Easy Does It [means] sometimes you need to go slow to go fast. Making a whole lot of mistakes often means that you have to start over. But if you think you are in a hurry to achieve sobriety, you are probably going to have a hard time acquiring it.”

Richardson also agrees with Hughes’ assessment of what the opposite of Easy Does It can look like in a treatment centre.

“We often speak of ‘addict behavior’ and ‘alcoholic behavior’ and that definitely is not Easy Does It,” says Richardson. “What comes to mind when I hear that is that, normally for an addict, it’s that 0-10 thing – it’s at 10 all the time. It’s not about slowing things down and taking it easy, it’s all or nothing. So, Easy Does It is also learning to slow down and recalibrate things. It’s okay to actually function somewhere in the middle rather than at 10 all the time, type of thing.”

After almost 12 years working with extended care patients at Edgewood, another counselor says Easy Does It simply means don’t be superman – or super anyone.

“The capital mistake that I see most often, especially with, like, let’s say a new dad, is I see this guy be like, ‘I’ve been neglecting my family, so I’m going to go home and be super dad. I’m just going to jump in and do the family thing like 100 per cent,” says Bill Caldwell. “Then start to give himself permission, like, ‘Nah, maybe I won’t do a meeting this week because I’ve got to spend time with my kids.’ They’ll let their program slip, right? Or they’ll be like, ‘I’ve got to be the best employee in the world. I’ve got to go back to work and work 16 hour days.” Or they’ll be like, ‘I’ve got to be the best guy in recovery.’ So, they’ll go to four meetings a day and burn out quickly on it. So, for me, I think it’s about keeping balance, doing it slow – slow is going to get you through, but 100 percent is going to burn you out.”

 

 

Is There a Relationship Between ADHD and Substance Use Disorder?

Written by: Dr. Charles Whelton, MD, FRCP(C ), ABAM

During their initial psychiatric evaluation at Edgewood, patients often describe a lifelong history of poor attention, hyperactivity and distractibility.  Many patients wonder if they have attention-deficit/hyperactivity disorder (ADHD), and ask if this could be tested for, and treated if it is present, while they are at Edgewood.

The relationship between ADHD and substance use disorder (SUD) is one that has significant clinical importance.

ADHD is an illness characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity, beginning in childhood, and causing functional impairment in social, academic or occupational settings.  Difficulty in sustaining attention is often the cardinal feature, but patients may also display disorganization, distractibility, forgetfulness, or failure to complete tasks.  Hyperactivity may be manifested by fidgetiness, restlessness, difficulty in remaining seated, excessive talking, or simply always being ‘on the go’, as if ‘driven by a motor’.  Impulsivity may present as impatience, interrupting others excessively, or engaging in activities without consideration of possible consequences.  Persons with ADHD may get bored easily, and consequently may frequently look for new experiences.  Paradoxically, individuals with ADHD may focus well or even hyperfocus, when the task is something that they are interested in.  Longitudinal data suggest that childhood ADHD persists in 50% of cases into adulthood.

Higher than expected rates of ADHD are found in populations with SUD.  Although ADHD affects 6-9% of children, and up to 5% of adults worldwide, fully 25% of adults with SUD have ADHD, with an earlier onset and more severe SUD associated with the presence of ADHD.  Conversely, approximately 20-40% of individuals with ADHD have a lifetime history of an SUD.  Prospective studies of ADHD children have provided evidence that ADHD itself is a risk factor for SUD. Children with ADHD who also have co-occurring conduct disorder or bipolar disorder seem to have the poorest outcome with respect to developing SUD.

There is some controversy about the effects of early ADHD treatment on the development of SUD.  An aggregate of the literature suggests that early stimulant treatment of ADHD reduces or delays the onset of SUD; however, the protective effect is lost in adulthood.  This may be due in part to adolescents stopping their ADHD treatment in later adolescence and young adulthood, and therefore losing the protective effect of this treatment.

The precise reason why individuals with ADHD develop SUD remains unclear. It has been proposed that some people with ADHD ‘self-medicate’ with substances, to treat their ADHD.  When substance abusing adolescents with and without ADHD were compared, adolescents with ADHD reported using substances more frequently to attenuate their mood and to help them sleep.  No overall differences in types of substance used emerged between these groups however.

Symptoms need to be assessed carefully before making a diagnosis of ADHD, particularly in persons with SUD.  Some ADHD symptoms are similar to symptoms that can be associated with SUD.  Attention problems can occur in some substance withdrawal syndromes, for instance.  Furthermore, some individuals may want to be diagnosed with ADHD in order to obtain a prescription for stimulants, and may feign ADHD symptoms. A thorough assessment is required.

The Canadian ADHD Resource Alliance (CADDRA) has designed a useful evaluation package, included in the Canadian ADHD Practice Guidelines.  This includes an evaluation of current symptoms and related functional impairment, as well as retrospective evaluations of childhood symptoms, by both the patient and by an independent observer such as a parent.  Collateral information can be very useful if available, such as past educational records and psychological assessments.  There are many conditions that can mimic aspects of ADHD including anxiety and mood disorders, conduct disorder and oppositional defiant disorder, personality disorders including borderline and antisocial personality disorder, and substance abuse itself.  When in doubt, neuropsychological testing can be helpful.

The treatment needs of individuals with SUD and ADHD need to be considered simultaneously, however, in general, the SUD should be addressed and stabilized first.  Addiction stabilization may require inpatient treatment.  Intervention for ADHD could then be considered in tandem with an addiction treatment program.

Not all patients with ADHD require medication.  Many adults with ADHD have learned ways of coping with their ADHD symptoms, and would prefer to not use medication.  Cognitive and behavioral therapies for both ADHD and SUD have been shown to be effective.  Adults with ADHD may benefit from psychoeducation, coaching or skills training.  However for others, medication can serve an important role in reducing the symptoms of ADHD and in improving functioning.

ADHD adults with SUD, noradrenergic agents (e.g. Atomoxetine) and antidepressants (e.g. Bupropion) should be considered first, to reduce the risks associated with using stimulants in this population.  If this approach is ineffective, extended-release or longer acting stimulants (Concerta or Vyvanse) with lower abuse liability and diversion potential are preferable to the short acting stimulants (Ritalin or Dexedrine), which can be more easily abused.

Regardless of the pharmacotherapy being used, patients with ADHD and SUD should be monitored carefully.  Treatment compliance should be evaluated regularly, and random drug screens performed as indicated.  If stimulants are used, care should be taken to monitor for abuse of the stimulant.  Treatment should be coordinated between all care providers, including family doctors, therapists and addiction counsellors.

When ADHD co-occurs with SUD, treatment for ADHD can help patients to focus and to complete tasks, and to be less restless and impulsive. This may in turn help with the treatment of the SUD.  Not all problems with attention are due to ADHD however, and careful assessment is required.  Furthermore, if ADHD is present in an individual with SUD, careful consideration of management options is essential.

 

(The following paper was the source of much of the information used in the preparation of this manuscript:   Wilens, TE and Morrison, NR.  The intersection of attention-deficit/hyperactivity disorder and substance abuse. Curr Opin Psychiatry, 2011 Jul: 24(4): 280-285.)

 

Registration is Open for 2015 Healing and Treating Trauma and Addictions Conference

Registration is now open for our 2015 fall conference!

Historically, the Edgewood Foundation has partnered with Jack Hirose to put on a conference about healing and treating trauma, addictions and concurrent disorders. With amazing speakers like Don Meichenbaum, Stephen Grinstead and Margaret Wehrenberg, the conference has been an informative and expanding experience for over 2500 clinicians.

This year, the Edgewood Health Network is joining that partnership and taking the event national.  Instead of one city, we’ll be in three! Clinicians across the country will get a chance to attend in either Richmond (Vancouver), Winnipeg or Oakville (Toronto).  And with a full roster of knowledgeable speakers and practical workshops, it’s a chance to expand your skills as a mental health professional.  Here are a few of the presentations we’ll be featuring:

 

This event is eligible for up to 21 continuing education credit hours for the full three day attendance.

We look forward to seeing you there! Register here: https://conference2015.jackhirose.com/