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Duncan McEwen, MD

3308 Durham-Chapel Hill Boulevard, Suite 131
Durham, NC 27707
Telephone: (919) 810-3536

Ending Chronic Suffering from Addiction

“I think the most important thing to remember about addictions and other mental illnesses that might be considered chronic,” observes Durham psychiatrist Duncan McEwen, “is that having a chronic disease doesn’t condemn you to chronic suffering.

Dr. McEwen

“Chronic mental health problems— including addiction—can be managed successfully,” he asserts, “and we can be optimistic that medical treatments are advancing at an astounding pace.

“There’s no question that many aspects of chronic disease arise from things beyond a patient’s control, such as their genes. And we are increasingly coming to understand the vulnerabilities in certain brain circuits that promote long-term psychiatric illness. These circuits don’t condemn a person to dysfunction, but they are certainly something that needs to be paid attention to.”

Equally important, notes Dr. McEwen, are the very individual factors influencing each patient’s life and disease. “Siblings sharing the same gene pool and mostly the same upbringing can still respond differently to life events and stresses. Let’s take two children with an alcoholic parent or grandparent. As an adult, one of the sibs early on gets onto a path that’s exciting and rewarding; the other is stalled and experiences a serious trauma. That difference may be enough for the genetic vulnerability to be expressed in one sibling and not the other.”

Understanding the highly individual nature of chronic mental illness, says Dr. McEwen, is the key to managing it. “We need to be aware, for example, that dysfunction can extend beyond one area or illness. The same vulnerability that might make someone susceptible to addiction might also be expressed with a predisposition to another condition, such as depression or chronic pain. Tending to any one of these dimensions often has a favorable impact on others.”

While managing chronic illness requires significant commitment, Dr. McEwen remains optimistic about treating these patients. “We have many good choices available today for motivated patients to participate actively in their care,” he says. “and I have seen again and again, that when people give treatment a chance, they have an early sense of improvement that can motivate them to really dig down and actively pursue the sometimes longer journey to recovery and healing.”

Health&Healing: Does the source of a person’s addiction problem matter? Do you work differently with a person who became addicted on recreational drugs versus someone who got addicted to painkillers after surgery?

DR. MCEWEN: Do different paths to addiction matter? It always matters; because everyone can be different in some really important ways. Addiction has to do with brain circuits as well as life circumstances. All of us have addictive circuits in our brains. They’re there to get us attracted to things in life that are good for us—in essence, to get us addicted to life.

For the addict, something—or maybe several things—happens that gets in the way of their being “addicted to life.” So, they turn to drugs instead. We need to know what those things were that caused the misdirection. There is some marvelous research that showed that it’s easy to get a rat addicted to drugs in a lousy lab cage, but much more difficult is you provide the rat with a rewarding environment. Getting the broad scope of what variables are at play in an individual person’s life is an important part of treatment. All of these things come to light with careful evaluation.

Health&Healing: What are the variables that you consider in evaluating patients and determining individualized courses of treatment?

DR. MCEWEN: We absolutely want to pay attention to genetics, such as a vulnerability to addiction. If that’s part of the picture, we have a better understanding of how to address other variables.

A second consideration is stress tolerance, or how the patient handles life’s provocations. A patient of mine comes to mind who illustrates this. She initially came in—about eight or ten years ago—with a history of trauma and very impaired stress tolerance; ordinary demands of life would cause her to feel like she was falling apart.

In the time we’ve known her, she’s grown tremendously. In recent years, she’s been through a number of tremendous challenges—including medical challenges—but she has developed a resilience that’s tenfold what it was when she started out. Stresses that earlier in life would have thrown her off balance are now seen as solvable problems. She has a new found sense of self-worth in being able to “take care of business” when challenged.

That example also speaks to another key variable in treatment—motivation—an attribute that is related to a biological vulnerability called future discounting.

Future discounting is one of the subtler aspects of chronic substance abuse. In short, it is a diminished capacity to vividly visualize future rewards. And the lack of being able to visualize longer-term rewards makes it hard for those with addiction issues to invest in their future. People undertake long-term challenges—such as recovering from addiction—only when they can visualize a future reward with sufficient clarity to push themselves in the direction of change. Helping patients get to a place where they can envision—and desire—the rewards in a future without addiction is a critically important part of what we do.

Another key variable with a biological basis is salience—something that stands out in the environment. You might say that a rabbit has a lot of salience to a fox. Basically, what we’re trying to do is change what’s salient in a person’s life. People with addictive problems will often attach a lot of salience to drugs while having a diminished salience for things that drive humans such as creativity, competition, or devotion to friends and family.

One example of this is a woman I met who is five years abstinent from addiction to pain meds. She is doing great in life, with a rewarding job, good family relations, and a sense of stability. She illustrated the subtle but evolving issue of salience when I asked her to compare something fun she expects to do in the next 24 hours compared to the experience she used to have popping pills.  She responded, “those pills would be tempting.” However, a moment later she added: “To think of it, I’m having breakfast with my grandmother tomorrow and there’s no way pills could compete with that.” Changes in salience—in what a patient values most—are a great way to measure a person’s progress.

H&H: Where does medication fit into the treatment of addiction?

DR. MCEWEN: It’s called MAT—medication-assisted treatment—and I would argue that it’s pretty darned important. It’s been my experience that patients seem to adhere to treatment better when they are not experiencing the ups and downs of withdrawal. Suboxone, for example, does a pretty good job at simulating being clean so that the patient can really focus on improving their life.

H&H: Can you cure an addiction, or just treat it?

DR. MCEWEN: If, by cure, you mean can you completely forget that there are issues about which you are vulnerable? Well no, it’s kind of like, can you cure diabetes? No. But, if by cure you mean can you manage the condition to the point that it doesn’t have to interfere with quality of life, then then answer is a resounding “yes.”

Ultimately our approach is to help a patient identify and work on his weaknesses, tap into his strengths, and visualize a future worth chasing down.