by Dr. David Arneson, NMD
(article originally published in the December 2006 issue of Naturopathic Doctors News and Review)
First of all, I am in recovery myself for more than 31 years, primarily from alcohol. Looking back at the journey, and my clinical experience treating alcoholics and drug addicts (over the last 17 years), I can say one thing with confidence – this is a body/mind/spirit disease. In fact, in the majority of cases, the clinician will come to the determination that this is little about drugs and alcohol and more about the need for the patients to anesthetize themselves from life in general. All the research in the world trying to find genetic determinants for alcoholism and, for that matter, drug addiction, have never determined a genetic cause per se, and never will. There is no gene in the human being that determines we are “doomed” to drink/drug our lives into oblivion. Unique genetics, life stressors, family and social stressors, improper nutritional intake and other factors affect biochemistry/neurochemistry. Depression and anxiety are the two most common symptoms early in recovery, and may exist before the first drink. Yet, it defies logic that as a profession we can treat most cases of alcoholism/drug addiction with Prozac or a multi-drug regime, and expect to find resolution of the diseases of dependency. However, an idea put forth by Terry Neher, DDS, CCDCIII, in an article entitled “Neuronutrient Therapy: A Study in Stabilizing the Stress of Recovery” (1993, p. 31), states our position clearly: “If we demand behavioral change from our patients without allowing them to bring their brain chemistry into more positive balance, we simply set them up for failure.”
Withdrawal Symptoms and Nutrient Therapy
As long ago as 1969, terms were being used about a protracted withdrawal syndrome. Today, this is known as post acute withdrawal syndrome (PAWS). The idea behind PAWS is that the average patient continues to have underlying symptoms of withdrawal long after the original drug or alcohol has been metabolized out of the system. These symptoms can include depression, lack of concentration, mental fogginess, anxiety, sleep issues, fatigue and immune system dysfunction. It is also noted in the literature that these symptoms can last from six months to two years in the average patient if they do nothing more than just quit the drug or alcohol.
The level of signs and symptoms of this withdrawal are different with respect to the following conditions: 1) type of drug, 2) amount of drug taken, 3) duration of drug use, and 4) genetic makeup of the individual. Without a doubt, withdrawal symptoms are the primary reason for chronic relapse into the drug of choice. In my clinical practice, both in-patient and outpatient, it is rare to see these symptoms last longer than three to six weeks in the average patient utilizing focused nutritional biochemistry as the primary treatment. Yet, nutritional therapy is a complex issue. Clinicians that wish to pursue this level of treatment for their clients must understand extensive information on metabolism and genetic function. Without understanding the intricacy of molecular functions and how they are activated and manipulated through nutritional treatment, the clinician is likely to create more harm than good. Even if harm is not caused to the client, treatment often fails to produce the desired result. Just taking one particular vitamin or amino acid to address health issues in detoxification and recovery is much akin to supplying the client with just Prozac to “cure” their depression. Majid Ali, MD says it best: “… No molecule exists in biology alone, functionally or structurally. This is self evident. And yet we physicians insist in diagnosing ‘a nutrient deficiency’ to understand ‘a disease’ which we can then treat with ‘a nutrient therapy’ … The central issue here is: Mono-nutrient therapy has no place in the clinical practice of molecular medicine.”
One thing must be made clear – Any drug that has an effect on neurochemistry has the potential to create emotional/physical dependency. This is also true for most prescription medications currently in use to treat chronic depression, anxiety and drug dependency. In fact, some of the most dynamic withdrawals I’ve ever seen come from detoxing patients from drugs such as Effexor, Paxil and Prozac. Generally, the longer the drug is taken, the more severe and long-term the withdrawal syndrome. The same applies to street drugs and alcohol, yet I find those infinitely easier to treat. It would behoove the physician that chooses to assist his patients in these pharmaceutical detoxes to read books such as Prozac Backlash (Joseph Glenmullen, MD) and Your Drug May Be Your Problem and Toxic Psychiatry (Peter Breggin, MD). These psychiatrists are writing about their own profession. Any drug that has an effect on neurochemistry changes the way the bio/neurochemistry normally functions. All street drugs, including alcohol, negatively affect the “normal parameters” of bio/ neurochemistry, down-regulate the production of neurotransmitters and lead to what is termed “neurotransmitter deficiencies.” Even chronic depression and anxiety have been shown to deplete neurotransmitters and the receptors that they act on … literally, all antidepressants and psychotropics serve to down-regulate neurotransmitter function over time. In fact, the research shows that the use of SSRIs will damage dopamine neurons over time (Glenmullen, 2001). I fully expect in the next five to 10 years that we will see an increase of Parkinsonism, “of unknown etiology.” One-sided treatment of any neurotransmitter creates changes in the other associated systems. As a result, I use comprehensive amino acid formulas to treat both the monoamines (serotonin and dopamine) and the catecholamines (norepinephrine and epinephrine) at the same time.
If we truly want to treat the deficiencies created by the use of alcohol and drugs, then we need to understand one thing clearly – like a house that has been damaged in a storm, we need proper building and repair materials. The body/mind house only knows nutritional building materials. One cannot say absolutely that all will respond completely to such nutritional treatment regimes. Yet in our experience, well more than 80% do respond favorably to such nutritional focus. The reason for this is quite clear: The only way to repair the damage, or to facilitate the return to normal function, is to utilize the knowledge of nutritional biochemistry. In holistic medicine, this is known as functional medicine, molecular medicine or cellular medicine.
A logical question put forward by many is, “Why doesn’t standard medicine utilize this nutritional knowledge to facilitate the return of health to the individual?” The Harvard medical school looked at this issue and discovered that more than 70% of its doctors received no nutritional biochemistry in medical school. Other studies calculate that only 5% or so of the standard medical doctors in this country receive any nutritional biochemistry in medical school.
The most important factor in choosing a nutritional treatment regime for any patient is the history, not only of the pre-use time but also of the amount of time used, type of drugs used and mechanism of action of the particular drug being utilized. More importantly, why is it that more than 85% of patients have a specific drug or alcohol that is their drug of choice? Each drug has what is known as a mechanism of action on bio/neurochemistry. People choose a drug of choice because it satisfies a deficiency … it “fixes them,” if you will, and makes them feel better than they have ever felt. Most drug and alcohol addiction can be looked at this way. It is about self medication; it is about what makes us feel “normal.” Initially, the reasons for starting to drink alcohol or take drugs may come from a variety of reasons or causes. These can be centered in genetics, peer group pressure, emotional-psychological, disconnection from life/disconnection with the spirit or the meaning and purpose of our existence. Viktor Frankl notes this in his book, Man’s Further Search for Meaning. He believes that addiction is primarily caused by a sense of emptiness at the heart level – the lack of a sense of purpose and meaning. He also believes that the patient’s failure in entering into long-term recovery is due to several factors: One is the patient’s failure to ultimately take responsibility for the journey of recovery and/or the clinician’s failure to facilitate this understanding of responsibility in the patient. Whatever the original cause – the biochemistry becomes more distorted and recovery becomes more difficult with time – if we want to move the patient to some sense of bio/neurochemical normalcy, then we must give the body the repair materials it needs, in sufficient quantities, to elicit movement back to health. Since emotional/spiritual health is largely dependent on adequate functioning of the bio/neurochemical processes, then certainly the first step in treating the patient is through detoxification and, subsequently, tonification.
If one looks at the bigger picture, it is in the act of detoxing that we start tonification. With the exception of certain antidepressants (especially ones with long half lives) and benzodiazepines, we don’t usually encourage step-down protocols. A good example of this is a patient that came to our clinic on 220mg of oxycontin per day. On the first day she asked, “Do you think that I should do 110mg tonight before I start this?” I asked her whether she’d even feel the 110mg dose. She said that she would not – which is typical of building tolerance to opiates. She went cold turkey, and today, 18 months later, she is completing her doctorate in oriental medicine. Most step-down protocols only serve to increase the time of misery for the patient. There is no weapon in the arsenal of the naturopathic physician that will exceed the power of nutritional biochemistry, especially during the detoxification stages.
Intravenous therapy is initiated on the first visit. These are usually two-bag events, with special consideration toward re-establishing membrane potential (electrolytes) and basic vitamin bags. Glutathione is often utilized in the first week to assist in liver detoxification. High-dose amino acid therapies are implemented in the form of tyrosine, 5-HTP, and glutamine dosed twice daily. In conjunction, we add a good-quality multivitamin (once per day in the a.m.), fish oil (2000-4000mg per day) split dose; methionine—the precursor for SAM-e (2000mg per day– split dose), and adrenal support orally. A natural form of L-dopa (from the plant Mucuna pruiens) may also be prescribed for the patient. This is important with respect to the mechanism of action of the drug the patient has been on. Methamphetamines, opiates and certain antidepressants that have action on the dopamine/ norepinephrine/epinephrine pathways will generally respond well to the amino acid formulas with Mucuna pruiens. Alcoholism, cocaine and antidepressants that principally have less caustic action to the catecholamines will generally do well with the TTL formula. While I would be first to agree that every patient is different, one must start somewhere. So we start every patient on the same protocols devised for their specific drug of choice. On average, one will know if the therapy is effective in 7-10 days, and in our clinical experience this happens in 80%-85% of the patients treated. The best measurement to the efficacy of the therapy and when to change dosages and supplement regimes is based on how the patient reacts to the therapy. I was told three basic rules in my clinical training: 1) know what you’re treating; 2) don’t overwhelm the patient with therapy; and 3) give the therapy time to work.
Dosing levels have to be considered in regards to the age of the patient; for those younger than 18, we start out at half dosing on the oral supplements. Liver detoxification is an important aspect of the treatment regime, with milk thistle, glutathione and lipoic acid being the mainstays.
It is noted in the literature that opiates and methadone negatively affect the hypothalamic/pituitary/adrenal axis. In truth, this can occur with all drugs and alcohol, and is why we use adrenal support in many of our protocols. Treatment for mitochondrial dysfunction must also be considered. Arginine and carnitine should be considered, along with the antioxidants – vitamin E, Co-Q-10, vitamin C and lipoic acid.
During the detoxification stage the withdrawal symptoms can be managed using pharmaceutical medication. We find in our clinical experience that these drugs are rarely needed after the first two weeks. Many of these drugs also have the potential for abuse, or to build tolerance, so extreme caution is advised so to not exchange one form of addiction for another.
In-Patient vs. Outpatient Care
It is interesting that most drug detoxifications that need stepping down over time, to reduce the risk of complications, are prescription antidepressants and benzodiazepines. At our clinic, we perform immediate withdrawal on alcohol, cocaine, methamphetamine and opiates (including methadone and abused pharmaceutical opiates). On the occasion that we do outpatient detoxification, patients must see me for 5-7 continuous days, so they can be assessed medically on a daily basis. Obviously, since each patient is different and each drug is different, there are some that I prefer not to do outpatient. Those drugs include the opiates (especially heroin and methadone), benzodiazepines and most cases of alcoholism. Even seven days in-house can stabilize most patients enough where outpatient treatment is a viable option. The exception to the seven day rule is methadone, heroin, benzoes and methamphetamines. It requires at least 14 days for most of these, and I insist that the methadone patient stay in-house for 30 days. Frankly, most of our in-house patients stay 30 days regardless of the drug or alcohol. Of course, it is not all about nutritional treatment; they also get an introduction into the 12-step program that they attend daily, along with daily Yoga, meditation and focused exercise, and biweekly master’s-level psychotherapy and group therapy. The failure of most out patient treatment programs point out the weakness inherent in outpatient therapy – how many really work on the holistic healing?
Assessment and Monitoring Tools
There is an interesting book entitled Third Line Medicine by Werbach, MD that describes research done in England on the value of basic medical tools in correctly diagnosing illness and disease. Patients were followed through time, and the results were tabulated some 15 years later. The conclusions were: 1) if the doctor listened to the patient, he or she could come up with the correct diagnosis and, hence, the correct treatment, 75% of the time; 2) If the doctor could do an adequate physical exam, he or she could come up with an additional 10% of the diagnosis; 3) if minor lab work was employed, an additional 5% could be utilized for the correct diagnosis; 4) major diagnostic tests, consisting of MRIs and other associated radiology and expensive testing not normally utilized at the basic level, would add another 5% to the diagnosis; and 5) 5% of the diagnosis would remain unknown. The results point out that 90% of the diagnosis can be made without expensive testing. The study also points out that of all the expensive testing performed, it only changed the first 90% for 3% of the time.
Assessing nutrient deficiencies is difficult. Many times, standard lab tests may show normal results even if specific levels are outside defined parameters. As an example, only 1% of the magnesium in the human body is free in the blood; the rest is found in the cell or bone. In one lab study involving alcoholic patients with low hemocrit, multiple-nutrient deficiencies were noted. The researchers found that normal laboratory parameters used for non-alcoholic patients were inadequate when applied to alcoholic patients. This is true for drug addicts as well. This makes sense, since nutrients have multiple and complex interactions at the cellular level and all alcoholics/drug addicts have varying degrees of deficiencies. All chronic alcoholics and drug addicts suffer from some level of nutrient deficiencies. Unfortunately, the only serum testing for intracellular nutrient deficiencies are expensive and out of the economic feasibility of the common alcoholic or drug addict. Lab testing early in detox convinced me of one thing: 99% of the time it did not change the treatment regime, since the idea behind nutritional treatment is to bring these parameters back into normalcy. However, when the patient is struggling beyond what we feel are the normal parameters for a typical detox, especially at the two- to three-week level, we run basic labs to assess any potential chronic problems.
Alcohol withdrawal assessment tools, psychological parameter measurement tools and other documents are easy to access online. The CAGE questionnaire will help the physician screen possible alcohol-related problems in the patient. Our clinic has generated comprehensive questionnaires for patients to assess the total history of their dependency, and this includes the forms of all treatments and types of treatment utilized, whether pharmaceutical or psychological. Assessing the patient’s vitals several times daily is essential in early detox. After detoxification, vitals are assessed every visit. Initial physical measurements, such as body weight, height and percent body fat, would allow the clinician a point from which to measure therapeutic efficacy of the treatment. A measurement of psychological parameters during treatment, whether subjective or objective, can also be used to measure therapeutic efficacy of the treatment protocol.
Use of Additional Therapies
As naturopathic physicians, we employ all the tools at our disposal to assist patients in their detox and recovery. The first step is detox and assistance into recovery. We utilize both acute and constitutional homeopathy on virtually every patient. Homeopathy is an effective and scientific system of healing that assists the natural tendency of the body to heal itself. Most will have multiple acupuncture treatments. Acupuncture is based on the ancient Chinese theory of qi (energy) flow through channels or meridian pathways that run through our body. Channels are like superhighways of energy. When the body is in balance, the qi travels smoothly through the channels in a specific direction or flow pattern. But sometimes when the qi is out of balance, it will stagnate or gather in particular points along the superhighway, creating a multitude of disease states. These are the points where we place the needles – to move, disperse or reroute the qi, thus restoring balance and the movement toward optimum health.
Physical medicine treatments are made available to all patients before they leave the in-house program and to all in the outpatient setting. It is amazing the number of patients who self medicate because of physical discomfort. Assessment of subluxations and the proper treatment to resolve these subluxations often makes the patient feel better and less likely to relapse. In the process of helping the patient in recovery, and achieving optimum health, the physician will find that most will end up being a patient over the long term for their general health.
Three things must be addressed – physical health, emotional health and spiritual health. There is absolutely no replacement for good oral nutrition and adequate exercise. The physician must guide the patient in these endeavors. It is known without reservation that whole-food diets increase the likelihood of success in recovery and detox. In one trial, coffee, junk food, dairy products and peanut butter (the “hospital” diet) were replaced by a special diet that included fruit and a whole-foods protocol. At the six-month review, fewer than 38% of those on the hospital diet had remained sober, compared to 81% of those eating the special diet. Other trials have shown that restricting sugar, increasing complex carbohydrates and eliminating caffeine reduced alcohol cravings. When alcoholics are placed on diets high in raw foods, many spontaneously avoid alcohol (and tobacco); those placed on nutrient-loaded diets along with multivitamin supplements did far better at follow-up in abstaining from alcohol than did the controls.
Joan Larson, director of Health Recovery Center and author of Seven Weeks to Sobriety, has compiled astonishing statistics after designing a program that utilized nutrition as the foundation of alcoholic recovery. One hundred alcoholic clients, chosen at random, were followed up 3.5 years after completing the program. At discharge (seven weeks), 85% were free of anxiety, 94% claimed no sleep problems, 98% claimed no shakiness, 96% were free from dizziness and 95% were subjectively depression-free. Furthermore, at the six month interview, 92% were abstinent from alcohol, 85% of whom had remained continually abstinent since treatment. Some three years later, 95 of the original 100 subjects were interviewed, and 74% had remained abstinent.
Exercise, in one form or another, is necessary for proper functioning of all biochemical systems. Exercise increases blood flow throughout the body/mind, increasing oxygen and vital nutrients to the body/mind, thereby enhancing and propagating biochemical processes. Exercise also enhances the movement of metabolic waste products out of the system. For those who are physically unable to exercise early in detox, I encourage them to swim. Yoga, tai chi and Chi Gong are alternatives as well.
In addition, I encourage everyone to attend 12-step meetings over a process of three months. Twelve-step meetings are a tool. Counseling, 12-step meetings, the physician, yoga, nutritional biochemistry and any and every tool are not answers. They are simply tools that enable the patient to find their way back to holistic health. Frankly, if the patient wants something different, they must do something different. Ultimately, success depends on the patient’s acceptance of the responsibility to access and utilize these tools, and it is the physician’s function to make the patient aware of possible options.
Certainly, there are other options than the 12-step programs. Most of my Native American patients choose what is called the Red Road. This in many ways is like the 12-step program in that it involves the reconnection to a spiritually based support group. The ee-nee-pee (or inipi), or the sweat lodge, is one such ceremony, which is about reconnection and rebalancing with life. The Vision Quest, the Long Dance and the Sun Dance are others. In fact, all in-house patients are invited to attend at least one Sweat Lodge while in the 30-day program. Even many outpatient clients have taken advantage of these ceremonies. Some will find their reconnection in religion. Regardless, one cannot heal holistically by feeding the body only. The emotional mind and the spiritual body need sustenance and healing as well.
When I was an undergraduate, I wrote a paper on alcoholism for a class assignment. One statistic has remained in my mind ever since: For every alcoholic, there are at least four other people directly affected by that case of alcoholism. In my experience, this is also true for any form of drug addiction. An article published in The New England Journal of Medicine, “Management of Drug and Alcohol Withdrawal” (May 1, 2003), states these statistics: “Each year in the United States, approximately 8.2 million persons are dependent on alcohol and 3.5 million are dependent on illicit drugs, including stimulants (1 million) and heroin (750,000).” The article goes on to state that 15%-20% of the patients seen in primary care and hospitalized patients have alcohol (abuse or dependency) problems. What this means to any doctor is that, on average, 10%-20% of patients will have either an abuse or dependency problem. It would be wise for all physicians to familiarize themselves with the signs and symptoms of alcohol or drug use, so that the appropriate diagnosis and treatment can be initiated.
Furthermore, my experience in treating drug and alcohol addiction has convinced me that the amount of anything material an addict has left has little bearing on the odds of successful recovery. I’ve had those that drove their Maseratis to my office, with their seven figure monthly incomes, and thought that money would buy sobriety. They rarely make it into long-term recovery, because they are constantly looking outside themselves for the answers that lie within. Then, there are those that literally spent the last 30 years with a heroin addiction – sticking needles in their arm until there was no place left to inject – make it into long-term recovery.
No one can know for sure whether any one patient will utilize the tools at his or her disposal. The ones that do most often make the journey back into life and recovery. In my personal journey into recovery, I’ve sat side by side with every known occupation in life – doctors, lawyers, contractors, day laborers, county commissioners, etc. In my role as a naturopathic physician, I’ve treated the same. It does us little good to stick our heads in the sand and pretend that this is a poor man’s disease. It exists all around us and needs our attention and knowledge. Ours is the perfect profession to get this done.
Neher T: Neuronutrient therapy: a study in stabilizing the stress of recovery, Professional Counselor Aug:31, 1993.
Majid Ali, MD, Intravenous nutrient protocols in molecular medicine. In: Nutritional Medicine: Principles and Practice (unpublished manuscript), Denville, n.d., Institute of Preventive Medicine, pp 1-7.
Glenmullen J: Prozac Backlash, New York, 2001, Simon & Schuster.
Breggin P: Your Drug May Be Your Problem, New York, 1999, Perseus Publishing.
Breggin PR: Toxic Psychiatry, New York, 1991, St. Martin’s Press.
Frankl V: Man’s Further Search for Meaning, New York, 1984, Washington Square Press.
Werbach: Third Line Medicine, New York, 1986, Arkana.
Larson J: Seven Weeks to Sobriety, New York, 1997, Ballantine Publishing Group.
Kosten TR and O’Connor P: Management of drug and alcohol withdrawal, The New England Journal of Medicine May 1, 2003.