Dr. Kevin McCauley is the author of 10 Principles of Successful Addiction Treatment, and the DVD Pleasure Unwoven: a personal journey about addiction. At the Institute for Addiction Study and its affiliated Le Mont treatment facility, he and colleague Dr Cory Reich created the Applied Recovery program, a sophisticated recovery-monitoring program based on a model used for impaired professionals commercial airline pilots, physicians, nurses and attorneys. Participants in these programs have extraordinarily high success rates in getting through their first year of sobriety. He and Dr Inaba expand on these topics.
Transcript (edited):
DARRYL: Hello and welcome again to another CNS Podcast, I am Dr. Darryl Inaba and I’m here today with Dr. Kevin McCauley from Utah. I am so pleased that Kevin came down to the first annual conference Addiction Recovery Center conference and gave just an outstanding presentation on the neurochemistry, neuroscience of addiction. First of all, thank you very much.
KEVIN: Oh, the pleasure is all mine. Thank you for having me to Medford.
DARRYL: I wondered if maybe you can start off by just saying what youre doing now in Utah and what your programs are – just let us know what thats all about.
KEVIN: Well, youre familiar with the work of Bill White, he published a monograph on recovery oriented systems of care and recovery management and then he wrote his book, Addiction Recovery Management, and were just trying to translate the things that he put in that very excellent book into a community based program at the Sober Living Level in Utah. So, you could call where I work a sober living house – I prefer to call it a recovery management residence We have 10 people 10 men in a house and were trying to use his book and also the blueprint studies from Robert Dupont and Greg Skipper as our blueprint. In other words, to give the same benefits that physicians health programs have been giving to physicians to everybody. And its worked quite well.
DARRYL: That is really a big thing. There is sort of a double standard or a double level of treatment. If a person has insurance or private monies or they are a person of means, they get one level of care in this country, one that has fairly good outcomes and if youre not in that level of society, I guess you get jail.
KEVIN: Thats right!
DARRYL: Different levels of care – thats something that I guess the Addiction Equity Act is going to have to start addressing and changing. I think anybody whos an addict deserves the best quality of care they can get. What have you found provides the client with the best possible interaction in terms of treatment and outcomes?
KEVIN: My feeling is it doesnt really matter as much if they did inpatient or outpatient, its really what they do after that in their first year of recovery. And so, we have 10 things that are common to the physicians health programs and if they do all 10 of those things, they do well. But if I had one thing `that I could give to everybody coming through the front door it would be a job. I really think that vocational rehab is a critical part of helping people with their recovery. So, thats something I think is very important. I also believe and Im known as a bit of an extremist on this, so Ill proudly wear that label that everybody should be drug tested every day. And thats not to police them, that is to give the same kind of support to a patient as if they were a diabetic and I was an endocrinologist. Im a physician Im just in the habit of knowing whats going on with my patients on a daily basis. So generally if people have a good peer group, a job, and theyre being tested every day, thats half the battle, as far as Im concerned. And even if they do relapse, that relapse is occurring in the context of us knowing about it right away and being able to deal with it in real time. Its not the kind of relapse that goes on and on and on for weeks until someone finds it out.
DARRYL: You know, in our Addiction Podcast, we review research every week and a lot of what we find validates what you say. Many foreign countries report that the best predictor of a positive outcome is the number of urinalysis tests a person in treatment has and the more they have, the better the outcomes over a longer period of time. Are you familiar with the sensor bracelets worn around the arms and legs that actually measure whether or not someone has used – slipped or not? I wonder how those work.
KEVIN: I havent seen those. We havent been using those. Mostly we just we have a clear waiver and we do the 12 panel dip stick and we have a breathalyzer and the bathroom is designed for one thing and one thing only, so there arent any pictures or plants .so that kind of sets the tone and makes sure that there isnt any duplicity. Its a witnessed test. The staff tests as well. I would never anyone to something that I wouldnt be willing to do myself. I certainly welcome new technologies, but weve found that testing doesnt need to be real high tech and weve been able to get the costs well under 4 dollars a day. I train the staff to maintain the patients dignity when we test. We dont make it an us versus them hunt. This is just something that we do as men in recovery. Everybody in the house we just test and were accountable to each other.
DARRYL: How big an impact has the neuroscience and the continued evolution of neuroscience of addiction had in people engaging in the recovery process – do they have a better understanding and acceptance of their situations and going on to positive outcomes or going on into recovery?
KEVIN: Well, there is research that shows that a number of factors help predict long-term recovery and one of them is acceptance of the disease model. I think that as long as there is a discussion of it, thats whats important. I dont necessarily consider myself an evangelist. If a patient says, well, I just dont think that its a disease, but Im glad to know all this I think that thats good. But I do want them to be able to defend their position one way or the other. I think we should at least engage in a discussion about it. So, I try not to be too heavy handed about that. But there is research to show that if they have that didactic instruction that it does help them in recovery. So, I consider my job as being a person who can translate that very complex neuroscience into terms that they can understand and that their family can understand and that gives some validation and voice to their experiences. And I think the neuroscience does that quite nicely.
DARRYL: Id like to give your film a plug because you did that brilliant film, your video the name
KEVIN: Pleasure Unwoven. It sounds a little bit like a pornographic movie, I admit! Its not. Trust me, its not!
DARRYL: I wanted to give you a plug because the film takes the complex neuroscience that you presented today the neurochemistry and you used the canyon lands and the arches in Utah as an analogy. I show it to all of my groups and I show it to all the clients I have in treatment and the way you did it finally brings them an understanding of all those complex issues better than anything Ive ever seen before.
KEVIN: Well, thank you. Coming from you thats a real honor and I appreciate that.
DARRYL: Congratulations on that and hopefully it gets around more. Thank you very much for making it available to our conference today. In looking at your presentation of 10 aspects of positive outcomes or predictor of positive outcomes the one that intrigued me most the one I try and emphasize the most is fun in recovery.
KEVIN: Right!
DARRYL: I just love fun in recovery. Whats your take on that? Why does it show a positive outcome?
KEVIN: Well, I dont know that I really thought of it in any formal sense. I was reading something by Dr. LeClair Bissell if you remember her and she was talking about play. I always try to look for analogs in all of medicine. If Im trying to figure out a problem in addiction medicine, I ask – what are they doing in cardiology? What are they doing in physical medicine and rehabilitation? And I know its reasoning by analogy and there can be problems with that line of logic, but for the most part, it does work. And if a person had a stroke and I was trying to rehabilitate them we would engage them in speech therapy and occupational therapy and all kinds of different aspects of physical therapy and there is a certain window and if it doesn’t happen in that window, then were in trouble. So why would the brain act any differently in addiction? And so it struck me that we spend so much time trying to keep addicts from having any fun kind of immersing them in this almost stoic lifestyle could we be doing some damage? So if you follow Bissell’s work, she says its the rate of dopamine that matters. We need to take out that surge of dopamine. But it strikes me that the only way that you can really get a return to normal dopaminergic function and to normal receptor population is to put a normal release of dopamine back into the picture. Now I realize that fun and play involve many more chemicals than just dopamine, but I think its important to take out the smoking take out the drug use take out the binge eating, but put in normal pleasures. That just strikes me as the key way to get away from the residual anhedonic as quickly as possible. At first its not going to work and people are going to wonder why are we doing this? It isnt any fun because theyre still quite anhedonic, but as they practice pleasure .as they practice normal pleasures, it comes back. I was very gratified by the chapter in Bill White and John Kellys book (Addictions Recovery Management) . by Rudolph Moos at Stanford, he talks about the 4 theories that describe the social processes that people engage in in long term recovery and one of them was behavioral economics. In other words, practicing protective pleasurable activities as an alternative to continued drug use. So, it was a number of other peoples thinking that coalesced for me and thats why we made it an integral part. Every Tuesday night we go out night skiing or we playpaint ball or we do something like that and we call it, Mens Night Out, and its pretty popular, folks like it.
DARRYL: That’s fabulous and it tweaks my interest and we try and replicate that because of your success and your compassion for addiction treatment. At our program, weve done that and actually its quite different. Even though its early in their recovery, people are amazed at how wonderful bowling is when theyre not drunk! And dancing to music. We just took them on a hike up Table Rock and it was just amazing to them that they can feel these feelings without having to smoke dope. So, my hat is off to you for causing some exciting things to happen.
When you look at this field and see whats happening with brain imaging and the science surrounding neurochemicals and relapse prevention
.where do you think were headed? Are we headed for more medication in treatment? Are we headed for more clinical interventions? Are we headed for more of those different
maybe even unconventional things like caffeine to treat addiction.
KEVIN: I think that this is the kind of thing that no one has a lock on. Were going to need all of it. Like I said, I like to look at other fields of medicine as analogs to try to solve problems and right now Im thinking a lot about physiatry you know, physical medicine and rehabilitation. If a person were to come back from Iraq and they had a terrible injury, a physical medicine and rehabilitation physician would take them through a series of steps to help them regain function. Maybe its their arm and through this exercise and that exercise – slowly they would regain function as best they could. Why couldnt the same thing be true for the human will? For volition? And I honestly think the day will come when thats what we will do. Maybe scans will help us see that the patient is having trouble here and this part of his decision making is still quite poor and there will be numerical scores that we can give and well then take them through a series of exercises to try to rehabilitate that volitional capacity. But it will never rely simply on a medication, or just cognitive behavior therapy or peer based support. Its going to be all kinds of things professional, pharmacologic, non-pharmacologic, community based, and all of these things together will help restore that persons capacity. I certainly wouldnt want to say no to medications, I think that would be wrong. But I think it will always be a better strategy to try to bring lots of things together. And I really think that we can see ourselves as physicians, therapists, psychologists who are along for the ride as people regain their capacity for choice. And I think that will be a beautiful process.
DARRYL: Along that line, you really tweaked my interest in knowing your feeling about slips and relapse because like you say, if we want to make analogies to physical medicine or endocrinology or whatever, there are just as many relapses in diabetes but the diabetic is not looked at as a pariah or a failure its a chance to re-engage in treatment so we can improve treatment. If a person has anxiety disorder, psychiatric anxiety disorder, we dont tell them we can only treat them if they never have another panic attack .or a stressed out reaction. Right now, the heavy emphasis in treatment considers relapse a terrible, terrible thing. You should never do it and if youre relapsing, youre a failure in our program. We dont want you in our group anymore that kind of thing.
KEVIN: I know that when a patient relapses in our program, I get scared. So I need to look at my own emotions and how this affects me and how that might be flawing my decision making a little bit. Theres definitely a counter transference issue that we need to address. When I was in treatment, I had a couple relapses and I know there was a part of me that really wanted to stay sober. And there was a part of me that really kind of wanted to use drugs too. And what was tragic about it, was even though the treatment was very good and I was very grateful, I couldnt talk about those relapses. I was sort of afraid, so so not only was I battling my cravings and my desire to use, but I was also battling the treatment too. And I think we have to be more comfortable with the fact that this is going to happen. We have to defend our patients against those forces in the world that might not have their best interests at heart and specifically Im talking about law enforcement and the judicial system. But, we also have the obligation to know whats going on with our patients in real time. I can call back to my house today and if weve got 8 people in the house, there are 8 drug tests and I can tell you exactly who is sober and who is not. And if Im not doing that, then Im leaving it all up to guesswork. But if Im testing every day if I know whats going on with my patient in real time as I would if I was taking care of a diabetic patient if I was an endocrinologist then the relapse becomes much, much less scary much less insulting to me. I know about it in real time. Im the first person who finds out not the sheriffs department or the probation department and then we can deal with it. Relapse to me is not the problem, its clandestine relapse, very pernicious on the patient, on the practitioner, certainly on any other monitoring authorities out there. I think if the patient knows that if they relapse, it will be detected in real time .today or the next day .then its something we can work with. Its the relapse that continues for several weeks without knowing about it that causes the problem. If I were an endocrinologist, I need to know what my patients blood sugar is running today not in a week not down the road – because thats not safe.
DARRYL: You know, you mentioned counter transference .I cant help but wonder how much of that makes people so upset about relapse.
KEVIN: Its jealousy. On some level!
DARRYL: But you also mentioned in your talk today .maybe Im reaching here, but you mentioned speaking to judges. Maybe some of them have counter transference, but I think its something beyond that when it comes to relapse. Its just total intolerance and there are heavy consequences when that occurs and the person is involved with drug courts, on probation, or parole. I have to present to a group soon so Im looking for advice. How do you approach this with judges who look at relapse as a total affront to the justice system.
KEVIN: Right, right.
DARRYL: Or an insult.
KEVIN: Its funny that you mentioned that because last week I did a lecture for the Tennessee judicial conference and the Supreme Court of the state of Tennessee was attending and as we were talking at dinner and I really started to understand all the different agendas that they have to balance and so I understand where they are coming from that they cant just look at whats good for the patient or the public good but they really have to look at the behavior and do whats right. Its my job to help the judge understand where we can .as best we can the difference between what was conscious about this behavior and what was not. From what I understand, the understanding of the judicial system is that we have to assume that if that bad thing happened that there was a conscious decision to do it. And its our job to explain, no there are gradations and the punishment should reflect only that. They see a relapse and they just say, “okay we gave him a chance he decided not to take it”. I must then say ” No .no let me walk you through this. Let me show you the evidence that the assumption of conscious decision making is exactly whats failing.” So if you want to incapacitate the person, if you want to put them on a block or if you want to take them off of medication or put them into a halfway house or treatment or something like that fine but the part of them that can consciously weigh “oh, if I do this Ill get punished” thats broken. And I dont see that judges quite grasp that and I see the goal of our field is to translate this neuroscience into information that will not only humanize the patient to a judge, but allow them within the confines of the decisions that they have to make, to make decisions that are lawful and just. And I think those are tools that we have to give them.
DARRYL: Kevin McCauley, thank you so much for coming out.
KEVIN: Thank you, Dr. Inaba, its been my pleasure.
DARRYL: Such a great presentation. You got everybody humming, everybody talking theyre inspired .it is just a real positive thing for us and thanks for being on our CNS Addiction Podcast.
KEVIN: My pleasure.
HOWARD: That wraps our pod for today. Thanks for visiting the CNS Podcast. Please check back soon for the next in the series and visit our website, www.cnsproductions.com