Early March brings National Gambling Awareness Week – reminding people of the strongly addictive properties of compulsive or problem gambling. About 85% of people in the US gamble at some point, so that means in excess of 200 million people. Of those about 3-5% are estimated to have a problem … and of that number only a small percentage ever even believe they have a problem, much less seek treatment. Also Darryl discusses his experiences creating culturally- tuned, or culture-specific treatment at the Haight-Ashbury Clinics in San Francisco in the 70s and 80s, and its value and efficacy. And what are the signs of addiction, and how do we know if we, or people we are close to, are afflicted?
Transcript (edited)
Podcast #144
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard LaMere. I’ve got a lot of material here – nothing that is very extensive but we’ll see where it leads. To start – here is the strange addiction of the week, maybe this will be a weekly feature – someone who likes to drink gasoline, only a modest 15 teaspoons full, or tablespoons full. That sounds really dangerous. In addition to sipping gasoline they like to carry around and smell doll heads. Go figure. It is gambling awareness week in early March and here are some figures about 88% of Iowans gamble and 3% of them have a problem and very few seek help. There wasn’t much more to the story other than to announce awareness week and list an 800 number, 800-522-4700, for help or the website: npgawnationalproblemgamblingawarenessweek.org.
Gambling is one of those things we don’t talk about often but it is definitely one that many people deny they have. So that in and of itself is interesting. Also in the news, culturally sensitive addiction treatment research is being conducted and Darryl, you know a lot about this from your work in San Francisco. A researcher at the University of Iowa, Anne Helene Skinstad, just received a three million dollar grant to research that issue. Let’s spend some time on this Darryl, and chat about the efficacy of tailoring treatment to the history and biology and culture of individuals as opposed to a broad blanket approach.
DARRYL: You know, Howard, it’s amazing. This is one of those things that really don’t need to be researched any further – it’s pretty much been proven in a variety of outcome studies, but for some reason, it won’t be accepted until somebody is given 3 million bucks to do the research. We did research on culturally-consistent treatment way back in the 1970’s and 1980’s and though it was a modest study, we were able to show a high degree of effectiveness compared to generic therapy or non-culturally consistent therapy. When we looked at the California, Cal Data studies during the 1980’s and 1990’s, – one of the most rigorous outcome studies done in addiction treatment – it was apparent that for every innovation that was made for anything every little tweak that was done to match the cultural belief and the cultural background of the population you were treating – every little modification resulted in a doubling of the positive outcomes of those treated. So definitely it make sense.
HOWARD: That’s very significant.
DARRYL: I’m interested in how the University of Iowa is going to do this we are, by choice, a nation that prides itself on multiple cultures. Each of these cultures have their own cultural paradigms, their own cultural needs, their own cultural-isms, and beliefs. And so, in order to design a treatment that is targeted toward one culture means that you are focusing on that culture and missing the many that are out there. So maybe that’s been thwarting good application of this for a long time, but the fact is despite us being a nation of multiple cultures, we still are an extremely segregated union. We’re supposed to be the melting pot, but you can go into any city in the United States and you know that there is a Latino area, a black area, an area where rich white people live, and another that is Asian. We tend to have de facto segregation in a multi-cultural society. But realized that, if you are targeting a specific, say Latino population for a drug problem or alcohol problem, it behooves you to learn about that culture and how they look at their use of drugs and alcohol, what things might be useful in helping them understand that there is a pathology in use of that drug. Learning everything that you can to motivate positive outcomes by bringing in their cultural variances is going to result in effective treatment. But you can’t take the Latino treatment format and apply it to an African American group because they have a totally different culture. When we were running the Haight Ashbury Clinic, we ended up serving 22 different cites and many of those cites were purposely targeted for a specific culture and to, first of all, attract their attention to the fact that addiction was a treatable condition and then to encourage them to enter treatment. Retention was accomplished by offering culturally specific and culturally consistent treatment so people were at ease and could engage in things that were meaningful to them. It was a challenge – when we tried to develop an Asian program, we found 36 meaningful groups in San Francisco who identified as Asians, but culturally they were totally different.
HOWARD: Wide varieties…
DARRYL: Wide variety of belief systems and behavior. And so, to do it right we should have had a Korean center, a Japanese center, a Japanese-American center as opposed to a newcomer Japanese center, first generation, second generation that all comes into play a Chinese center. And there are different cultural groups in China alone. It is an expansive undertaking but the more you pay attention to it … like the trauma informed care that Oregon is doing now… realizing that our clients all have a high incidence of early childhood trauma and that everything we do in treatment and every treatment program must be designed not to exaggerate or precipitate any of those terrible feelings that people have from major trauma. And as you do that, the overall outcome increases so you can have cultural amendments to treatment.
HOWARD: I should mention that the Iowa study is focused on Native Americans and indigenous Alaskans. Think about the different cultures that will involve.
DARRYL: Exactly. They will learn the same things we did when we tried to develop the Asian program. You can’t. There are many different nations with many different ideas and values. Take Inuit and the Native Americans in the north, there are several, several different cultures there, so it’s going to be a daunting task to come up with something that could impact outcomes in a population that’s extremely diverse, although these peoples are all identified as a singular Native American population.
HOWARD: Right, right.
DARRYL: I should mention this too, Howard, one of the big things we found in doing this work in San Francisco was that some in the treatment community didn’t pay attention to gender and age. Age creates a different culture and we’re coming into a period where we’re going to see a great increase in older Americans who are going to need treatment that must be more culturally specific.
HOWARD: We’ve talked about that a little bit and we’re going to see more and more of it.
DARRYL: Absolutely – and we know women are different than men, and clinicians and programs continue to hold onto the idea of having a more eclectic approach or treating both genders in the same way – I think the evidence will be clear. Hopefully the Iowa study will look into that as well. When you make cultural changes to treatment approaches and to engagement approaches and to ways of reaching out to populations for treatment – gender as a culture is important and will result in better outcomes.
HOWARD: In the context of early trauma, it’s important to point out that violence is profoundly involved in addiction issues and it seems like that is not talked about adequately either.
DARRYL: You know, it really is one of those “duh” concepts…. everybody should totally understand and accept that drugs, especially alcohol, but all psychoactive drugs or abusive drug situations play a major role in trauma for everyone who has been touched by major domestic violence or major sexual trauma. So, you would think that this is something that everybody should grasp and address, but it’s not. There are people who have suffered major sexual or physical abuse as an adult or as a child and we don’t address the addiction or the drug use patterns that may have been at play at the time the situation occurred. We oftentimes totally ignore the perpetrators other than criminalize them, put them in jail, lock them up, take them out of society only to commit those crimes again. We need to treat them so they understand what their problem is with violence, with sexual abuse and other behaviors. Part of that treatment should incorporate treatment of alcoholism and other addiction. There are studies the numbers are fairly small, but studies are showing that if you address the addiction problem or the alcohol problem, it is likely that there will be a decrease in domestic and other types of violence perpetrated by the person who happens to also be an addict and an alcoholic.
HOWARD: Related to this is a recent “Journal of the American Medical Association” article that talks about the increase in overdose deaths, primarily from prescription drugs, in particular Vicodin and OxyContin and also to an extent, heroin. For the past 11 years the OD deaths have gone up and that presents the question of how to recognize the signs of addiction and – no answer was provided. A lot of times you don’t know. You can know a person really well and still not know. So, Darryl, what should people be looking for?
DARRYL: In terms of properly diagnosing addiction, people can self diagnose . They can go online to NIAAA, (www.niaaa.nih.gov/) or NIDA (www.drugabuse.gov/) and find evidence based accepted diagnostic assessment tools that are available. One very simple one – KJ – has only 4 questions, the Assist which is more popular with National Institute of Drug Abuse, asks 8 questions and based upon honest answers, you can self-assess. You can see where you fit in terms of whether or not you are on the verge of having a problem, whether you have a severe problem or whether you have nothing to worry about. There is also information on what to do seek treatment, seek education or whatever. There are also number of evidence based standardized tools out there that clinicians use to make a diagnosis and that insurance companies are going to mandate. If insurance is paying for a person’s treatment they are going to ask what tools were used, and they’re going to make sure they are evidence-based tools. Saying that though, in terms of where you’re coming from, we still know that there is an awareness gap that is 75% of people who meet diagnostic criteria from the DSM 4 right now or from the Assist model or from the KJ model or any ASAM assessment model, 75% of people who meet criteria are going to say they have no problem that alcohol is no problem, drugs are no problem. So, we have that awareness problem. In my day we used to call it denial. Drugs can alter the brain creating a chemical denial, but there is also emotional denial and psychological denial about how drugs or alcohol are impacting your life. And that certainly plays a role, I think, in the other topic we began with – gambling. There is a tremendous exaggerated denial when it comes to gambling because people don’t consider gambling – until now that they codified it – as an addiction.
HOWARD: We’ll see if the information in the new DSM (Diagnostic and Statistical Manual) makes a difference.
DARRYL: Right. Most people will look at their gambling and see it as a form of recreation.
HOWARD: And nothing will happen until the person is deeply, deeply, deeply in debt.
DARRYL: It’s tragic how deeply they get in debt. When we work with gambling addicts, many of them say they’ve never heard the term pathological gambler or problem gambler. They just thought that they were down on their luck, in a losing phase and then they look at the catastrophic consequences that occurred because they wanted to stay in the game even though they had no resources to do so after they spent all their money. Here in Oregon they recognized the potential problem so when they approved the state lottery system and gambling system here, some state monies that were obtained from that activity were allocated toward treatment for gambling. The number of people participating in treatment continues to rise. There are Gamblers Anonymous groups and the state also has residential inpatient treatment as well. So this state is doing the responsible thing. I think it is very rare that other states have addressed gambling as a true addiction. But getting back to the other topic about increased drug use and self awareness. Unfortunately addiction still remains the only chronic persistent medical disease or disorder that requires a self-diagnose before participation in treatment. I will be interesting to see if the Addiction Equity Act is going to change the level of awareness in society, the fact still remains that people do not accept that they are an addict or an alcoholic even when another professional or medical professional tells them that they meet the diagnostic criteria for addiction. They just do not accept that and they often get angry at you and beat you up for suggesting that. So, in order for a person to come to that conclusion on their own it takes self-diagnosis.
HOWARD: We’re almost out of time and there’s one more question I want to ask about evidence based treatment and that is, how does this impact 12-step programs?
DARRYL: Well, when 12-step programs started in the 1930’s they were just groups of alcoholics who got together in order to come to some resolution as to why they were drinking … why they had no ability to control their drinking and they came up with their own mechanism to help overcome or to process not overcome because you don’t get cured, you’re always in the process of treatment, but to get control over their drinking problem. The evidence-based model grew from insurance company mandates and 3rd party payer mandates and governmental mandates that pay for treatment. They said we want to see where our money is going. We want to know that treatment actually works and that it is actually going to some good. And because of that, evidence based programs became a necessity in order to do anything in treatment and to assess people for addiction. No state sanctions just sitting down and dealing with an alcoholic or an addict in a treatment setting without using some form of evidence based treatment. The problem with that – as we’ve talked about before – is that many treatments are practice based and are historical based and 12-step has a historical base. It is probably one of the most effective treatments in addiction. It is not the only effective treatment and it doesn’t work for some people. Some people are very offended by some of the tenants, but for a lot of people it does work. These programs have no resources or money to do all of the science and employ the controls necessary to establish an evidence-based system. Having said that though, because it has such a powerful place in addiction, there are universities and other scientists starting to study the impact of 12-step treatment12 steps on intervention of alcoholism and other addictions and all the studies I’ve seen so far have definitely shown that they are evidence based. They do meet the criteria to effectively get people engaged, accepting their condition, participating in treatment and monitoring the results for good outcomes.
HOWARD: We’re out of time for this week. Thanks for listening and stop back again soon. Comments, questions, suggestions are always welcome leave us a note on our website. That wraps our pod for today. Please check back soon for the next in the series and visit our website, www.cnsproductions.com