Substance Addiction – An Integrative Approach (continued)

History

SP had a long and extensive history of stress and associated complications, including substance overuse as a coping mechanism; large joint and lower back pain; and reflux. She also noted a more recent history of cellulitis in her right foot.

SP had a previous history of childhood pneumonia; HSV-1; childhood eczema, including long-term topical corticosteroid use; haemorrhoids; asthma and hayfever.

Physical Exam/Vitals

On examination she appeared quite thin, but had a healthy complexion and was in good spirits. There were multiple severe discoid plaques, ø 4-10cm, over her trunk and limbs, featuring weeping and open edges that adhered to clothing. Healing cellulitis was evident on her right foot, which was still dusky, swollen and tender.

Her blood pressure was 100/75mmHg while sitting, and her pulse 55bpm. Fasting blood glucose measured at 5.2, and zinc tally indicated that deficiency was unlikely with a strong response in one second. Dipstick urinalysis showed Protein ++++, and SG 1.030. She was not pregnant. She described numbness in her peripheries, worse in her feet than hands. She was relaxed, mentally alert and established rapport easily.

Medications/Supplements

Levlen, recent course of antibiotics for cellulitis, and Ventolin and antihistamines as required.

Lifestyle

SP drinks alcohol in a binge drinking pattern. On weekdays, she does not drink, but would have 5-10 per night on weekends. She has been a tobacco smoker for 5 pack years: 5-15/day on weekdays, 20-30/day weekends, and also smokes home-grown cannabis daily, either rolled, in a pipe or with a water bong.

She arrived in Australia in 2014 from New Zealand, and is of Maori heritage. She currently lives with her partner in a supportive, low-stress relationship, although they both regularly use drugs and alcohol to excess.  They have many family members in their local area and they enjoy weekly get-togethers that are very social and pleasant, but include heavy alcohol, tobacco and cannabis use.  SP enjoys her job in admin and customer service, although it is extremely stressful and not fulfilling with a high workload and low income.  She has a good social support network, but is often embarrassed by the appearance of eczema plaques. SP does no formal exercise, although tries to get daily sunshine.

Diet

Analysis appeared to yield adequate caloric intake, but was very low in fruits, vegetables and lean meat, and she preferred almond or coconut milk to dairy. She often skipped meals during the day, and dinners were low-nutrient convenience foods such as bread, pasta, beans, cheese, eggs or pizza. Desserts and sweets, including chocolate, ice-cream, cake, chips and dried fruit were consumed daily, due to the ‘munchies’ from cannabis use. She consumes 1-2 cups of tea or coffee per day, and up to 600mL of water per day.

Family History

  • CVA – mother, cousin, maternal great-aunt (all young age)
  • Cancer – paternal grandfather, grandmother, grand-uncle
  • Denies family history of substance abuse, however maternal grandfather passed away of choking on vomitus while intoxicated

Treatment Plan

Short term: symptomatic relief by rehydration, wet wrapping and barrier creams, as well as trigger avoidance (excessive heat, dryness, trauma).

Long term: address binge drinking, smoking, malnutrition, kidney function, possible food intolerance testing.

Prescription

Products recommended: Initial consultation focused on providing immediate relief for the physical aspect of her presentation, while using some products the patient already had and was already familiar with, and slowly introducing new techniques and products.

  • Barrier cream – Bepanthen ointment
  • Healing cream 1 – goldenseal + zinc
  • Healing cream 2 – silver sulfadiazine
  • Washing lesions – colloidal silver

With complex cases, it is important to take small steps so as to not overwhelm the patient. One technique is to encourage simple changes that build on the familiar.

Dietary guidelines:

Add a handful of frozen vegetables to 1-2 meals per day; add some probiotic or prebiotic foods several times per week.

Lifestyle advice:

Techniques to decrease alcohol use on weekends, using delay, distractions and alternatives.

Expected Outcome

Best case outcome: complete cessation of alcohol, tobacco and drug use. This was not expected, given the unchangeable variables, including family influence, workplace stress and known difficulty in treating multiple substance abuse.

Likely outcome: greatly diminished substance use, leading to significant reduction in symptoms.

Least likely outcome: little to no reduction in substance use, with no improvement in symptoms.

Actual Outcome: Excellent; complete cessation of alcohol, tobacco and cannabis.  Follows a mostly plant-based diet.  Improvement in self-esteem along with lower stress overall.

Follow up 2/52:

  • Focus: nutrition, smoking cessation
  • Goal: daily breakfast with protein, smoking interventions as per RACGP guidelines (readiness, CBT techniques)
  • Examination: Proteinuria ++++, SG 1.030, fatigue, poor appetite (except with cannabis)
  • DDx: Kidney disease (high risk due to long history of smoking, drinking, family history, Maori); steroid-induced Cushing’s, but does not have excessive hypertension or BMI

Products prescribed: Probiotic, essential fatty acids, vitamin D for eczema.

Support for effects of smoking: B vitamin complex, N-acetyl cysteine (3g/day), Tyrosine

Follow up 4/52:

  • Tobacco: 4/day, does not always ‘finish’ a cigarette (mindful smoking – sated after 2-3 pulls). Noted improvements in smell, taste and breathing
  • Partner has also decided to quit smoking – improves chance of success
  • Ready to reduce alcohol, but social setting challenges. CBT techniques of avoidance, delay, distraction used
  • Not ready to cease cannabis

Products  prescribed: as previous, now added herbal mix containing: Andrographis, Echinacea, St John’s Wort, St Mary’s Thistle, Withania.

Follow up 7/52:

  • Crisis – death of close family friend
  • Tobacco and alcohol intake returned to previous high levels – relapses are to be expected!
  • Noticed skin and respiratory symptoms worsened, and has realised that one week of previous habits requires 3-4 weeks of healing
  • Nutrition: adding handful of frozen vegetables to all current meals, e.g. 2-minute noodles, rice or pasta.

Follow up 10/52:

  • Nutrition: eating vegetables daily
  • Tobacco cessation progressing well, although plateaued at 4/day
  • Alcohol reduced to 2-3 per day on weekends
  • Not ready to cease cannabis, but down to one joint per day
  • Stress: ready to apply for promotion; stressful but enhances income

Products prescribed: essential fatty acids (2 cap tid); N-acetyl cysteine (1g), B vitamin complex

Follow up 22/52 (email):

  • Eczema is much improved and nearly completely resolved
  • Still smoking, but has accepted she is not ready to completely give up – knows it is necessary long term
  • Still taking prescribed supplements when remembered
  • Still having serve of veggies with meals etc
  • Feeling much more in control in general

Final contact 51/52 (email):

  • Has been tobacco free for six months
  • Ceased alcohol completely
  • Does not feel need for cannabis
  • Follows a mostly plant-based diet, almost vegan
  • Shops at the organic markets
  • Feeling great overall
  • Skin is still in recovery, but overall much improved
  • Interested in trying a seven-day water fast and wanted guidance

Discussion

SP showed various stages of readiness to change over the course of nearly a year. Therefore, treatment was tailored to her level of readiness for each substance. This is vitally important when treating multi-substance addiction and where various life factors are in play.

A variety of factors may predispose some individuals to developing a substance dependence. Addictions are not exclusive to any particular gender, age group, profession or even socioeconomic status. Due to the stigma associated with being labelled an ‘addict’, people may delay or deny assistance.

An integrative approach can address physical, psychological and social aspects for optimal results.  Patients may present with physical complaints, but the problem is rarely purely physical. Ignoring the psychological aspects will result in poor compliance and ineffective treatment. Remember that psychosomatic disorders are real; even without a physiological cause, the end result is the same.  Addressing the psychological aspects is vital for many physical symptoms that patients may present with, especially when pain-related.

It is important to expect relapses, and to plan for them by preparing for triggering events or anniversaries, such as one year sober or five years clean. Readiness is important, as patients cannot maintain new habits if they are not ready. Smaller steps are more achievable and sustainable than drastic changes, so improvement is most likely if the treatment can start where the patient already is. For example, frozen vegetables are perfectly fine for many people when cooking fresh foods is too daunting.

Education on improved lifestyle habits is important, but avoid lecturing as clients have often heard it all before, and need to come conclusions themselves.  It’s important to avoid underestimating the social pressure surrounding alcohol use, which is a socially sanctioned and even promoted addiction that can create many setbacks on the path to recovery.

Key psychotherapy techniques include CBT (classical); MCBT (Mindfulness-based CBT); hypnotherapy; journaling; family counselling, which can be useful where family support is important but currently lacking; and group therapy to reduce feelings of isolation. However, the client must be ready to accept there is a problem to address. For those not trained in therapeutic techniques, there are two main options: further education or referring the patient on to someone else. Being comfortable in referring out is especially important when dealing with complex cases involving addiction, mental illness or long term chronic pain. A multi-faceted care team can mean the difference between long term habit change and successful treatment or a patient falling through the cracks.

When it comes to prescribed products, financial priorities will change over the course of treatment in many cases of addiction. Practitioners must start where they are, and be realistic about what they can manage. An extensive and expensive prescription list is not feasible, so choose what is most effective and important at that point.

Conclusion

Individually tailored treatment is vital to maximise chances of success when dealing with complex addiction issues.  Having a diverse treatment toolbox or team you can refer to allows for variety and individualisation. Naturopaths should aim to maintain or expand their knowledge in a variety of fields, including nutritional medicine, herbal medicine and counselling techniques.

Naturopathic Teaching Points

With complex cases, it is key to treat the whole person and take time to assess every aspect of their life that could affect their health journey, especially potential blocks or pitfalls. When formulating a treatment plan it is important to avoid causing harm, including by overwhelming the patient with too many changes at once, which can lead to relapses and a loss of hope. While identifying and treating the underlying causes of ill health will provide long term benefit, short term symptomatic relief is often what prompts patients to initially seek assistance. The value of several small scale successes should not be underestimated when working through a large scale problem.

Further Education

If you are interested in advancing your counselling skills, most universities offer online studies through the psychology departments. Some offer single subject enrollments, and smaller colleges may offer short (single subject), Certificate or Diploma courses. Associations may offer workshops, usually 4-7 days, of full time training in a specific technique, but check accreditation as not all are recognised methods.

References available upon request.