Breaking the habit
FEATURE - 12TH JANUARY 2018
Addiction—once thought of as a moral failing—is now widely recognised as a disease. The Harley Street Medical Area’s addictions specialists talk to Prognosis about how rounded, personalised treatment can help people fight this highly destructive illness
“You can lead a horse to water, but you can’t make it drink.” That’s what we say, often with a sigh, when contemplating those people who are seemingly incapable of helping themselves. Raymond Dixon has a slightly different spin on this hoary old proverb. “You can lead a horse to water. You can’t make it drink,” he smiles, “but you can make it thirsty. You can make an addict thirsty for a normal life.” The lead addiction counsellor at the Nightingale Hospital in Marylebone, Dixon helps addicts of all stripes find their way into and through a series of treatment programmes—and, as a recovering addict himself, he knows all too well the barriers that can stand in the way of success.
The complex nature of addiction means that these barriers—physical, mental, emotional or practical—can vary from person to person. “We are never just dealing with addiction,” says Dr Najem Al-Falahe, medical director and lead consultant of London and Surrey Care. “We are always dealing with addiction plus something else. Always.” It’s for this reason that the addiction programmes available in the Harley Street Medical Area (HSMA)tend to adopt a holistic approach to the disease—treating the addiction’s root causes as well as its symptoms—that is highly tailored to the individual.
Each programme begins with a comprehensive assessment of the medical history and personal and professional life of the patient. “Sometimes we can end up seeing the family, without the patient, for six months,” Dr Al-Falahe explains. “That’s because patients who suffer from addiction are in denial and we need to work with the family to create the right setting for the patient to accept starting the treatment. Patients need to feel like we are here for them non-judgmentally, and they need to understand the journey they are on.”
This emphasis on understanding is all a far cry from a few decades ago, when Dixon himself was undergoing treatment and attitudes were “quite punitive”. The once-dominant idea that if you are an addict “you are a bad person and you need to just stop what you are doing” is fading—slowly. Today, the prevailing understanding is that addiction has nothing to do with moral fibre, and everything to do with having a bona fide disease: a health problem that requires treatment, not admonishment.
Addictive behaviours are driven by changes to neurochemical and molecular activity in the brain. Brain scans shown to me by Dr Al-Falahe indicate starkly the difference between the brain chemistry of an addict and a non-addict. “Two areas of the brain are affected: the limbic system, which rewards the addictive behaviour, and the pre-frontal cortex, which is involved in decision-making. It becomes a bit of a vicious circle—they don’t have control, so they go back to the substance, which rewards that behaviour, and so on and so on. Addiction fulfils all the criteria of an illness,” he continues. “It is an illness. And it is an illness that affects 8% of this country.”
This is the scale of the problem: four to five million people dragged down by drug or alcohol addiction and a dizzying array of related issues. Factor in the impact this has on friends and family, and the chances are that pretty much everyone in the country has been touched by this insidious, often life-threatening disease. “One of the biggest failures in public health has been not taking on alcohol addiction with the same rigour as we took on smoking—one of the most successful health campaigns ever seen in this country,” says Dr Paul McLaren, adult psychiatrist at the Priory Wellbeing Centre Harley Street. “Alcohol is the biggest substance abuse problem.” Yet public investment in tackling alcohol addiction remains disappointingly thin.
‘Addictions’ to gambling, sex, food and shopping are not technically addictions, though they resemble them. They’re classified as impulse control disorders. But the consequences and drive of these behaviours are exactly the same
“When you talk about addiction, you are in essence talking about loss of control over a substance or behaviour that is causing you harm,” explains Dixon. For it to be technically classed as addiction, your misuse needs to be marked by withdrawal symptoms and increased tolerance. “So, where once you’d have been high on a line of coke, it now can take several lines.” So-called ‘addictions’ to gambling, sex, food and shopping are not technically addictions, though they resemble them in their impact on the brain’s reward systems. “They’re classified as impulse control disorders,” he continues. “That said, the consequences and drive of these behaviours are exactly the same.”
Impulse control disorders evolve with the times. “One that’s been rearing its head a lot recently comes under the umbrella of technology ‘addiction’: mobiles, social media, gaming and so on. The key in this case is really, if they’re young, to spark their personal motivation: being realistic about the fact that while that might seem okay at 16, you’ll cut a pretty sad figure when you’re 27, jobless and alone.” It is early days. The compulsive potential of technology is not yet fully understood, and while Dixon’s persuasive approach, in tandem with other tactics like cognitive behavioural therapy, has proved fairly successful, he is all too conscious of a major challenge: that abstinence is not an option when it comes to something we depend upon every day.
“When you talk about technology or eating, these are things we cannot avoid on a daily basis—so dealing with the problem is all about controlling your relationship with the internet or food, for example, rather than abstaining altogether.” This contrasts starkly with the abstinence model favoured by all three of the HSMA clinics when it comes to alcohol or drug addiction. One of the biggest concerns of Dr McLaren, as well as Dixon and Dr Al-Falahe, is the strand of thought that says an alcoholic can be restored to being a social drinker. “It’s what they call ‘harm reduction’. While it has its place for those using at harmful levels, I personally don’t think it helps with tackling addiction,” Dr McLaren insists. As Dixon points out, the whole basis of addiction is a fundamental loss of control. “It’s a contradiction in terms to try to teach control as treatment. You don’t say to the diabetic, ‘Just have one jam doughnut and you’ll be fine.’”
For Dixon, the three pillars that have underpinned Alcoholic Anonymous in the UK since 1947 remain at the heart of effective treatment. The first is that addiction is a disease; the second, that abstinence (as far as alcohol and drugs are concerned) is the only option; and the third, that the power of one addict talking to another is among the most effective cures. To these principles, those clinics at the forefront of addiction treatment have added the hallmarks of a more rounded approach: psychiatry, pharmaceuticals and practical support, such as debt management or relationship counselling. “If you have a gambling problem, and a debt of thousands, you aren’t going to be able to concentrate on treatment until that’s been cleared,” Dixon points out. Likewise, a marriage failing, legal problems, or issues in the workplace. Stress feeds addiction. “If we don’t address it, there is a high likelihood the patient will relapse.”
Programmes can take a long time—up to 14 months—and will likely involve multiple professionals, from GPs and psychiatrists to occupational therapists and marriage counsellors. HSMA clinics are also anxious wherever possible to involve and support the patient’s family.
Some patients are treated effectively outside of the hospital environment, attending therapy sessions while maintaining their home and even their working life. Some are too dependent, or too physically ill, to be treated purely on an out-patient basis, and require a period of hospitalisation.
Pre-frontal cortex: A part of the brain located in the frontal lobe, responsible for complex behaviours such as planning. Intricately linked to personality development. Limbic system: A series of brain structures involved in functions including emotion, behaviour, motivation and long-term memory. Neurochemicals: Organic molecules that influence the function of and communication between neurons.
Dixon, like many of the specialists in the Harley Street Medical Area, places great store by the power of abstinence and talking therapies to help restore equilibrium to the brains of addicts. Yet that doesn’t preclude looking to the developing areas of neuroscientific and genetic research. On the contrary, all the clinics I speak to have a watchful eye trained on new findings emerging from centres in the UK and the USA, and there is an expectation that new pharmaceuticals and diagnostic aids will soon emerge.
“Currently, pharmaceuticals are not magic bullets, but they can certainly help,” says Dixon. Medicines in use today generally fall into two categories: those that reduce an addict’s cravings and those that block the pleasure receptors in the brain. “Their effectiveness is only temporary—you need to find other permanent coping mechanisms while taking them,” Dixon continues. “The use of pharmaceuticals for us is really to help a patient during that treatment period, to readjust and change.”
“One of the most exciting areas of research is vaccination,” says Dr Al-Falahe. “These would render immunity to the substance in question—morphine, for example.” Another source of hope is an enhanced understanding of the conditions that may predispose someone towards addiction. “Why do some people try smoking once and are able to leave it, and others go on to be addicted?” he continues. As Dr McLaren points out, while there are always environmental factors at play, the existence of a genetic component to addiction has become increasingly plausible. One theory centres around there being an ‘addictive gene’, which can be activated by certain substances or circumstances, and can lie dormant until later in life: “There are a lot of people whose addictive use of alcohol doesn’t begin until their forties, fifties or sixties,” says Dixon. “There was a foot-break on this gene—their career, perhaps, or their children—but then they retire or their kids go off to university.” Gradually, what was one glass of wine a night becomes a bottle, then two, then three during the course of the day.
There are three basic stages along the path to addiction. “There is the social use of alcohol and drugs, where we have control. Most of us stay in this zone all our lives,” explains Dixon. “There is the abuse stage, which might be triggered through a crisis or through prolonged use, but it escalates and there is a partial loss of control. The third stage, into which a percentage of abusers will move, is dependency. That’s where control is lost. It is no longer a social activity, it is a coping mechanism—and there’s no going back to the abuse or social use stage after that.” What determines whether you end up there appears to be a cocktail of environment, experience and genetics. What determines whether you seek help or not is whether the reasons to quit become so overwhelming, you’d rather seek treatment than continue to drink or take drugs.
“By the time people reach us they’ve often lost their jobs, their marriage, their homes,” says Dr McLaren. “Their motivation is enormous— but that motivation fades as they get better.” That’s why post-treatment support groups are so important, be that Alcoholics or Narcotics Anonymous, or one of the many alternative support programmes. “Some people last a week and then relapse. Some people last a year and then relapse. Some people last 20 years and then relapse.” The key is the follow-up and the involvement of friends and family. “If you only open the door, the probability of relapse is much higher. We have a group here, which is free for patients who have had treatment with us, and it tremendously increases their chances of success continuing.”
However effective the treatment, relapse is often part of the process. But a horse that has been thirsty before can, particularly within the comfort of a whole herd of horses, quickly become thirsty again.
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There are a lot of people whose addictive use of alcohol doesn’t begin until their forties, fifties or sixties. There was a foot-break on this gene—their career, perhaps, or their children—but then they retire or their kids go off to university