THE DOCTOR’S THE DOCTOR’S OPINIONOPINION

An explanation of addictive illness found in the An explanation of addictive illness found in the “Big Book” of Alcoholics Anonymous“Big Book” of Alcoholics Anonymous

Dawn Farm Lecture SeriesDawn Farm Lecture SeriesNovember 15, 2011November 15, 2011

Herbert Malinoff, MD, FACP, Herbert Malinoff, MD, FACP, FASAMFASAM

Specialist in Chronic Pain and Addictive Illness Specialist in Chronic Pain and Addictive Illness

Medical Director, Pain Recovery Solutions, PCMedical Director, Pain Recovery Solutions, PC

Attending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MIAttending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MI

Clinical Faculty, University of Michigan Medical Center, Dept. of Clinical Faculty, University of Michigan Medical Center, Dept. of AnesthesiologyAnesthesiology

Consultant to Michigan Pain Specialists, Ann Arbor, MIConsultant to Michigan Pain Specialists, Ann Arbor, MI

Secretary, American Society of Addiction MedicineSecretary, American Society of Addiction Medicine

4870 Clark Road W. Suite 2014870 Clark Road W. Suite 201

Ypsilanti, MI 48197Ypsilanti, MI 48197

734/434-6600734/434-6600

Declarations of Potential Conflicts Declarations of Potential Conflicts of Interestof Interest

The content of this presentation is The content of this presentation is non-commercial and does not non-commercial and does not represent any conflict of interestrepresent any conflict of interest

ObjectivesObjectives

Discuss Dr. Silkworth’s explanation of Discuss Dr. Silkworth’s explanation of alcoholism as a twofold disease, affecting alcoholism as a twofold disease, affecting mind and bodymind and bodyRelate Silkworth to the modern Relate Silkworth to the modern neurobiolgy of addictive illnessneurobiolgy of addictive illnessIdentify therapy for alcoholism as Identify therapy for alcoholism as promoted by Alcoholics Anonymous and promoted by Alcoholics Anonymous and its relationship to Dr. Silkworth’s opinionits relationship to Dr. Silkworth’s opinionStill have time for questionsStill have time for questions

BORING

Alcoholism 101, Revisited

90% Ever drank60% Current drinkers>40% Temporary problems10-20% Abuse3-10% Dependence

Alcohol PrevalenceAlcohol Prevalence

>Regard Addiction as a moral problem>1% of medical school curriculum>Fail to adequately screen>Believe interventions are ineffective

JAMA, 2003:290, 1299

William Silkworth, M.D.William Silkworth, M.D.

Psychiatrist at Towns Hospital 1930’sPsychiatrist at Towns Hospital 1930’s

Thought alcoholism a twofold illness (mind Thought alcoholism a twofold illness (mind & body)& body)

Gave Bill W. Step 1 (the problem)Gave Bill W. Step 1 (the problem)

Published in Published in Journal-LancetJournal-Lancet, 1939, 1939

The Problem The Problem Determines the Determines the

SolutionSolution

The Solution makes The Solution makes no sense without an no sense without an understanding of the understanding of the problemproblem

What is the What is the problem…..NOT problem…..NOT

Lack of willpowerLack of willpower

Lack of moral characterLack of moral character

Lack of understanding or Lack of understanding or educationeducation

Alcohol and/or drugsAlcohol and/or drugs

The Problem:The Problem:

Lack of WillpowerLack of Willpower(weak)

The Solution: “Just Do It”The Solution: “Just Do It”

Avoid barsAvoid bars

Avoid drinking buddiesAvoid drinking buddies

Avoid liquor storesAvoid liquor stores

Think of baseball Think of baseball

The Solution:The Solution:

LecturesLectures

BooksBooks

Tapes & VideosTapes & Videos

Self-Knowledge Self-Knowledge

The Problem:The Problem:

Lack of KnowledgeLack of Knowledge

(dumb)

The Problem:The Problem:

Deep Psychological Deep Psychological ProblemsProblems

(crazy)

The Solution:The Solution:

CounselingCounseling

PsychotherapyPsychotherapy

Medication (tranquilizers) Medication (tranquilizers)

10,000 Pounds of Insight 10,000 Pounds of Insight Isn’t Worth 1 Ounce of Isn’t Worth 1 Ounce of

Behavior ChangeBehavior Change

The Problem:The Problem:

Lack of CharacterLack of Character(bad)

The Solution:The Solution:

A solemn oathA solemn oath

A better code of moralsA better code of morals

A better philosophy of lifeA better philosophy of life

Organized religionOrganized religion

The Problem:The Problem:

Alcohol & DrugsAlcohol & DrugsI have a “drug problem”I have a “drinking problem”

The Solution:The Solution:Abstinence (Dry)Abstinence (Dry)

RestlessRestless

IrritableIrritable

DiscontentDiscontent

ResentmentResentment

FearFear

Shame & GuiltShame & Guilt

Alcohol Problem vs.Alcohol Problem vs.AlcoholismAlcoholism

Then What Then What ISIS the the Problem?Problem?

An allergy of the body and an An allergy of the body and an obsession of the mindobsession of the mind

Allergy to AlcoholAllergy to Alcohol

Definition of AllergyDefinition of Allergy

““An abnormal reaction to any An abnormal reaction to any beverage, food, or other beverage, food, or other substance” substance”

The Brain’s DesignThe Brain’s Design

Because the brain is so wondrous that Because the brain is so wondrous that most of us assume it has an elegant most of us assume it has an elegant design.design.

In fact, the brain is a kludge (A kludge in In fact, the brain is a kludge (A kludge in the words of Jackson Grandholm is “an ill the words of Jackson Grandholm is “an ill assorted collection of poorly matched assorted collection of poorly matched parts, forming a distressing whole”).parts, forming a distressing whole”).

From the work of David Linden, Ph.D., described in The Accidental Mind

The Reward CircuitThe Reward Circuit

What is the “Abnormal What is the “Abnormal Reaction?” Reaction?”

getting drunk repeatedlygetting drunk repeatedlygetting sick repeatedlygetting sick repeatedly

getting into all kinds of trouble getting into all kinds of trouble repeatedlyrepeatedly

This does not happen to This does not happen to “social drinkers”“social drinkers”

““The only relief we have to The only relief we have to suggest is entire abstinence”suggest is entire abstinence”

““The Doctor’s Opinion”, The Doctor’s Opinion”, Alcoholics AnonymousAlcoholics Anonymous p. xxx p. xxx

Can’t start drinkingCan’t start drinking

Rx: “entire abstinence”Rx: “entire abstinence”

Alcohol vs. CarrotsAlcohol vs. Carrots

ObsessionObsession

“ “Compulsive preoccupation Compulsive preoccupation with a fixed idea”with a fixed idea”

““They are restless, irritable They are restless, irritable and discontented, unless and discontented, unless

they can again experience they can again experience the sense of ease and the sense of ease and

comfort…..”comfort…..”

The Doctor’s Opinion, The Doctor’s Opinion, Alcoholics AnonymousAlcoholics Anonymous pp. pp.

xxviii-xxixxxviii-xxix

How do we manage primitive How do we manage primitive drives?drives?

The primitive parts of our brain control the The primitive parts of our brain control the less primitive (basic drives change our less primitive (basic drives change our thoughts, we are not rational beings)thoughts, we are not rational beings)

Thus, as long as they are in control our Thus, as long as they are in control our thoughts will not changethoughts will not change– ““Live your way into sober thinking rather than Live your way into sober thinking rather than

trying to think your way into sober living”trying to think your way into sober living”

InsanityInsanity::

Alcohol vs. a hot stoveAlcohol vs. a hot stove

““Being unable to judge or Being unable to judge or comprehend the comprehend the consequences of ones consequences of ones actions.” actions.”

Can’t stop startingCan’t stop starting

Rx: “Personality change Rx: “Personality change sufficient to recover…”sufficient to recover…”

Allergy + Insanity =Allergy + Insanity =

Can’t start drinking (allergy)Can’t start drinking (allergy)

Can’t stop starting (insanity)Can’t stop starting (insanity)

PowerlessPowerless

firm resolve

restless irritable discontent

THE CYCLE OF ADDICTION

one drink

Allergy Insanity

drunk sick all kinds of trouble

a spree

Robert Holbrook Smith, MDRobert Holbrook Smith, MD“Dr. Bob”“Dr. Bob”

UM Med (1908-10)UM Med (1908-10)Akron SurgeonAkron SurgeonCo-founder of Alcoholics AnonymousCo-founder of Alcoholics AnonymousTreated over 5,000 Alcoholics Treated over 5,000 Alcoholics Current AA membership 2.8 millionCurrent AA membership 2.8 million24+ million copies of 24+ million copies of Alcoholics AnonymousAlcoholics Anonymous sold since 1939sold since 1939

Step 1: THE PROBLEMStep 1: THE PROBLEM

HopelessHopeless

HelplessHelpless

IncurableIncurable

““We admitted we were We admitted we were powerless…powerless…

Step 2: THE SOLUTIONStep 2: THE SOLUTION

No human power could relieve No human power could relieve our alcoholismour alcoholismGod could and would if he were God could and would if he were soughtsought

““Came to believe”Came to believe”

The Actions Which Bring The Actions Which Bring About the Solution About the Solution

Don’t DrinkDon’t Drink

Go to meetings Go to meetings

Get a sponsorGet a sponsor

Work steps 4-9 Work steps 4-9

Prayer Prayer

One day at a time One day at a time