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“In the News” – Reuters features Lindner Center “Reboot” Internet Addictions Program


Reuters featured the success story of a teenager who found help with Internet and gaming addiction through a new treatment program at the Lindner Center of HOPE. The story explains why more medical professionals are taking Internet addiction seriously and how the Lindner Center has pioneered a program to meet this modern condition.

A 2012 study estimates that between 1.5 percent and 8.2 percent of people in the U.S. and Europe experience “problematic computer use.” In 2018, The World Health Organization even classified video game addiction as a mental health disorder.

To combat Internet and gaming addiction, and provide a resource for families who need help, Lindner Center of HOPE has introduced a new program, called “Reboot.”

“This program helps those struggling with a loss of control to re-center their lives to avoid additional complications,” said Dr. Chris J. Tuell, Lindner Center of HOPE Clinical Director of Addiction Services.

Your donation will help more people like Danny recover from mental illness and return to feeling more like themselves. Donate here:



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“In the News” – Dr. Tuell joins Fox and Friends to Discuss Internet Addiction

Lindner Center of HOPE Clinical Director of Addiction Services Dr. Chris J. Tuell joined Fox & Friends on January 28, 2019 to talk about a new program at the Lindner Center designed to identify and treat Internet addiction.

“This program helps those struggling with a loss of control to re-center their lives to avoid additional complications,” said Dr. Tuell.

According to Mental Health America, children with Internet addiction often struggle with other mental health problems like alcohol and substance use, depression, and/or aggression.

Addiction experts at the Lindner Center of HOPE assess if patients are suffering from one or more co-occurring disorders, like depression, in addition to unhealthy Internet habits. Studies have suggested pre-existing depression or anxiety could lead to a gaming addiction. Identifying underlying mental health conditions can help personalize treatment plans for each “Reboot” patient.

Your donation can help the Lindner Center of HOPE continue similar services to help patients find help on their road to wellness. Donate here:




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Recovery Supporters Can Also Experience a Rough Road, But The Journey Is Still Worthwhile


Peter White, M.A., LPCC, Lindner Center of HOPE, Addictions Counselor

Many loved ones of people with substance use disorders are often discouraged by the severity and duration of distress initiated and endured by their loved ones. In a related manner, many professionals working with people with substance use disorders become disillusioned and discouraged by the extent of problems, and a lack of progress in treatment. It seems that experiencing burnout, or feeling just plain burnt, are two common emotional consequences of committing time and energy in trying to help people with substance use disorders. I would argue that one of the most important things we can do, being the people who care, is revisit our understanding of the fundamentals of substance use disorders, and reorient our recovery approach in a manner that aligns with these fundamentals.

Substance use disorders are chronic, behavioral disease conditions that if not addressed will progress into increasingly diseased states up to critical illness and death.  They do not have a cure.

It is easy to be initially discouraged by this reality, until we consider an additional reality – substance use disorders are imminently recoverable. That is to say, at any time a person with a substance use disorder can make the changes that stop the progression of his or her disease process, ( a major accomplishment in itself,) and begin the process of establishing and consolidating a healthy and rewarding recovery. The bad news is that there is no cure. The good news is that once we accept this, we are then free to focus on the ever present possibility of sobriety, health and growth taking root as our loved one’s lifestyle.

Our real challenge is to remain continually present, authentic and hopeful as we develop interventions and support over the course of a disease and recovery process that will often endure for decades. Think about that. If we appreciate the nature of a chronic condition, then we acknowledge that the process of growth, as well as the potential threat to growth, is never over. In a way, I would say that the experience of burnout isn’t logical, because people with terrible conditions can and do get better all the time. It is the maintenance of this very realistic hope for the advancement of recovery in the face of the loss and distress of alcohol and drug use that is the most effective way to help our loved ones, as well as to prevent burnout for ourselves.

I once asked clients during a group to state what their definition of recovery was. I noticed that their answers really focused on the establishment and expansion of behaviors that were in line with their values much more than they were focused on the cessation of drug use  -“Dealing with responsibilities, ”Complete change of focus, ”Knowing I can change and grow,” Doing my best- healthy, clean, sober, ”Becoming self-reliant.” It was a very reassuring moment for me as a helping professional in that the clients were not searching for a tabulation of “clean” days vs. “using” days. What they were really focused on was a direction that would incorporate every part of their lives away from risk, disease and loss, and towards the pride and enjoyment of health and growth that I think all people desire.

Let me end on a note where we do acknowledge that substance use disorders are often very destructive. If you are a loved one or a professional who is becoming overwhelmed or burdened too long by the losses you’ve encountered, lets acknowledge that disengagement and the establishment of boundaries are often the healthiest option for all involved. Disengagement does not need to be related to the rejection of people or the abandonment of hope for recovery. It is most often a very appreciable need for self-care in the face of risk and loss. Just as we help those with substance use disorders by decreasing our focus on the multiplicity and duration of problems, let’s help ourselves by not focusing on all the problems that we find we can’t deal with. Instead let’s focus ourselves on our limits relative to all the help we have or might offer, and remind ourselves that our own growth is imminently available, and that we should honor any rest we need until we able to make ourselves available for help once more.

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Is the opposite of addiction really sobriety?

By Chris Tuell, Ed.D., LPCC-S, LICDC-CS

Lindner Center of HOPE Clinical Director of Addiction Services


In April of 1975, the Viet Nam War came to an end. During this 10 years of military strife, 58,220 U.S. soldiers lost their lives.  However, the end of the war also brought another difficult issue to light.  A never before scene was about to appear on the horizon.  Estimates indicated that approximately 20% or 1 out of 5 American soldiers returning from Southeast Asia were addicted to heroin.  Experts believed that once these soldiers returned home, our country would be faced with a heroin pandemic.  How would we manage such an issue?  It never happened.

Today, our knowledge of the neurology of the addicted brain has grown by leaps and bounds. We have gained a better understanding of the disease of addiction and how this new awareness clearly indicates that it is not an issue of character, nor is it a moral failing or a lack of will power.  Addiction is the result of the brain’s reward system being hijacked by outside substances (alcohol and drugs) and various behaviors (gambling, pornography, gaming, Internet).  This hijacking tricks the brain in believing that the drug or behavior has more importance than it really does.  Because of this pairing with certain neurochemicals, the brain believes this drug and/or behavior (like food) become necessary for survival.  Each of us knows that we don’t need alcohol, drugs, or gambling to survive. That’s true.  But, the brain thinks we do.  This survival drives the urges and cravings for the patient to use substances.  We know that patients who suffer from addiction, will engage in negative behaviors.  These individuals unfortunately will lie, cheat and steal in the midst of their addiction.  But equally important is the understanding that bad acts do not necessarily mean bad actors.  If each of us would be without water for three days or without food for three weeks, every one of us would lie, cheat and steal to survive.  This is what’s happening within addiction.

So why did the heroin epidemic of the 1970s not occur? Our new knowledge of the workings of the brain has also demonstrated that when substances are introduced, it impacts the very area of the brain where we develop meaningful, connected relationships. When mental illness issues surface, such as depression, anxiety, and trauma, the drug brings about relief.  It is this relationship that allows a sense of meaningful connection, even though that connection is unhealthy and problematic.  As one patient shared, using heroin was like “getting a hug from your grandmother on Thanksgiving morning.”  This experience becomes meaningful for the drug-addicted individual.  The drug’s influence on the brain creates a sense of connection causing a disconnect with truly meaningful relationships.  For the patient, the drug relationship becomes “on par” with other important relationships (i.e., spouse, children, parents, relatives, friends).  Unfortunately, sometimes the drug becomes number one.  For the Viet Nam soldier who was addicted, connection was re-established with loved ones, family and friends, and were able to reconnect within his or her community.  The heroin addiction ceased.  When an individual suffers with mental illness, the depression, anxiety, trauma, disconnects them from others resulting in a vulnerability to substance use and a hijacking of the brain’s reward system.

This phenomenon also occurred within the laboratory. In the early 20th century, research-involving rats found that when a rat was placed within a small cage and given the choice of two forms of water (pure water or water laced with heroin or cocaine) the rat would prefer the water laced with drugs.  The rat continued to use the drug laced water, eventually developing addiction, overdosing and dying.  Experiments like these shaped our view of addiction for many years.

However, a series of new research looked at the same experiment, but this time expanding the cage. In fact, the researchers created a “rat park.”  The cage was bigger with various levels and tunnels along with the addition of other rats.  The same two samples of water were provided.  Rats in this study preferred the pure water to the water laced with drugs.  No instances of overdose were recorded.

Mental illness interferes with our ability to connect with ourselves, others, and the world in which we live.   This isolation and disconnect creates the perfect storm for addiction.  Nearly 80% of individuals with a substance use disorder also have a mental illness. How many of us who have never experienced mental illness lose site of the importance of a meaningful connected relationships in our lives?   Perhaps the opposite of addiction is not sobriety.  Perhaps the opposite of addiction is connection.

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Integrative Mental Health: Can health occur without mental health? By Chris J. Tuell, EdD, LPCC-S, LICDC-CS, Lindner Center of HOPE Clinical Director of Addiction Services

Integrative mental health (IMH) combines conventional biological psychiatry and psychological interventions with traditional and complementary alternative medicine (CAM) to provide holistic patient-centered care. Using non-hierarchical interdisciplinary teamwork, the patient and practitioner are able to explore psychological paradigms involving biological, cultural and spiritual dimensions of health and illness. Kindness, avoidance of harm and informed consent are core ethical principles of practice. As well as addressing immediate mental health problems, the patient is encouraged to become actively involved in their own prevention of mental illness and maintenance of mental health.

Mental health is a key determinant of wellness, and has been shown to be strongly influenced by lifestyle factors such as chronic stress, sedentary life style, poor nutrition, obesity, substance abuse, and social isolation. Use of complementary alternative medicine in mental health conditions has been driven by the high cost of conventional care, and the growing list of medication safety concerns reported by the FDA, but due caution must be used with all Interested in touring therapies, conventional or complementary.

The fundamental goal of an integrative approach to mental health is to find the most appropriate treatments (conventional and complementary) that safely and effectively address the symptoms
of the individual, while taking into account personal preferences, cultural beliefs and financial constraints, an approach endorsed by the American Psychiatric Association.

Integrative mental health is an evolving, whole-systems approach to wellness of mind, body, and spirit. It considers that symptoms are associated with multiple causes and that multiple approaches to assessment and treatment may be necessary so that each individual may attain an optimal state of health and well-being. Therefore, the integrative mental health professional is knowledgeable about complementary and alternative medicine and trained in the art of collaboration so that they can discuss patient care with medical doctors, as well. The goal is to understand as much as possible about the whole person and to be aware of what treatments are occurring simultaneously. Approximately half of the individuals diagnosed with mood or anxiety disorders are using a combination of therapies and conventional strategies to alleviate symptoms. For this reason, it is important for health care professionals to ask the right questions and to collaborate in seeking answers when treating individuals who come seeking help.

Today, these individuals may first seek counsel from a medical doctor, a psychotherapist, a chiropractor, an acupuncturist. Therefore, it is important that patients disclose all of their treatments to all of their health care professionals. Mental health professionals trained in integrative approaches frequently serve as the historians of each patient’s care, especially since they are the ones who spend the most time with each patient during the course of treatment.

Recent years have witnessed growing openness to nonconventional therapies among conventionally trained clinicians and researchers. At the same time people who utilize Western biomedicine as currently practiced are turning increasingly to integrating non-conventional therapies for the treatment of both medical and mental health problems. Approximately 72 million U.S. adults used a non-conventional treatment in representing about one in three adults. If prayer is included in this analysis almost two thirds of adults use non-conventional therapies. Anyone diagnosed with a psychiatric disorder is significantly more likely to use nonconventional therapies compared to the general population.

Integrative health care is based on the philosophy that health is influenced by a variety of interrelated factors such as life choices, environment, genetic makeup, intimate relationships, and the
meaning and purpose in life. As a model it is collaborative and multidisciplinary. It is open to and recognizes the importance of conventional medicine, complementary and alternative medicine, mental health care, and mind-body approaches (such as meditation, yoga, hypnotherapy, Reiki, and therapeutic massage). There is a respect for each individual’s journey and for the stories that make up the history of their lives. There is a belief that these individual journeys influence the biology that manifests in illness or in health. Integrative health care supports all of the important
aspects of life, including creativity, cultural expression and the celebration of community. To have “health” means that the whole person is in balance – physically, emotionally, psychologically, and spiritually. Is health really health without mental health?

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Free Community Education Series to Address Substance Use Disorders, Behavioral Addictions, Treatment and Strategies for Coping

FOR IMMEDIATE RELEASE                                                                                                                                     

Jennifer Pierson
Lindner Center of HOPE
(513) 536 -0316

Free Community Education Series to Address Substance Use Disorders, Behavioral Addictions, Treatment and Strategies for Coping

March session to explore Stress and Family Functioning

Lindner Center of HOPE with the support of Manor House in Mason, Ohio is offering a Free Community Education Series in 2017 on topics related to addiction. The series will offer expert discussion of Substance Use Disorders, Behavioral Addictions, Treatment and Strategies for Coping for community members seeking information.

The series will be held at Manor House, 7440 Mason-Montgomery Rd., Mason the third Wednesday of the month at 6 p.m. starting January 18, 2017 for one year (though sessions will not be offered in May 2017 or December 2017. On May 7, 2017 Lindner Center of HOPE will offer their second Education Day, a ½ day workshop about mental illness and addiction.)

Register by calling Pricila Gran at 513-536-0318. Learn more by visiting

The third session is March 15, 2017. Michael K. O’Hearn, MSW, LISW-S, Clinical Director of the Lindner Center of HOPE’s Stress Related Disorders program and staff provider, will present Stress and Family Functioning.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic and short-term residential services for adults and adolescents, outpatient services for substance abuse through HOPE Center North location and co-occurring disorders for adults and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.

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Mental illness, Addiction and Digital Infidelity

By: Chris Tuell Ed.D., LPCC-S, LICDC-CS
Clinical Director of Addiction Services Lindner Center of HOPE
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience University of Cincinnati College of Medicine

Fifty years ago, I was six years old.  My family, like many families of the day, subscribed to Life magazine.  On the cover of the magazine for the week of September 16, 1966 was a picture of Sophia Loren.  The Hollywood starlet was portrayed wearing a black see-through lacy dress that covered all the necessary parts, and covered all the necessary standards for 1966.  But the picture left an image upon my brain that I can easily recall to this day.

Fifty years later, digital pornographic images are now easily accessible.  The Internet has made it possible for thousands of images and videos to be accessed within seconds.  The Internet has made it available for instant digital infidelity to occur.  Such images and encounters can easily be accessed on any smartphone, tablet, and computer.

So how concerned should we be as a society?  Do we accept this dark digital domain as a part of our technological culture?  How harmful can pornography and digital infidelity be?  Is it possible that sexual images and/or compulsive sexual behaviors reside within the same realm as problematic alcohol and drug use?  The answer is plain and simple.  It does.  Pornography and cybersex can become addictive.  In the long run, this behavior rewires the brain, and can lead to abusive and destroyed relationships for men and women.

Sixty-eight percent of young men and 18% of young women view pornography at least once a week, and those numbers are growing. A sexual addictive epidemic is on the rise, not only because of easier access, but also the lack of information people have had on the negative and harmful effects associated with this addictive behavior.

Many researchers and clinicians in the field of mental health no longer discriminate between behavioral addictions (i.e., pornography, sex, gambling) and chemical addictions (i.e., alcohol, drugs).  Simply stated: The brain doesn’t care.  The brain doesn’t care whether you pour it down your throat, place it in your nose, see it with your eyes, or do it with your hands.  Pornography and sex, along with other addictions, flood the brain with dopamine and make the recipient feel good.   They help you to escape, as you seek the behavior over and over again.  Over time, as more dopamine is released, the individual will begin to feel the effects of this neurochemical less and less. This leads one to search for more graphic images, increase high-risk sexual behaviors, escalating the addictive behavior in order to obtain the desired effect.

Researchers indicate that nearly 80% of individuals who have an alcohol or drug issue will also have a mental illness issue as well.  This is the rule rather than the exception.  So what is the relationship that pornography, cybersex, and other addictive behaviors have with mental illnesses like depression and anxiety?  This could be better understood by the CUBIS model, an acronym that represents five areas that I believe demonstrates this relationship between addiction and mental illness.

Chemical Imbalance 

Within the field of psychiatry a basic premise is that some individuals may have issues of mental illness as a result of a chemical imbalance. When an individual experiences challenges of depression and/or anxiety, for example, particular neurochemicals within the brain may not be producing at desired levels, resulting in symptoms of mental illness (e.g., depression, fear, anxiety, paranoia).  This is where medications can be helpful.  However, addictive behaviors like sex and pornography, as well as alcohol, drugs and gambling, can also serve to temporarily regulate this imbalance, resulting in the individual feeling better and distracting his or herself with undesirable and destructive behaviors.

Unresolved Issues

For many, issues of trauma, abuse, grief, loss and/or abandonment, can lead some individuals to seek out ways to escape and numb one’s self from the aforementioned mental health challenges.  Whenever these problems bubble up to the top, the individual doesn’t want to think about or feel the emotions associated with these particular issues.  Cybersex and pornography, like other addictive behaviors, serve a purpose in suppressing these thoughts or feelings and help the individual to escape, distract, or forget about mental health concerns.

Beliefs (that are distorted)

We all grow up with a belief system.  This system consists of the messages we receive from our parents, relatives, neighbors, and society in general.  It’s how we see the world, and how we see ourselves.  But what if some of these beliefs are untrue, irrational, or distorted?  What if one had the belief that the only way to be social is to have a drink, or the only way to relax is to smoke a joint?  These beliefs, of course, are untrue.  Anyone is able to relax and become social without substances.  But how do these distorted beliefs materialize with sexual acting-out behaviors?  Typically within healthy relationships, the initial element is one of friendship.  This is usually followed by trust, increased commitment, and closeness through intimacy (love), and then sex.  But for some, the way one develops friendship, establishes trust, makes commitment, is by being sexual.  Sex provides a way to meet his or her unmet needs.  One’s distorted and irrational beliefs may perpetuate this unhealthy cycle of addiction.

Inability to Cope

Think for a moment of someone who has been a best friend. A best friend is someone that you can always count on, and is always reliable, 24/7.  This is the same relationship that the addict has with pornography, sex, and other addictive behaviors.  Our digital world has made cybersex and pornography readily available 24/7.  It is accessible during good times and bad.  It always delivers what it promises to do when reality can be so unpredictable.  In addition, the area of the brain affected by addiction is the same area where meaningful relationships are developed.  One’s addiction becomes on par with his or her spouse, children, parents, and friends. Sometimes, unfortunately, it becomes number one.  For the addict with mental illness issues, in order to get well, I have to give up my best friend.

Stimulus-Response Relationship

When it comes to the brain and addiction, there are two main areas of the brain which play an important role with the other: the prefrontal cortex (PFC) and the midbrain.  The prefrontal cortex is the executive functioning part of the brain.  The PFC is where   decision-making, morality, and personality exist.  Everything about who one is as a person resides in the PFC.  The main role of the midbrain is to reinforce behaviors which are necessary for the organism to survive.  The midbrain does this by the release of certain neurochemicals, especially dopamine.  Dopamine provides pleasure. Behaviors that are necessary for survival are reinforced with dopamine.  If food and sex were not pleasurable, humankind would have expired thousands of years ago.

The midbrain reinforces behaviors necessary for our survival by the release of the pleasure chemical, dopamine.  But addictive behaviors also trigger dopamine.  Behaviors such as sex and pornography, as well as other addictions (drugs, alcohol, gambling) do this too.  When dopamine is released from the midbrain and begins to flood the PFC, there is a shutting down of the rational, logical, decision-making part of the brain.  The midbrain overrides the PFC which now no longer functions correctly. A hijacking of the brain’s reward system occurs.  When this happens, the memory neurochemical Glutamate is released and informs the midbrain:  “Don’t forget this!  Go out and get it!”

The brain now believes and remembers that addictive behaviors are essential for survival.  Logically, one knows that one does not need alcohol, drugs and other addictive behaviors to survive, but the brain does not realize this.  As a society, we have unfortunately responded and treated addiction as an issue of morality, a weakness, a lack of will power, a character flaw, an addictive personality, sociopathy, etc.  Our society has unfortunately responded to addiction with shame, guilt, blame, coercion, and incarceration for many years.  This old approach has and continues to be a failure.  Addiction starts earlier and deeper within the brain and hijacks its reward system by believing the addictive behavior is necessary for survival.


What should the treatment be for these issues?  When it comes to pornography, gambling, alcohol, heroin, or in fact any addictive behavior, a strong correlation exists with mental illness.  Treatment approaches must include integration of the co-occurring disorders.  For years substance use disorders and mental illness have been treated separately from one another.  Unfortunately, this view continues in many treatment communities.  Research indicates that an effective treatment model of addiction must integrate with the individual’s mental illness issues.  If only the addiction is addressed and not the mental illness, both will get worse.  Likewise, if only mental illness is treated and not the addiction, both will get worse.

The CUBIS model provides a template for treatment:

  • Medication management:  For individuals who experience a chemical imbalance, medication management can be beneficial in assisting the individual in regulating issues of anxiety, mood, and depression.  The development of medication-assisted treatment for those in recovery has also proven to be therapeutically beneficial for individuals suffering from addiction.


  • Psychotherapy:  Therapy serves as a means to relieve symptoms, resolve problems in living and/or seek personal growth.  The utilization of psychotherapy can be helpful in assisting individuals with unresolved issues of trauma, abuse, grief, loss, abandonment, etc.


  • Cognitive-behavioral therapy:  Individuals experiencing issues of irrational, maladaptive, or distorted beliefs may benefit from cognitive-behavioral therapy.  This therapy approach focuses on issues of thoughts, perceptions, attitudes and actions in choosing healthier behaviors.


  • Skill development:  For individuals who need to find better ways of coping, developing skills to assist in the regulation of mood and anxiety can be helpful.  These skills may consist of various ways of coping including mindfulness, meditation, community support groups, exercise, dialectical behavior therapy, spirituality, etc.


  • Education:  Knowledge serves as a means of increasing understanding and awareness for individuals and family members in how addiction impacts the brain.  This level of education and awareness can hopefully reduce elements of shame, guilt and blame of the individual who suffers from addiction and mental illness.  Individuals suffering from addiction may lie, cheat and steal, but bad acts do not necessarily mean bad actors.

Final thoughts

For this clinician, a simple cover from a 1963 Life magazine has left an imprint.  It remains unclear what the long-term effect of exposure to pornography and digital images have upon the brain and especially on the developing brains of young people.  The Internet and the digital world have made many aspects of our lives more productive, informative, connected and creative.  However, in today’s world of social media, chat rooms, digital pornography, interactive webcams, instant messaging, “adult friend finder” apps and sexting, our digital world also provides more destructive means to escape from life stressors, depression, anxiety and all other forms of mental illness.  Individuals suffering from mental illness may be easily drawn into other means of regulating mood, thoughts, and behaviors by high-tech addictive behaviors.  No longer can humanity afford to turn a blind eye as men, women, and children are pulled into the seductive charms of the dark side of the digital world. There is nothing romantic about pornography. Instead, it promotes an unrealistic and unhealthy view of relationships and true intimacy.

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The Benefits of Residential Assessment.

On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.

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Opioid Addiction: What we need to know.

(Part 1) Introduction and Accidental Overdose

Jolomi Ikomi, MD, Chris J. Tuell, EdD, LPCC-S, LICDC, Lindner Center of HOPE, Staff Psychiatrist; University of Cincinnati College of Medicine, Adjunct Assistant Clinical Professor of Psychiatry


Opioids are indicated in treatment of acute and chronic non-cancer pain. Opioids are psychoactive substances and can cause an increased sense of euphoria via their action on the brain opiate receptors. This effect, which is beneficial for altered pain perception, is also the main reason for their misuse potential.

Opioids can be highly addictive. When used for recreational purposes, or when prescribed by treatment providers and not adequately monitored, can progress rapidly to an opioid related disorder. Opioid related disorders include opioid use disorder, opioid withdrawal, opioid intoxication, opioid induced mood disorder, opioid induced anxiety disorder and opioid induced psychotic disorder. There is an increased prevalence of mental illness in individuals with opioid related disorders than within the general population. About 90% of patients with opioid dependence will also have an additional psychiatric disorder, most commonly major depressive disorder, alcohol use disorders, anxiety disorders and personality disorders.

Since the 1990s, there has been greater awareness about adequate pain control for patients experiencing not just acute pain, but also chronic non-cancerous pain. This has led to an increase in the rise of prescription opioids, which in turn has led to a steady rise in opioid prescription addiction. The United States and Canada have significantly higher rates of prescribed opiates than any other developed country in the world. Prescription opioids are costly and the high cost of obtaining them has led individuals to seek cheaper alternatives. Heroin resurgence has occurred in the last decade. Patients addicted to prescription opiates are seduced by its cheap price and more rapid onset of action.  Increased prevalence of heroin use has led to a rise in drug related felonies (larceny, prostitution) and medical complications such as HIV and Hepatitis C seroconversion and accidental overdose.


Accidental Overdose

Opioid overdose is a global health concern accounting for considerable mortality among patients with opioid use disorders. About 50% of all deaths of heroin users in the United States are as a result of opioid overdose. 73% of all prescription overdose related deaths are due to prescription opioid medications.

To understand overdose, we first need to define the term “Tolerance”. This refers to an individual requiring more of a psychoactive substance to achieve a desired effect or when the same dose of a previously used substance does not give the desired effect. Individuals with opioid use disorders develop tolerance to the drug over a prolonged period of time. Opioids have respiratory depressant as well as euphoric effects. Tolerance to respiratory depressant effects occurs much slower than to the euphoric effects. This means whenever an individual rapidly increases the amount of the drug used in order to achieve a euphoric effect, they are at significant risk of respiratory compromise and death.  Tolerance also rapidly decreases during periods of abstinence, such as following an opioid detoxification. Risk of overdose is greatly increased during the immediate opioid detoxification period. This is as a result of intense craving for the drug, as well as loss of tolerance to the drug.


Treatment of Overdose

Naloxone (Narcan) is a short acting opioid receptor blocker that is a life saving measure and should be immediately administered in suspected overdose. Signs to look for in an individual with suspected overdose include diminished level of consciousness or coma, pinpoint pupils and respiratory depression with rate less than 12 per minute (normal is 12-20). Administration of intravenous Narcan works within 2 minutes and slightly longer if given intramuscularly. This medication is safe and has no significant side effects. The main draw back with Narcan is the short half-life so its effects last much shorter than the effects of most opioids. Thus, once the medication has been administered, emergency medical services must be called immediately. Failure to do so will lead to immediate return of overdose symptoms within minutes, after effects of Narcan have worn off.

Administration of Narcan is easy and everyone, not just trained professionals can administer it. It can be administered in the community by trained lay persons. Family members and friends usually witness early symptoms of overdose. Training the support network as well as the individual with a history of opioid use disorder is imperative for the risk reduction of overdose deaths. Prescription of a Narcan kit to all individuals with a history of opioid use disorder has been shown to significantly reduce overdose deaths in the community. This is being practiced in some European countries and in several states across the U.S.

Narcan is not treatment, it is only an emergency life saving measure to prevent death and buy time before the arrival of emergency services and referral to treatment centers for long term treatment. Long-term treatment of opioid use disorders will be discussed in the subsequent series.

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Understanding Addictive Disorders

Each year, millions of Americans find themselves caught in a cycle of addiction to alcohol, drugs, gambling, or other substances/ behavior.  They must struggle daily with the effort to become and remain free of the drugs or behaviors to which they feel uncontrollably drawn.

Affected individuals are diagnosed on the basis of the particular substance or activity to which they are addicted.  However, individuals with any type of addictive disorder may exhibit related symptoms, and both causes and treatment are similar.

The Nature of Addiction

An addictive disorder, as opposed to temporary reliance on a particular substance or behavior, can be distinguished by several distinct symptoms:

Tolerance. Over time, an individual requires increasing amounts of the preferred substance/behavior to achieve the same physical or psychological effects.

Withdrawal. When an individual tries to curb the addiction, withdrawal symptoms such as anxiety, rapid heartbeat, sweating, etc., will occur.

Lack of control. The individual has extreme difficulty cutting back or controlling the addictive behavior, even when aware of negative consequences.

Preoccupation. Cravings for the desired substance or behavior are constant.  Increasing amounts of time are spent planning, participating in, and then recovering from the addictive behavior, with employment and relationships often threatened.

Causes of Addiction

Are addicts “born that way,” or do they develop addictive disorders due to environmental factors?  In this nature vs. nurture debate, both answers may be true. Psychological, genetic, environmental, and other factors that determine a particular individual’s likelihood of developing an addiction may be interrelated.

Biological factors.  Studies have shown that the likelihood of twins developing the same addiction is 50-70%, and familial rates of such addictions as alcoholism are significant. Other research has pointed to such biological factors as abnormal dopamine levels influencing addictive behavior.

Psychological factors.  Is there such a thing as an addictive personality? While no such diagnostic code exists, many experts believe that certain personality traits make individuals more vulnerable to addiction.  They include: sensation seeking, impulsivity, poor coping skills, anxiety or depression, insecurity, and feelings of social alienation.

Environmental factors.  Stress may the factor that figuratively pulls the addiction trigger in an individual who is biologically or psychologically prone to develop one. A history of trauma, for example, is frequently found in individuals who develop an addiction, particularly any type of severe stress in childhood.  Physical or sexual abuse also increases the risk of developing an addictive disorder.

Treatment of Addiction

Numerous treatment approaches have developed that provide benefit to individuals in acute stages of addiction, and a robust recovery movement provides ongoing support and management of the illness. Treatment modalities include:

Medical approaches.  Depending upon the nature of the addiction, an individual may benefit from medical detoxification and an inpatient rehabilitation program.  While the use of medication is often discouraged, short-term use of medication is necessary in some instances.

Psychotherapy.  Many contemporary forms of “talk therapy” have demonstrated positive results in individuals with addiction, including the following:

  • Cognitive behavioral therapy;
  • Motivational enhancement therapy;
  • Dialectical behavioral therapy;
  • Relapse prevention therapy.

These therapies teach individuals better coping skills, including recognition of triggers to addictive behavior, stress reduction, relapse avoidance, and impulse control.

Psychotherapy may be conducted in an individual or group setting. Family therapy is often encouraged in order to reduce enabling of addictive behaviors, as well as to heal broken relationships.

Community and family supports. Peer support is a cornerstone of most successful recovery programs. Recovering individuals find ongoing support through a variety of community organizations such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or similar groups.  Many support groups are based on the twelve-step recovery model first established for AA.

In addition to counseling, families may benefit from support groups such as Al-Anon for assistance in dealing with a loved one’s addictive behavior.

Addictive disorders can be daunting, but with proper treatment and support, individuals can experience recovery and return to full function in their homes and communities.