Lecture 3, June 9th - Dr

1INTEGRATED CLINICAL STUDIES – JUNE 9th, 2008 DR. ARVIN JENAB – NATUROPATHIC MEDICINE AND THE TREATMENT OF ADDICTIONS LECTURE 3 Addiction: dependence and tolerance develop with use. These factors cause the withdrawal symptoms that develop when the patient stops taking the drug. Is it the substance, or it is the user? It is both. Can’t lose sight of the fact that the substance needs to be focussed on too. Has its own substance or pattern of use. Part of addictive picture. Can’t only focus on the mental/emotional/behavioural. Life and death instinct : Freud. Life instinct: looking for life-affirming experiences. Death instinct: constantly engage in self-destructive behaviour to dissociate from their experience of the world. Page 2: • Mindfulness based meditation + CBT: good starting point for patients that want to quit. • Addiction recovery program: not very accessible for average patient, in Ontario. • CAMH: offers a lot of great resources for us and for patients. 5 sites • Renaissance centre: abstinence program. Check in, stop using. Have urine tests. Option for lower-income patients.

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MAARS: Metro addiction referral service for all addictions. http://www.camh.net/About_CAMH/Guide_to_CAMH/Addiction_Programs/Addiction_Treatment_Programs/guide_maa rs_clinic.html Substitute replacement therapy: give 5HTP and serotonin to manage symptoms as part of a system. Restorative medicine: how can we restore the balance of co-factors etc. to restore functioning of brain. The more treatments you use, the better, without overwhelming patient. Ensure that your patients are there for themselves, not for family, because they are made to be there, etc. They need to have commitment. What are reasons they have become addicted? If it is to pharmaceutical that was prescribed, may be more physiological addiction if they didn’t seek out drugs: they were prescribed for condition, they didn’t seek out addictive substance. If a patient is addicted to a drug that was prescribed (eg. For anxiety), the symptoms of original condition will likely come back as they go off drugs: symptoms were suppressed if they didn’t go through entire process of dealing with emotions the first time. Stabilizing blood sugar can reduce cravings by 1/2 . Heart Fire: withdrawal symptom of anxiolytics. Identify their obstacles: know what these are before you start treatment. Exercise for patient: write list of resources (activities, hobbies, finances, colleagues… Then write list of obstacles: may see things they have never said before. Great exercise to follow the first visit. What are the patient’s emotional needs? Are they being met? Addictive behaviour: may show up in other parts of their lives: work, other relationships etc. Sometimes easier to start here, because there isn’t same stigma attached to it as dealing with addiction directly. Dream work may also offer you a “backdoor” to access addiction. Talking about dreams is safe for many people: reflects their emotions, but easier for them to talk about because it is a dream, they are more detached. What are we UNABLE to address? Easy to want to be everything to your patient. We can co-ordinate care, but don’t need to do everything (be crisis line, give all support)

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Addition: behaviour/emotion first, then object/activity (not always the case, eg. After accident, start drugs) Primary drive: may have started drinking because of anxiety, but may now have secondary drive (physiological depletion of GABA: can focus on this with naturopathic treatment.

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All behaviour serves a purpose, by nature we are not destructive. If we are engaging in destructive pattern, on some level, it is preventing a greater harm that we perceive. Essence of drugs: homeopathic remedies have been made from many drugs.

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Abstinence (person stops, goes through detox, recovery etc.) vs. harm reduction (we support the body to reduce harm, but educate the patient while doing this. Can teach the patient about the effects of the drug on their body, eliminate the secondary drives, may get them to a point where they want to change their behaviour. Can take this approach if we have a patient that we are concerned with, but who doesn’t want to change their behaviour at this time.

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Common goals shared by addiction treatments:

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Drugs deplete kidney essence, and the heart. Cocaine depletes Heart Yin. Wipeout syndrome: from long-term use of drugs

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Patient taking many drugs long term, has moved to harder drugs from others when he developed tolerance, wipeout syndrome to drugs. Completely exhausted, depleted. Start by nourishing the patient, nourish the Yin, but don’t stimulate first. Stimulating first will cause more of a deficiency. Acupuncture: maybe not first treatment as it requires Yin, blood, Qi. If they are lacking material essence, won’t help. Have to use herbs first to support the deficiency. B-vitamins? Stimulating! After IV treatment, would have anxiety and panic attacks. Put him on nutritive treatment plan for months. Can’t start liver detox if their elimination functions are already overwhelmed.

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Rules to live by: • Identify dependence (cravings) • Identify tolerance (withdrawal symptoms) How do we manage these? • • •

Decrease craving: replacement/substitute therapy. If they are addicted to nicotine (increases blood sugar, increases adrenal function), stimulate adrenal glands, stabilize blood sugar. Also very important to restore nutritional deficiencies (B6 from carb/alcohol addiction) B vitamins, Vitamin C, zinc (co-factors of serotonin metabolism) Alcohol is GABA agonist (anti-anxiety). Can take glycine (pre-cursor to GABA) Herbs: patient on anti-anxiety meds coming off, give nervine (see Dr. Saunders’ notes). Muscle relaxant too? (Diascorea, skullcap,

Second component of treatment: reduce withdrawal symptoms. o Decrease dose gradually. If prescribed, work with prescribing doctor. Pharmacist can advise patient too, give dosing schedule. Varies between drugs. May be cutting pills in ½, ¼, or skipping day. o Support the body. For anti-depressants, there is decrease in serotonin activity. Will be depressed (have crash) without drug. Same for Ecstasy. 5-HTP: Thorne makes one. Start with low dose. o Depression: gotu kola, st. john’s wort, rosemary. Multi-B6, use as base. Nervine and adaptogenic support needed too (tailor to specific patient: depressed AND anxious?). Gingko: increase circulation to the brain. o As patient reduces dose of AD drugs, 50mg 5-HTP, take for 5 nights, take 2 nights off, then 4 nights, 2 nights off, then 3 nights, 2 nights off, … to 0. May need more, but don’t want to cause serotonin syndrome (anxiety and discomfort). If at end of course, patient has depressive withdrawal symptoms, can repeat. Chronic gastritis and digestive weakness: from coffee, nicotine, alcohol, marijuana withdrawal Bronchitis, pneumonia: smoking, cocaine, alcohol, marijuana Malnutrition (common in many addicts). People on anti-depressants: trend towards carb-rich diet. Insulin can help uptake of serotonin, tryptophan from blood stream. Support elimination, alkalinize Anemia: secondary to gastritis, poor diet Important to assess cognitive deficits Schizoid tendencies: linked to increase in dopamine. Can result from drug use. Tremors: get these if CNS depleted (internal wind in TCM). Angel dust: people using this damaged neurons producing Dopamine, had ‘parkinsonism’: symptoms of Parkinsons. 2 kinds of tremor: resting tremors (may see in cocaine use, from drop in cocaine (it increases dopamine)). Also senile tremors (tremors that come with movement: associated with Ach activity in brain.) Precursor to Ach is phosphatidyl choline. ICS JUNE 9TH, 2008 – PAGE 2

Page 8 Amino acid therapy: gaining acceptance. Downside: this is a linear treatment. Have to look at whole patient. Always start at lower end of range of dose and work up. A few cautions: Tyrosine is precursor to dopamine, but also melanin, epinephrine, norepinephrine. May increase risk in patients prone to melanoma, anxiety. Page 9: TCM approaches addictions from different perspective. Other clinical tip: remove stasis before you nourish yin. Nourish yin before increasing yang.

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