This is a paper I wrote that was published in the California Journal of Chinese Medicine published around 2015.
Teaching Chemical Dependence in the CM School
Teaching chemical dependence has become mandatory in Oriental medicine (OM) schools. Becausesubstance abuse is no longer simply an issue of “illegal drugs,” the class often takes a broad approach, Looking at substance abuse and addiction from a larger context students allows students to explore the unique benefits that OM offers in treating chemical dependence, and its limitations in this realm as well. The author reflects on some issues that arise from teaching about chemical dependence in Chinese medicine colleges, with suggestions regarding the importance of the class and the form it can take.
Introduction:
For many Oriental medicine students in the West, a class in chemical dependence is a step back into familiar territory. By the time they take this class, students will have had several years of training in new and unfamiliar concepts of xiao ke, yin/yang, phlegm and repletion. A class in chemical dependence, probably more than most classes in the Oriental medicine school, touches on a student’s personal issues, histories and cultural assumptions and raises themes that resonate through the entire practice of medicine. While the safety and health interests of our patients is foremost, we often see the intersection of what it means to be a healer with what it means to be healed. For students with an interest in the psychoemotional, the class often challenges their beliefs, assumptions and limitations.
In the first minutes of the first class of the seven-week class that I teach, I emphasize that substance abuse is a professional study and clinical practice onto itself and that the class will explore differing facets of that study. Like Oriental medicine itself, chemical dependence has numerous interlocking parts that inform each other, both interiorly (mindset) and in exterior manifestations (effects). Because of the dichotomy between the personal and technical nature of addiction, the class is both a formal and informal discussion of the physiological, cultural and legal definitions of substance use, abuse, dependence and addiction.
Teaching the class: Guidelines and assumptions.
I have found it essential to quickly set down numerous guidelines and my own assumptions that are followed in the class. I find that having an initial openness and honesty prevents offending, misunderstandings, backtracking and defensiveness later on. My first rule for the class is that nobody is allowed to bring their own experiences or those of their family into the classroom. I guarantee no anonymity, beyond the reasonable discretion of fellow students to keep personal behaviors secret. I explain that sharing with a patient one’s own history or problems presents issues of boundaries between the patient and practitioner. Even if, or perhaps especially if, one’s history and personal experience matches that of the patient, the practitioner should not share that with the patient, including those with substance abuse. In the classroom, this first guideline greatly frees discussion. I stress that if anyone feels uncomfortable, has objections or wants to share with me their issues, I am available outside of class time for discussion. Secondly, I tell the students my assumptions about them. I assume some have little or no experience with substance abuse, while others may be addicted to any numbers of drugs and have been or are currently in a 12-step program. If not themselves, they will have secondhand experiences through family or friends. I don’t know, nor I do want to know, who may be in any category, but I can be certain that everyone will fit into one. By maintaining these first two guidelines, classes don’t digress into stories of personal or familial difficulties. Each student in the classroom is allowed to view the material professionally.
The third assumption that I bring to the first class is that 12-step programs are a good thing (for many) and that the intersection of 12-step and Buddhism is interesting. I explain that I am neither “in recovery” nor have taken Buddhist vows, but I still maintain an interest in the two systems and how they can be used in drug dependence recovery. We look at the many objections to the 12-step programs and alternative programs such as Rational Recovery/cognitive behavior. The point is not that students must only recommend 12-step, but they be aware of the alternatives that their clients have. Still, I find the language of 12-step to be helpful in later discussions (eg,”it’s an inside job”). Many of their clients will be in a 12-step program and they should have some knowledge of its details.
I make the assumption that everyone (save those fully realized and enlightened beings) is an addict to some degree. What differentiates drug abuse from say, sex addiction or shopping, is only in degrees of harm to the person and society. The ancient image of the monkey who grasps a piece of food in a trap which she or he won’t let go of represents all of our “unreasonable” desires.
The next assumption I tell my class is that “addicts are smart people.” This, of course, shocks the students, but I say it because we can’t assume that one has to stupid to take drugs. Addiction is a way for a person to differentiate themselves from the environment and thus resist integration into what they may feel the inadequacies of society and themselves in it. “Rationality” itself often binds people to beliefs that “logically” resolve in addiction. As a practical matter, long-term addicts often are very clever or otherwise they would be dead or in jail. In addition, addicts have to use their wits through manipulating others and their environment in order to continue their habits.
The final assumption is that all addictions are yin (substance) deficiencies. The addict attempts to replace this yin deficiency with an object or substance. The psychiatrist Francis F. Seeburger writes, “What counts in addiction is that one relate to something, whether a substance, a process, a relationship, or whatever in such a way that one experiences one’s self unable to do without it. What counts is only that one learn the existential equation of addiction for that ‘object’. “1
Know the different substances/drugs/medications and to recognize the dangers.
Much of the class is taken with reviewing the different substances of abuse. We look at the biochemistry of each of the abused substances in biochemical terms from nicotine to opiates in terms of their capacity for addiction. Students should know the behavioral and cultural habits of addiction as well as treatment options, both Western and Chinese.
Students come from different backgrounds and ages and I am often surprised by their views of different drugs (as perhaps they are of mine!). For example, alcohol is so widely available that many underestimate its harmful effects, the depth of its abuse, and don’t realize that detoxification from it can be fatal. On the other hand, cannabis consumption and detox for my middle-aged generation, was generally seen as extremely benign. However, for many current patients, new potent strains of cannibas present issues in detox and depression that would have been disregarded 20 years ago. MDMA (Ecstasy) is a relatively new and commonly used substance that older and non-Western students may be totally unfamiliar with.
Patients come to us in differing stages of intoxication and withdrawal. Patients hope that an acupuncture treatment can relieve their symptoms and certainly we can help with that. However, states of intoxication and detoxification carry varying degrees of risk. For example, understanding that the difference between opium detox and Valium (benzodiazipine) detox is important because they have vastly different risks. The heroin abuser, although certainly uncomfortable to say the least, is not in danger of dying from his withdrawal, while the Valium abuser might. Knowing when to refer out, or to call an ambulance is, of course, vitally important. For those patients still using or abusing substances, any health professional should be familiar with the concept if not the particulars of harm reduction to advise the patients.
Build a vocabulary to talk to patients and professionals
Substance abusers come from varied backgrounds, however while currently using or in recovery always form sub-cultures with specific terminologies. When a practitioner is naive to the nature and effects of drugs, a patient has less trust in them. If the practitioner can identify with the terminology and “technical language” of addiction, greater trust can be found. To admit to addiction is to inherently invite judgment from others. Patients are more comfortable when they don’t have to explain in detail behaviors that are embarrassing, humiliating and shameful. Practitioners should ask questions dispassionately without judgment.
Recovery also has its special terminologies. Students often need to educated about the differences between detox, rehab and recovery. Relapse, slipping, dry drunk, sobriety and enabling are just a few of the many terms we explore.
Know the limits of treatment, dependency and co-dependency.
I believe in OM and I think it can play a crucial role in drug dependence treatment. However, just because we treat something doesn’t mean we can cure it. For the drug user, OM might appear to be just the magic (external) cure that they are looking for. For the eager and enthusiastic student or practitioner, they might be just as happy to be the one to supply it. I would suggest that both are often going to be disappointed. Chinese medical treatment should be seen as an adjunct to all the efforts that the drug user is making on her or his own.
For most OM students, treating chemical dependency is their first step into being a health provider professional in a clinical setting. In our student clinics, we supervisors tolerate if not tacitly encourage a certain amount of bonding between our students and patients. Students are often very enthusiastic about treating chemical dependency and addiction because it comes back to familiar cultural and personal terrain. At first glance, OM offers, with some knowledge of NADA and herbs, a solution which other therapies find elusive. One of the strongest features of addiction is to rely on outside “help” for problems, and health providers are all too willing to be there to fill that role. Students are encouraged to look upon themselves as professionals with skills unique to the larger discipline of chemical dependence.
We have to see how our own behavior as practitioners fosters dependence and co-dependence in our patients, be it through esteem or economic issues. Institutions as well can become “co-dependents” in their relationship with their clients. Michael Smith, founder of NADA, has famously said, “Remember your program is always sicker than your sickest client”2 Recognizing co-dependent behavior is often crucial in patients with particular stress issues. These behaviors may be outside substance abuse, but the patterns remain constant. The theme of dependence and co-dependence and enabling often overlaps not only with the “wounded healer” health practitioner, but also with gender and economic inequality.
Use and abuse.
Much of the first class focuses on defining drug dependence from medical (biochemistry), behavioral and legal standpoints. Throughout the semester, we often return to these definitions of use and abuse, choice and dependence. The term addiction itself is a matter of inquiry, which becomes especially relevant when discussing “recreational” drug use and cultural constructs of alcohol consumption. Addiction is often a matter of predictable and repeatable results from the behavior of choice. Understanding the features of ritual and the “narrowing of repertoire” (Douglas, can you define/explain what you mean by narrowing of repertoire?) is an essential feature that can also be exploited in treatment. The lack of predictability in hallucinogenics make them unlikely candidates for addiction, yet available for abuse. Conversely, heroin, the standard bearer for substance abuse study, has very predictable results and highly physiological properties that make it extremely addictive at all levels.
The importance of dual diagnosis.
Dual diagnosis refers to a patient with both drug abuse and mental health issues. Dual diagnosis can be labeled in drug abuse concurrent with HIV, Hep C etc., as well as mental health diagnoses. Substance abuse is often an effort to “self-medicate,” and because drug use often starts in the late teens as an expression of experimentation and before personalities are fully formed, it often masks other mental issues. This process does not end, of course, in adolescence. Recovery always lays bear deep inner issues that must be confronted either through intense personal spiritual reflection and/or psychological/medical intervention. It’s important to remind practitioners that once a drug is successfully withdrawn that everything will not necessarily return to normality, especially for the dual diagnosed.
Familiarity with NADA, 12-step and other treatment approaches
Familiarity with the NADA philosophy and protocol is relatively straightforward but often leads to deeper discussion. The five NADA points are not a magic cure for all addictions. Students tend to have two assumptions about NADA. First, they may think that these points will enable a person will ro stop abusing substances spontaneously. The second assumption is that NADA is a limitation and using it for treatment is mechanical and uncreative. They may think it is better to use their newly learned OM zang-fu diagnosis, eight principles or other more sophisticated skills. It is important to review the history of NADA and to explore the nature of community, ritual, reliability and codependence. Far from being mechanical, using speechless contact with patients forces the practitioner to exhibit compassion “straight from the heart” without reassuring words or methods. The patient learns not to rely on, nor manipulate, the special skills of one particular practitioner or method in their recovery. The ritual of daily auricular sessions mimics the narrowing of repertoire of addiction and hopefully replicates the ritual and dependability of substance abuse. The practitioner learns to view clients with “a non-attached compassion.”
Few substance abusers make it to sobriety without help. I discuss 12-Step programs in class not to endorse them but to help practitioners understand what many of their patients are going through in recovery. We discuss in detail the objections to 12-Step Programs and 12-Step alternatives such as cognitive behavior (often labeled Rational Recovery). Patients often use their objections to 12-Step programs as a reason to avoid any type of recovery process. Fortunately, in my classes I have yet to find anyone vehemently opposed to 12-Step programs although more than a few have voiced their doubts. Hopefully more will have understood why it is important for many in recovery.
Not all drug treatment is based on the NADA, of course, and students alsolearn about individualized treatment within a private clinic. We look at the zang-fu mechanisms and treatment with acupuncture and herbs. Steve Given’s paper from the Journal of Chinese Medicine is particularly helpful in these lectures.3 Differences between Tian Wan Bu Xin Dan, Wen Dan Tang, Long Dan Xie Gan Tang and Chai Hu Long Gu Mu Li Tang, among others, are explored in their relevance to stages of abuse, withdrawal detoxification and recovery. Other helpful journal articles include , “The Acupuncture Treatment of Alcohol and Chemical Dependency” by David Blow.4 lso Sean and William Scott’s American Journal of Acupuncture article “A Biochemical Hypothesis for the Effectiveness of Acupuncture in the Treatment of Substance Abuse: Acupuncture and the Reward Cascade” suggests physiological mechanisms for how acupuncture works in the treatment of substance abuse.5
I have often contemplated Taoist issues of the hun and po in their relation to addiction. The hun, which likes to move, and the po, which likes stillness, are at odds in addiction, and certainly in recovery. The intellectual hun can justify substance abuse to absurd levels, even when it knows that it is “wrong.” The po reacts to the physical withdrawal. I have recently been aware of qigong and Taoist concepts in the work of qigong expert, Dr. Liu Dong.
Resources and projects
In lieu of a final exam, I have the students do a project for presentation the last week of class. These presentations are done individually or in small groups, and the topic originate from the students with my guidance. Projects range from the biochemistry of particular substances to conjectures about treatment from various spiritual traditions including Taoism and Islamic Sufism. I find it interesting that many of the papers and presentations on other traditions find resonance in the 12 steps among initial skeptics. Even my provocative comment about how “addicts are smart” gets reflected in ideas that spirituality can not be “learned through books” and that knowledge without reflection can impede spiritual growth.
In past semesters, students created essays based on films, such as Man with the Golden Arm, Traffic (or Traffik, the longer and better English television version on which the film was based), To the Bone, , and other films of their choosing. Courtesy of the internet and cable TV, students now keep me up to date on shows such as Intervention where they can graphically see situations I can only hint at in the classroom.
The structure of the class comes largely from Steve Given, my teacher at Emperors College in the subject who has graciously let me use his class notes to supplement my own handouts. The one required text is by Alex Brambaugh,6 which conforms to my practical training working with Lianne Audette at Turnabout A.S.A.P. in Santa Monica. I have benefited from her workshops in this subject as well as those given by Shelley Bobbins in Los Angeles. Both teachers are highly recommended for practitioners and students interested in this area.
Conclusion
Teaching chemical Dependence and Oriental Medicine can be challenging as it can directly touch upon student’s lives. With boundaries fully established and a recognition of the professionalism of the addiction field it can be a rewarding class for students, teachers and the field of medicine itself.
Bibliography
Brumbaugh, Alex. Transformation and Recovery, Santa Barbara:Stillpoint Press,1994
Rossi, Elisa, Shen. Elsevier Ltd, 2007
Seeberger, Francis F. Addiction and Responsibility. New York: Crossroad Publishing, 1993
May, Gerald G. Addiction and Grace. New York: Harper Collins, 1988
Griffin, Kevin E. One Breath at a Time: Buddhism and the Twelve Steps. New York, St. Martins’s Press, 2004
Given, Steve. “Understanding Addiction According to Traditional Chinese Medicine”, Journal of Chinese Medicine, No. 54, May 1997
Sean Scott, William N. Scott. “A Biochemical Hypothesis for the Effectiveness of Acupuncture in the Treatment of Substance Abuse” American Journal of Acupuncture Vol. 25, No 1, 1997
Jiang, Yongping. “Addiction and Chinese Medicine”, Journal of Chinese Medicine, Number 88 October 2008
Douglas Eisenstark LAc teaches Chemical Dependence and Oriental Medicine at Emperors College in Santa Monica, California and has taught auricular and microsystems classes at Yosan University. He has worked at Turnabout A.S.A.P., a nonprofit outpatient acupuncture drug detox center, and thanks Lianne Audette, Ben Hekmatnia, Steve Given and Shelley Bobbins, and especially his students and patients for his education vital to this article. He maintains a practice in Los Angeles.
1 Seeberger, Francis (1993). Addiction and Responsibility, An Inquiry into the Addictive Mind. Crossroad: New York p. 58
2 Michael Smith, M.D. from Transformation and Recovery, A Guide for the Design and Development of Acupuncture-Based Chemical Dependency Treatment Programs by Alex Brumbaugh, Stillpoint Press, Santa Barbara, 1994 p. 167
3 Given, Steve (1997). “Understanding Addiction According to Traditional Chinese Medicine” , Journal of Chinese Medicine, No. 54, May 1997
4 Blow, David (1994) No. 45, May 1994
5 Sean Scott, William N. Scott (1997) American Journal of Acupuncture Vol. 25, No 1
6 Brumbaugh, Alex, 1994, Transformation and Recovery, Stillpoint Press: Santa Barbara