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THE DOCTORSTHE DOCTORSOPINIONOPINION

An explanation of addictive illness found in theAn explanation of addictive illness found in theBig Book of Alcoholics AnonymousBig Book of Alcoholics Anonymous

Dawn Farm Lecture SeriesDawn Farm Lecture SeriesNovember November 15, 201115, 2011

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

FASAMFASAMSpecialist in Chronic Pain and Addictive IllnessSpecialist in Chronic Pain and Addictive IllnessMedical Director, Pain Recovery Solutions, PCMedical Director, Pain Recovery Solutions, PCAttending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MIAttending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MIClinical Faculty, University of Michigan Medical Center, Dept. of Clinical Faculty, University of Michigan Medical Center, Dept. of AnesthesiologyAnesthesiologyConsultant to Michigan Pain Specialists, Ann Arbor, MIConsultant to Michigan Pain Specialists, Ann Arbor, MIRegion VI Director, American Society of Addiction MedicineRegion VI Director, American Society of Addiction Medicine

4870 Clark Road W. Suite 2014870 Clark Road W. Suite 201Ypsilanti, MI 48197Ypsilanti, MI 48197734/434734/434- -66006600

Declarations of Potential ConflictsDeclarations of Potential Conflictsof Interestof Interest

The content of this presentation isThe content of this presentation isnonnon--commercial and does notcommercial and does notrepresent any conflict of interestrepresent any conflict of interest

ObjectivesObjectives

Discuss Dr. Silkworths explanation of Discuss Dr. Silkworths explanation of alcoholism as a twofold disease, affectingalcoholism as a twofold disease, affectingmind and bodymind and bodyRelate Silkworth to the modernRelate Silkworth to the modernneurobiolgy of addictive illnessneurobiolgy of addictive illnessIdentify therapy for alcoholism asIdentify therapy for alcoholism aspromoted by Alcoholics Anonymous andpromoted by Alcoholics Anonymous andits relationship to Dr. Silkworths opinionits relationship to Dr. Silkworths opinionStill have time for questionsStill have time for questions

BORING

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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 1930sPsychiatrist at Towns Hospital 1930s

Thought alcoholism a twofold illness (mindThought alcoholism a twofold illness (mind& body)& body)Gave Bill W. Step 1 (the problem)Gave Bill W. Step 1 (the problem)Published inPublished in Journal Journal- -Lancet Lancet , 1939, 1939

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The ProblemThe ProblemDetermines theDetermines the

SolutionSolution

Our previous view of chemicalOur previous view of chemicaldependencydependency

The Solution makesThe Solution makesno sense without anno sense without anunderstanding of theunderstanding of theproblemproblem

What is theWhat is theproblem ..NOTproblem ..NOT

Lack of willpower Lack of willpower Lack of moral character Lack of moral character Lack of understanding or Lack of understanding or educationeducationAlcohol and/or drugsAlcohol and/or drugs

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The Problem:The Problem:

Lack of Willpower Lack of Willpower (weak)

The Solution: Just Do ItThe Solution: Just Do It

Avoid barsAvoid barsAvoid drinking buddiesAvoid drinking buddies

Avoid liquor storesAvoid liquor storesThink of baseballThink of baseball

The Problem:The Problem:

Lack of KnowledgeLack of Knowledge

(dumb)

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The Solution:The Solution:

LecturesLecturesBooksBooks

Tapes & VideosTapes & VideosSelf Self--KnowledgeKnowledge

The Problem:The Problem:

Deep PsychologicalDeep PsychologicalProblemsProblems(crazy)

The Solution:The Solution:

CounselingCounselingPsychotherapyPsychotherapy

MedicationMedication(tranquilizers)(tranquilizers)

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10,000 Pounds of Insight10,000 Pounds of InsightIsnt Worth 1 Ounce of Isnt Worth 1 Ounce of

Behavior ChangeBehavior Change

The Problem:The Problem:

Lack of Character Lack of Character (bad)

The Solution:The Solution:

A solemn oathA solemn oathA better code of moralsA better code of morals

A better philosophy of lifeA better philosophy of lifeOrganized religionOrganized religion

The Problem:The Problem:

Alcohol & DrugsAlcohol & DrugsI have a drug problemI have a drinking problem

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

RestlessRestlessIrritableIrritable

DiscontentDiscontent

ResentmentResentmentFear Fear

Shame & GuiltShame & Guilt

Alcohol Problem vs.Alcohol Problem vs. Alcoholism Alcoholism

Then WhatThen What ISIS thetheProblem?Problem?

An allergy of the body and anAn allergy of the body and anobsession of the mindobsession of the mind

Allergy to AlcoholAllergy to Alcohol

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Definition of AllergyDefinition of Allergy

An abnormal reaction to anyAn abnormal reaction to anybeverage, food, or other beverage, food, or other substancesubstance

The Brains DesignThe Brains Design

Because the brain is so wondrous thatBecause the brain is so wondrous that

most of us assume it has an elegantmost of us assume it has an elegantdesign.design.In fact, the brain is a kludge (A kludge inIn fact, the brain is a kludge (A kludge inthe words of Jackson Grandholm is an illthe words of Jackson Grandholm is an illassorted collection of poorly matchedassorted collection of poorly matchedparts, 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 AbnormalWhat is the AbnormalReaction?Reaction?

getting drunk repeatedlygetting drunk repeatedly

getting sick repeatedlygetting sick repeatedlygetting into all kinds of troublegetting into all kinds of troublerepeatedlyrepeatedly

This does not happen toThis does not happen tosocial drinkerssocial drinkers

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The only relief we have toThe only relief we have tosuggest is entire abstinencesuggest is entire abstinence

The Doctors Opinion,The Doctors Opinion, Alcoholics Anonymous Alcoholics Anonymous p. xxxp. xxx

Cant start drinkingCant start drinking

Rx: entire abstinenceRx: entire abstinence

Alcohol vs. CarrotsAlcohol vs. Carrots

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ObsessionObsessionCompulsive preoccupationCompulsive preoccupation

with a fixed ideawith a fixed idea

They are restless, irritableThey are restless, irritableand discontented, unlessand discontented, unless

they can again experiencethey can again experiencethe sense of ease andthe sense of ease and

comfort ..comfort ..The Doctors Opinion,The Doctors Opinion,

Alcoholics Anonymous Alcoholics Anonymous pp.pp.xxviiixxviii--xxixxxix

How do we manage primitiveHow do we manage primitivedrives?drives?

The primitive parts of our brain control theThe primitive parts of our brain control theless 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 thanLive your way into sober thinking rather than

trying to think your way into sober livingtrying 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 thecomprehend theconsequences of onesconsequences of onesactions.actions.

Cant stop startingCant stop starting

Rx: Personality changeRx: Personality changesufficient to recover sufficient to recover

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Allergy + Insanity =Allergy + Insanity =

Cant start drinking (allergy)Cant start drinking (allergy)Cant stop starting (insanity)Cant stop starting (insanity)

PowerlessPowerless

firm resolve

?? restless

?? irritable

?? discontent

THE CYCLE OFADDICTION

one drink

Allergy Insanity

?? drunk

?? sick

?? all kinds of trouble

a spree

Robert Holbrook Smith, MDRobert Holbrook Smith, MDDr. BobDr. Bob

UM Med (1908UM Med (1908- -10)10)Akron SurgeonAkron SurgeonCoCo--founder of Alcoholics Anonymousfounder of Alcoholics AnonymousTreated over 5,000 AlcoholicsTreated over 5,000 AlcoholicsCurrent AA membership 2.8 millionCurrent AA membership 2.8 million24+ million copies of 24+ million copies of Alcoholics Anonymous Alcoholics Anonymous

sold since 1939sold since 1939

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Step 1: THE PROBLEMStep 1: THE PROBLEM

HopelessHopelessHelplessHelpless

IncurableIncurable

We admitted we wereWe admitted we werepowerlesspowerless

Step 2: THE SOLUTIONStep 2: THE SOLUTION

No human power could relieveNo human power could relieveour alcoholismour alcoholismGod could and would if he wereGod could and would if he were

soughtsought

Came to believeCame to believe

The Actions Which BringThe Actions Which BringAbout the SolutionAbout the Solution

Dont DrinkDont DrinkGo to meetingsGo to meetingsGet a sponsor Get a sponsor

Work steps 4Work steps 4- -99Prayer Prayer One day at a timeOne day at a time

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