Tagged Addiction (Psychology)

A.A. to Zoom, Substance Abuse Treatment Goes Online

Until the coronavirus pandemic, their meetings took place quietly, every day, discreet gatherings in the basements of churches, a spare room at the YMCA, the back of a cafe. But members of Alcoholics Anonymous and other groups of recovering substance abusers found the doors quickly shut this spring, to prevent the spread of Covid-19.

What happened next is one of those creative cascades the virus has indirectly set off. Rehabilitation moved online, almost overnight, with zeal. Not only are thousands of A.A. meetings taking place on Zoom and other digital hangouts, but other major players in the rehabilitation industry have leapt in, transforming a daily ritual that many credit with saving their lives.

“A.A. members I speak to are well beyond the initial fascination with the idea that they are looking at a screen of Hollywood squares,” said Dr. Lynn Hankes, 84, who has been in recovery for 43 years and is a retired physician in Florida with three decades of experience treating addiction. “They thank Zoom for their very survival.”

Though online rehab rose as an emergency stopgap measure, people in the field say it is likely to become a permanent part of the way substance abuse is treated. Being able to find a meeting to log into 24/7 has welcome advantages for people who lack transportation, are ill, juggling parenting or work challenges that make an in-person meeting tough on a given day and may help keep them more seamlessly connected to a support network. Online meetings can also be a good steppingstone for people just starting rehab.

“There are so many positives — people don’t need to travel. It saves time,” said Dr. Andrew Saxon, an addiction expert and professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. “The potential for people who wouldn’t have access to treatment easily to get it is a big bonus.”

Participants of the combined virtual and in-person therapy group at Ottagan. While the convenience and ease of telehealth is undeniable, some say they crave the intensity of physical presence.
Participants of the combined virtual and in-person therapy group at Ottagan. While the convenience and ease of telehealth is undeniable, some say they crave the intensity of physical presence.Credit…Emily Rose Bennett for The New York Times

Todd Holland lives in northern Utah, and he marvels at the availability of virtual meetings of Narcotics Anonymous around the clock. He recently checked out one in Pakistan that he heard had a good speaker, but had trouble with some delay in the video and in understanding the speaker’s accent.

Some participants say the online experience can have a surprisingly intimate feel to it.

“You get more a feel for total strangers, like when a cat jumps on their lap or a kid might run around in the background,” said a 58-year-old A.A. member in early recovery in Portland, Ore., who declined to give his name, citing the organization’s recommendations not to seek personal publicity. Plus, he added, there are no physical logistics to attending online. “You don’t go into a stinky basement and walk past smokers and don’t have to drive.”

At the same time, he and others say they crave the raw intensity of physical presence.

“I really miss hugging people,” he said. “The first time I can go back to the church on the corner for a meeting, I will, but I’ll still do meetings online.”

Mr. Holland, who for decades abused drugs until Narcotics Anonymous helped him stay sober for eight years, said the online meetings can “lack the feeling of emotion and the way the spirits and principles get expressed.”

It is too early for data on the effectiveness of online rehabilitation compared to in-person sessions. There has been some recent research validating the use of the technology for related areas of treatment, like PTSD and depression that suggests hope for the approach, some experts in the field said.

Even those people who say in-person therapy will remain superior also said the development has proved a huge benefit for many who would otherwise have otherwise faced one of the biggest threats to recovery: isolation.

The implications extend well beyond the pandemic. That’s because the entire system of rehabilitation has been grappling for years with practices some see as both dogmatic and insufficiently effective given high rates of relapse.

A worksheet to help patients clarify their thoughts and behaviors during the Ottagan group session.Credit…Emily Rose Bennett for The New York Times

“It’s both challenging our preconceived concerns about what is necessary for treatment and recovery but also validating the need for connection with a peer group and the need for immediate access,” said Samantha Pauley, national director of virtual services for the Hazelden Betty Ford Foundation, an addiction treatment and advocacy organization, with clinics around the country.

In 2019, Hazelden Betty Ford first tried online group therapy with patients in San Diego attending intensive outpatient sessions (three-to-four hours a day, three -to-four hours a week). When the pandemic hit, the organization rolled out the concept in seven states, California, Washington, Minnesota, Florida, New York, Illinois and Oregon — where Ms. Pauley works — and has since expanded to New Jersey, Missouri, Colorado and Wisconsin.

Ms. Pauley said 4,300 people have participated in such intensive therapy — which entails logging into group or individual sessions using a platform called Mend that is like Zoom. Preliminary results, she said, show the treatment is as effective as in-person meetings at reducing cravings and other symptoms. An additional 2,500 people have participated in support groups for family members.

If not for Covid, Ms. Pauley said, the “creative exploration” of online meetings would still have happened but much more slowly.

One hurdle to intensive online rehab involves drug testing of patients, who would ordinarily give saliva or urine samples under in-person supervision. A handful of alternatives have emerged, including one in which people spit into a testing cup while being observed onscreen by a provider who verifies the person’s identity. The sample then gets dropped at a clinic or mailed in, though the risk of trickery always remains. In other cases, patients can visit a lab for a drug test.

Kim Villanueva, of Muskegon, Mich., shared a story during the group therapy session at Ottagan.Credit…Emily Rose Bennett for The New York Times

Additionally, some clinical signs of duress can’t be as easily diagnosed over a screen.

“You can’t see the perspiration that might indicate the person suffering mild withdrawal. There are limitations,” said Dr. Christopher Bundy, president of the Federation of State Physician Health Programs, a group representing 48 state physician health programs that serve doctors in recovery. He said that hundreds of physicians in these programs are attending regular virtual professionally monitoring meetings in which they meet with a handful of specialists for peer support and to assess their progress.

“This sort of thing has challenged our assumptions,” he said of the pandemic and the use of the internet for these therapies. “There’s a sense it’s not the same, but it’s close enough.”

Other participants in drug rehab and leaders in the field say that while online has been a good stopgap measure, they also hope that in-person meetings will return soon.

“It’s been a mixed blessing,” said David Teater, who wears two hats: he’s in recovery himself since the 1980s, and he’s executive director of Ottagan Addictions Recovery, a residential and outpatient treatment center serving low-income patients in western Michigan whose therapy typical gets paid through Medicaid.

In that capacity, he said online tools have been a godsend because, simply, they allowed service to continue. Through $25,000 in grants, the center got new computers and other technology that allowed it to do telemedicine, and set up a “Zoom room.” It includes a 55-inch monitor so that people who are Zooming in can see the counselor as well as the people who feel comfortable enough to come in-person and sit at a social distance wearing masks.

“We think it works equally well, we really do,” Mr. Teater said.

It’s Time for a Digital Detox. (You Know You Need It.)

When is enough enough?

Even though the presidential election is over, we’re still doomscrolling through gloomy news about the coronavirus surge. The rest of your daily routine is probably something like mine while stuck at home in the pandemic: Divided among streaming movies on Netflix, watching home improvement videos on YouTube and playing video games. All of these activities involve staring at a screen.

There has to be more to life than this. With the holiday season upon us, now is a good time to take a breather and consider a digital detox.

No, that doesn’t mean quitting the internet cold turkey. No one would expect that from us right now. Think of it as going on a diet and replacing bad habits with healthier ones to give our weary eyes some much needed downtime from tech.

“There’s lots of great things to do online, but moderation is often the best rule for life, and it’s no different when it comes to screens,” said Jean Twenge, a psychology professor at San Diego State University and the author of “iGen,” a book about younger generations growing up in the smartphone era.

Too much screen time can take a toll on our mental health, depriving us of sleep and more productive tasks, experts said. I, for one, am experiencing this. Before the pandemic, my average daily screen time on my phone was three and a half hours. Over the last eight months, that has nearly doubled.

So I turned to psychology experts for their advice. From setting limits to finding alternatives to being glued to our phones, here’s what we can do.

Come Up With a Plan

Not all screen time is bad — after all, many students are attending school via videoconferencing apps. So Step One is assessing which parts of screen time feel toxic and make you unhappy. That could be reading the news or scrolling through Twitter and Facebook. Step Two is creating a realistic plan to minimize consumption of the bad stuff.

You could set modest goals, such as a time limit of 20 minutes a day for reading news on weekends. If that feels doable, shorten the time limit and make it a daily goal. Repetition will help you form new habits.

That’s easier said than done. Adam Gazzaley, a neuroscientist and co-author of the book “The Distracted Mind: Ancient Brains in a High-Tech World,” recommended creating calendar events for just about everything, including browsing the web and taking breaks. This helps create structure.

For example, you could block off 8 a.m. to read the news for 10 minutes, and 20 minutes from 1 p.m. for riding the exercise bike. If you feel tempted to pick up your phone during your exercise break, you would be aware that any screen time would be violating the time you dedicated to exercise.

Most important, treat screen time as if it were a piece of candy that you occasionally allow yourself to indulge. Don’t think of it as taking a break as that may do the opposite of relaxing you.

“Not all breaks are created equal,” Dr. Gazzaley said. “If you take a break and go into social media or a news program, it can get hard to get out of that rabbit hole.”

Create No-Phone Zones

We need to recharge our phones overnight, but that doesn’t mean the devices need to be next to us while we sleep. Many studies have shown that people who keep phones in their bedrooms sleep more poorly, according to Dr. Twenge.

Smartphones are harmful to our slumber in many ways. The blue light from screens can trick our brains into thinking it’s daytime, and some content we consume — especially news — can be psychologically stimulating and keep us awake. So it’s best not to look at phones within an hour before bed. What’s more, the phone’s proximity could tempt you to wake up and check it in the middle of the night.

“My No. 1 piece of advice is no phones in the bedroom overnight — this is for adults and teens,” Dr. Twenge said. “Have a charging station outside the bedroom.”

Outside of our bedrooms, we can create other No-Phone Zones. The dinner table, for example, is a prime opportunity for families to agree to put phones away for at least 30 minutes and reconnect.

Resist the Hooks

Tech products have designed many mechanisms to keep us glued to our screens. Facebook and Twitter, for example, made their timelines so that you could scroll endlessly through updates, maximizing the amount of time you spend on their sites.

Adam Alter, a marketing professor at New York University’s Stern School of Business and author of the book “Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked,” said that tech companies employed techniques in behavioral psychology that make us addicted to their products.

He highlighted two major hooks:

  • Artificial goals. Similar to video games, social media sites create goals to keep users engaged. Those include the number of likes and followers we accrue on Facebook or Twitter. The problem? The goals are never fulfilled.

  • Friction-free media. YouTube automatically plays the next recommended video, not to mention the never-ending Facebook and Twitter scrolling. “Before there was a natural end to every experience,” like reading the last page of a book, he said. “One of the biggest things tech companies have done was to remove stopping cues.”

What to do? For starters, we can resist the hooks by making our phones less intrusive. Turn off notifications for all apps except those that are essential for work and keeping in touch with people you care about. If you feel strongly addicted, take an extreme measure and turn the phone to grayscale mode, Dr. Alter said.

There’s also a simpler exercise. We can remind ourselves that outside of work, a lot of what we do online doesn’t matter, and it’s time that can be better spent elsewhere.

“The difference between getting 10 likes and 20 likes, it’s all just meaningless,” Dr. Alter said.

More Nonsmoking Teens Inhaling Flavored Nicotine

Photo

A study shows that many teenagers who would have never smoked are now vaping.

A study shows that many teenagers who would have never smoked are now vaping.Credit Katie Orlinsky for The New York Times

Many teenagers who never would have smoked cigarettes are now “vaping” with flavored e-cigarettes, leading to a new generation using nicotine at rates not seen since the 1990s, a new study suggests.

The study, released Monday in the journal Pediatrics, tracked the use of cigarettes and e-cigarettes among 5,490 California high school seniors who graduated between 1995 and 2014. E-cigarettes do not burn tobacco, but are battery-operated inhalers that heat up and vaporize liquid containing flavors and nicotine, a practice known as vaping. The liquids used in vaping range in taste from traditional tobacco and menthol flavors to fruity and sweet combinations like gummi bear, banana bread and cotton candy.

When e-cigarettes came on the market in 2007, some public health experts hoped that they would serve as a substitute for traditional tobacco products and lead to declines in tobacco use.

But the data from the latest study, conducted by researchers at the University of Southern California, tell a different story. E-cigarettes do not appear to have made a dent in regular cigarette use — the number of high school seniors who reported smoking tobacco in the past 30 days has largely plateaued. In 2004, the number of 12th graders who reported smoking tobacco in the past 30 days was 9 percent; in 2014 that number was just under 8 percent.

But the rate of teenagers using nicotine — either through tobacco cigarettes or e-cigarettes — is on the rise. About 14 percent of Southern California high school seniors in 2014 said they had smoked or vaped in the last 30 days. Researchers say they have not seen similar levels of nicotine use among teenagers since 1995, when 12th grade smoking rates were 19 percent.

The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine. While the study focused on California teenagers, researchers say the numbers are consistent with national trends.

“Kids are not just using e-cigarettes instead of cigarettes. That is what we were frankly hoping to find,” said Jessica Barrington-Trimis, the lead author of the study and a postdoctoral scholar research associate in the department of preventive medicine at the U.S.C. Keck School of Medicine. All of the teenagers that were expected to be using cigarettes in 2014 are using them, she said, “and then there is a whole group of kids using e-cigarettes on top of that.”

The amount of nicotine in the liquids used with e-cigarettes — often called “vape juice — varies, and users can purchase liquid with no nicotine or nicotine content ranging from 3 milligrams per milliliter to 18 milligrams per milliliter or even higher. While earlier studies have suggested that some teens are using nicotine-free vaping liquids, researchers say the majority of teens appear to be using nicotine-infused liquid in their e-cigarettes.

Dr. Jonathan Winickoff, professor of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, who wrote an accompanying paper in Pediatrics, said this is the first study of e-cigarette use in adolescents to show such a strong longitudinal sample with such a drastic effect.

“We had a trend of decreasing nicotine use,” said Dr. Winickoff. “What the e-cigarette has done is halted that decrease in its tracks…. We don’t want a fifth of our high school students graduating with nicotine addiction.”

While e-cigarettes do appear to be safer than smoking tobacco, they are not risk free. Nicotine disrupts neurotransmitter activity and is highly addictive, particularly in a developing brain. And the liquids contain solvents, formaldehyde and other ingredients that pose health risks when inhaled.

While it’s true that there are nicotine-free vaping liquids, the e-cigarette industry is not regulated, which makes it hard to know what ingredients are actually in any given product. Though the Food and Drug Administration recently took jurisdiction over e-cigarettes, it will be years before any regulations are put into effect. Currently, many products continue to be made in China with little — if any — oversight by the United States.

“The F.D.A. has done tests on these vaping products that supposedly do and do not contain nicotine, and what is advertised is really not what’s in the product,” Dr. Winickoff said. “When the product is labeled as no nicotine, they’ve found nicotine. So kids don’t know what they’re getting, and as a pediatrician it really scares me.”

Not everyone agrees that e-cigarettes pose a significant risk to teenagers. Dr. Michael Siegel, professor of community health sciences at the Boston University School of Public Health, countered that many teenagers say they are using e-cigarettes that contain only flavorings and no nicotine, and therefore are not getting addicted.

“E-cigarette use among teenagers is a largely social phenomenon,” he said. “The fact that you tend to see teenagers doing this in groups, not out in the cold vaping alone, suggests that e-cigarettes are not addictive.”

But there is a growing body of research showing that e-cigarettes do serve as a gateway to traditional tobacco products. Last month, the U.S.C. researchers also reported in Pediatrics that adolescents who vape are six times more likely to smoke cigarettes in early adulthood as non users.

“Once kids get hooked on e-cigarettes, they are more likely to go on to become cigarette smokers,” said Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.

More Nonsmoking Teens Inhaling Flavored Nicotine Through Vaping

Photo

A study shows that many teenagers who would have never smoked are now vaping.

A study shows that many teenagers who would have never smoked are now vaping.Credit Katie Orlinsky for The New York Times

Many teenagers who never would have smoked cigarettes are now “vaping” with flavored e-cigarettes, leading to a new generation using nicotine at rates not seen since the 1990s, a new study suggests.

The study, released Monday in the journal Pediatrics, tracked the use of cigarettes and e-cigarettes among 5,490 California high school seniors who graduated between 1995 and 2014. E-cigarettes do not burn tobacco, but are battery-operated inhalers that heat up and vaporize liquid containing flavors and nicotine, a practice known as vaping. The liquids used in vaping range in taste from traditional tobacco and menthol flavors to fruity and sweet combinations like gummi bear, banana bread and cotton candy.

When e-cigarettes came on the market in 2007, some public health experts hoped that they would serve as a substitute for traditional tobacco products and lead to declines in tobacco use.

But the data from the latest study, conducted by researchers at the University of Southern California, tell a different story. E-cigarettes do not appear to have made a dent in regular cigarette use — the number of high school seniors who reported smoking tobacco in the past 30 days has largely plateaued. In 2004, the number of 12th graders who reported smoking tobacco in the past 30 days was 9 percent; in 2014 that number was just under 8 percent.

But the rate of teenagers using nicotine — either through tobacco cigarettes or e-cigarettes — is on the rise. About 14 percent of Southern California high school seniors in 2014 said they had smoked or vaped in the last 30 days. Researchers say they have not seen similar levels of nicotine use among teenagers since 1995, when 12th grade smoking rates were 19 percent.

The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine. While the study focused on California teenagers, researchers say the numbers are consistent with national trends.

“Kids are not just using e-cigarettes instead of cigarettes. That is what we were frankly hoping to find,” said Jessica Barrington-Trimis, the lead author of the study and a postdoctoral scholar research associate in the department of preventive medicine at the U.S.C. Keck School of Medicine. All of the teenagers that were expected to be using cigarettes in 2014 are using them, she said, “and then there is a whole group of kids using e-cigarettes on top of that.”

The amount of nicotine in the liquids used with e-cigarettes — often called “vape juice — varies, and users can purchase liquid with no nicotine or nicotine content ranging from 3 milligrams per milliliter to 18 milligrams per milliliter or even higher. While earlier studies have suggested that some teens are using nicotine-free vaping liquids, researchers say the majority of teens appear to be using nicotine-infused liquid in their e-cigarettes.

Dr. Jonathan Winickoff, professor of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, who wrote an accompanying paper in Pediatrics, said this is the first study of e-cigarette use in adolescents to show such a strong longitudinal sample with such a drastic effect.

“We had a trend of decreasing nicotine use,” said Dr. Winickoff. “What the e-cigarette has done is halted that decrease in its tracks…. We don’t want a fifth of our high school students graduating with nicotine addiction.”

While e-cigarettes do appear to be safer than smoking tobacco, they are not risk free. Nicotine disrupts neurotransmitter activity and is highly addictive, particularly in a developing brain. And the liquids contain solvents, formaldehyde and other ingredients that pose health risks when inhaled.

While it’s true that there are nicotine-free vaping liquids, the e-cigarette industry is not regulated, which makes it hard to know what ingredients are actually in any given product. Though the Food and Drug Administration recently took jurisdiction over e-cigarettes, it will be years before any regulations are put into effect. Currently, many products continue to be made in China with little — if any — oversight by the United States.

“The F.D.A. has done tests on these vaping products that supposedly do and do not contain nicotine, and what is advertised is really not what’s in the product,” Dr. Winickoff said. “When the product is labeled as no nicotine, they’ve found nicotine. So kids don’t know what they’re getting, and as a pediatrician it really scares me.”

Not everyone agrees that e-cigarettes pose a significant risk to teenagers. Dr. Michael Siegel, professor of community health sciences at the Boston University School of Public Health, countered that many teenagers say they are using e-cigarettes that contain only flavorings and no nicotine, and therefore are not getting addicted.

“E-cigarette use among teenagers is a largely social phenomenon,” he said. “The fact that you tend to see teenagers doing this in groups, not out in the cold vaping alone, suggests that e-cigarettes are not addictive.”

But there is a growing body of research showing that e-cigarettes do serve as a gateway to traditional tobacco products. Last month, the U.S.C. researchers also reported in Pediatrics that adolescents who vape are six times more likely to smoke cigarettes in early adulthood as nonusers.

“Once kids get hooked on e-cigarettes, they are more likely to go on to become cigarette smokers,” said Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.

When It’s Not Just a Boo-Boo: The Push to Treat Children’s Pain

Photo

Credit Sally Deng

It began with a roller-skating accident three years ago. Taylor Aschenbrenner, then 8 years old, lost her balance amid a jumble of classmates, tumbled to the floor and felt someone else’s skate roll over her left foot. The searing pain hit her immediately.

The diagnosis, however, would take much longer. An X-ray, M.R.I.s, a CT scan and blood tests over several months revealed no evidence of a break, sprain or other significant problem. Taylor’s primary symptom was pain — so severe that she could not put weight on the foot.

“Our family doctor first told us to give it some time,” said Taylor’s mother, Jodi Aschenbrenner, of Hudson, Wis.

But time didn’t heal the pain. After about a month, an orthopedist recommended physical therapy. That didn’t end the problem, either. “I couldn’t walk or play outside or do anything,” Taylor said.

After she had spent a year and a half on crutches, her orthopedist suggested she see Stefan Friedrichsdorf, the medical director of pain medicine, palliative care and integrative medicine at Children’s Hospitals and Clinics of Minnesota. He and his team promptly recognized Taylor’s condition as complex regional pain syndrome, a misfiring within the peripheral and central nervous systems that causes pain signals to go into overdrive and stay turned on even after an initial injury or trauma has healed.

He came up with a treatment plan for Taylor that included cognitive behavioral therapy, physical therapy, mind-body techniques, stress-reduction strategies, topical pain-relief patches and a focus on returning to her normal life and sleep routine.

“That turned things around so fast, if I didn’t see it myself, I wouldn’t have believed it,” Mrs. Aschenbrenner said. “I thought, ‘finally, someone understands what this is, has experience with it, and knows how to fix it!’”

But why did it take so long for a child in unbearable pain to find relief? Experts say children’s pain is, for the most part, grossly underrecognized and undertreated.

“Unfortunately, in 2016 pain management in the United States and all Western countries is still abysmal,” said Dr. Friedrichsdorf, who noted that pediatric pain receives the least attention. “Data shows that adults with the same underlying condition will get two to three times as many pain medication doses as children.”

There are effective treatments. But pediatricians, specialists and even parents have been slow to turn to them because pain in children has long been misunderstood and medical training in pain management is scant. Veterinary schools require “at least five times more education on how to handle pain” than medical schools, Nora D. Volkow, the director of the National Institute on Drug Abuse, said..

As recently as the 1980s, babies would routinely undergo invasive medical procedures, including open-heart surgery, without anesthesia or analgesics because physicians believed that infants’ brains were not developed enough to feel the pain. And it was thought that even if babies did feel pain, it wouldn’t ultimately matter because they wouldn’t remember it later on.

The emphasis in Western medicine has traditionally been on “saving lives and executing medical procedures effectively, while pain has been pushed way down on the priority list,” said Christine Chambers, a professor of pediatrics, psychology, neuroscience and pain management at Dalhousie University in Halifax, Nova Scotia.

Many doctors and parents also fear that pain medications will have dangerous side effects, like developmental problems and addiction. But current scientific evidence supports a different conclusion.

“Research shows that poorly managed pain exposures early in life can actually change the wiring in the brain and prime children to be more sensitive to it later on, putting them at risk for developing chronic pain in childhood and adulthood,” said Anna C. Wilson, a child psychologist and assistant professor of anesthesiology at the Pediatric Pain Management Center at Oregon Health & Science University. And while babies or young children may not consciously remember it, their nervous systems will.

There is, however, reason for optimism. Contrary to previous conventional thinking, the effective use of pain medication for children does not hinder brain development, according to several studies.

Research has also shown that the appropriate medical use of prescription pain medications, such as opioids, when properly monitored, does not lead to addiction in young children and adolescents, Dr. Friedrichsdorf said.

A host of other behavioral interventions have been shown to prevent and treat pain as well. Pain experts say these can and should be used even during seemingly minor medical procedures, such as vaccinations. Parents can hold their children during the procedure, breast-feed or give them a sweet solution to suck on, distract them with a song or breathing exercises, and use a topical numbing cream.

One recent study also found that a parent’s behavior and approach to their children’s vaccinations can affect a child’s response to needles.

“That vaccination at age 5 might not seem like a big deal to you, but if it goes wrong and causes a lot of pain, then the child becomes fearful,” Dr. Chambers said, which can perpetuate a cycle of fear and pain over medical care.

“One of the best ways to address the epidemic of chronic pain in this country is to stop it before it starts,” Dr. Wilson at Oregon Health & Science University said.

“If we could reduce painful experiences and problems in childhood, we might be able to reduce chronic pain in the next generation.”

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Visiting to Lose Weight, Then Calling It Home

Photo

After a trip to Fitness Ridge, Jennifer Morton ended up staying there.

After a trip to Fitness Ridge, Jennifer Morton ended up staying there.Credit Victoria Tarter

There was no reason for Jennifer Morton to move to Utah, except one: It was the place she lost 40 pounds.

In 2009, Ms. Morton was working 90-hour weeks as the director of learning at a large company outside Louisville, Ky. She traveled 80 percent of the time, and her weight shot up. Panicked and exhausted, she quit her job and checked into Fitness Ridge (now called Movara Fitness Resort), a weight-loss and fitness retreat in southern Utah.

She ended up staying a month.

“All of a sudden I was in a place where everybody was like me,” said Ms. Morton, 40. “It felt like home.”

Five weeks later, it really was: She packed up her belongings and settled into a house less than a mile from the resort in the town of St. George. Not long after, she began teaching classes at Movara on emotional eating and food addiction, guiding clients through their own body battles.

“It just made sense to do this,” Ms. Morton said. The low cost of living was appealing, as was the natural beauty. But most importantly, she could continue the healthy lifestyle she had embraced.

“At the resort, the way you feel about who you are is so important to protect that you’re willing to stay in that environment to make sure it sticks,” said Ms. Morton, who began doing triathlons after her stay. “If you find your best self somewhere, you definitely don’t want to leave it.”

People like Ms. Morton are adopting a model familiar to those fighting substance abuse, who are often encouraged to change their environments and relationships post-rehab in order to “stay clean.” (Minnesota, for example, is half-jokingly referred to as “Minnesober” because of the large number of rehab centers there and the many people in various stages of recovery, who often remain in the state after treatment.)

“Addiction is a lifelong problem that people have to deal with, and it’s the same with weight,” said Dr. William Yancy, director of the Duke Diet and Fitness Center in Durham, N.C. “Even if they reach their goal, it’s something they need help and support with.”

“It speaks to the power of the proverbial ‘toxic food environment,’” said David Sarwer, director of the Center for Obesity Research and Education at Temple University’s College of Public Health. “When we’re in our normal day-to-day routines, and those routines have become second nature to us, there are countless negative influences on our eating habits and sedentary behavior that contributes to weight gain.”

Relocating, he said, offers an opportunity to create new habits. “In these cases, people have the opportunity to make a significant commitment to health and well-being to live in a geographical location that promotes health,” he said.

From 2007 to 2012, Marjorie S. Fine went twice a year to the Duke diet and fitness program. She would lose about 30 pounds during her two-month stay, and regain half when she returned home to Miami. “I would chip away at the weight, but never really be anywhere near 99 percent successful,” said Ms. Fine, 69.

Late in 2015, she and her husband moved full-time to Durham (once called the “diet capital of the world” because of the number of weight-loss facilities there). She exercises and eats lunch at Structure House, a residential program in town, six days a week, and attends individual therapy and weekly Overeaters Anonymous meetings there.

“As with any other addiction, you have to work on it on a daily basis,” said Ms. Fine, who has now lost 65 pounds and hopes to lose another 40.

“It’s very important to have that shared experience and problem solve together,” said Catherine J. Metzgar of the University of Illinois at Urbana-Champaign, the lead author of a study that found social support and being accountable to others helped some women lose and maintain weight loss. “Having your family and others in your social circle buy into what you are doing is also important.”

Cindy MacKenzie, 62, a former teacher and self-described yo-yo dieter, retired with her husband in 2015 to southern Utah. The couple purchased a home about a five-minute drive down the road from Movara, where Ms. MacKenzie used to go for annual weight-loss visits.

“We have definitely bought into the program,” said Ms. MacKenzie, who still regularly attends the resort. Back in Silicon Valley, where they used to live, “we would go out to eat all the time, we would drink. Here, there are no threats, no temptations.”

“If you’re living in a community where every single one of your friends and family members is devoted to overeating and an unhealthy lifestyle or to misusing various drugs and alcohol, it’s really hard to change in that environment,” said Maia Szalavitz, a former heroin and cocaine addict and author of the book “Unbroken Brain: A Revolutionary New Way of Understanding Addiction.”

On the other hand, surrounding yourself with too many people with similar issues can be risky. “A lot of people get into a very closed world that’s kind of limited,” she said. “Sometimes you make each other better, and sometimes worse.”

Of course, most of us cannot afford to uproot our families, lives and jobs in the name of healthy living. (Structure House’s base price for new participants, for example, is $10,500 for a four-week stay.) And even if we could, we bring our struggles with us. (In bumper sticker terms: “Wherever you go, there you are.” )

Jean Anspaugh, 62, lost 100 pounds at the Rice House program in Durham, where she stayed for seven years, renting an apartment nearby and taking odd jobs to pay the costs. She figured she would “stay thin forever.” But she didn’t. Work, bills and relationships took their toll, and she got “mainstreamed back into the dominant culture, which eats all the time.”

“Nobody realizes how hard it is to lose weight and keep it off,” said Ms. Anspaugh, a folklorist in Fairfax, Va., and author of “Fat Like Us.” “It’s a full-time job.” She has regained some of the weight but still feels that Durham, “the place where the magic happened,” is home. “I miss the mind-set,” she said. “I miss my tribe.”

Ms. Morton, too, acknowledged that moving to Utah wasn’t a panacea. “You still have to do the same things: build your community, get involved, find the people you like,” she said. And she now is wrestling with “emotional management — meaning, working through the parts of myself that will keep me successful over the long run.”

Still, she has no plans to leave.

“Weight and fitness is definitely on the forefront of my mind, so I think it keeps me accountable because I have to face it every day,” she said. “Also, it helped me realize — we’re all the exact same. We are all dealing with the same set of four or five problems; they just manifest differently in each one of us. It has helped me on my weight management program, and also on my journey to be a good human.”

Seeking Painkillers in the Emergency Room

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Credit Stuart Bradford

A couple of months ago, a patient well known to the emergency room where I work came in requesting his usual cocktail of narcotic pain medications. It was early Saturday morning, before the usual bustle of patients had begun, and I had some time.

The patient was well documented in the electronic medical record for his frequent emergency room visits for painkillers. To further confirm, I called his pharmacy, and as soon as the pharmacist heard the patient’s name, he sighed loudly, said he knew him well, and began listing the litany of different doctors and hospitals from which the patient had gotten narcotic painkillers.

I then sat down with the patient for a good 25 minutes — a considerably long time in a busy, urban emergency room— and explained why I could not give him what he wanted. It was clearly stated in his medical record that he had an extensive history of opioid abuse, and the shopping-around for prescriptions, as suggested by his pharmacy, further validated that. I knew if I waved him off with another supply of painkillers, I would only perpetuate his addiction problem.

He protested loudly and repeatedly said, “I don’t know why you can’t be like all the other docs and just give me the drugs. Everybody does it.” Finally, realizing that he would not get what he wanted, he stormed out after shouting at me: “If you doctors don’t want me taking the drugs, why’d you all give me all those pills after my surgery last year?”

Patients like him are not uncommon in the emergency room. A 2014 study confirmed that from 2001 to 2010, the percentage of emergency room visits during which opioids were prescribed jumped by 10 percent. My patient’s story stuck with me because I was actually able to spend time counseling him instead of caving to his request — and because he had the insight to know that his addiction started with a doctor’s prescription.

The opioid epidemic is explosive, and laws are being passed to address the problem. Two-thirds of emergency room visits involving overdoses are due to prescription drugs. The highest number of deaths caused by opioid painkillers was in 2014. The data for 2015 has yet to be released.

But, as one of my colleagues whom I greatly respect said to me in the emergency room recently: “Why wouldn’t I give patients a Percocet prescription? It makes their life easier and my life easier.” Another colleague overhead this and wholeheartedly agreed, speaking truth to the fact that the system is set up so that refusing these demands is much more difficult and time-consuming than it is to simply give in to them.

I know it, too. I’ve had patients seeking painkiller prescriptions who kept the hospital administrator’s number in their cellphones and have called pre-emptively before I’ve even had a chance to talk to them. I’ve had patients who’ve had tremendous outbursts in the emergency room, completely disrupting care and taking up the time and attention of many of the hospital staff members, often to the detriment of other patients. This sometimes results in my colleagues asking if I could simply prescribe a couple of pills so the patients would leave.

Several years ago, I even had a patient formalize a letter of complaint to the state health department that I did not give her the opioids she requested. At the very least, I have to worry about patient satisfaction scores, which have come to be valued ever more greatly as they’re now linked to Medicare reimbursements. For individual physicians, low scores may result in a slap on the wrist or decreased pay or, in extreme cases, even be grounds for dismissal.

I appreciate that new safeguards are being implemented. In New York State, where I now work, a higher-level electronic prescribing system is rolling out to closely track and protect against narcotic painkiller over-prescribing; my colleagues and I all went through the training process and are mandated to start the new system on March 27. Under the new system, only digital prescriptions that are electronically transmitted to the pharmacy are allowed, and if a physician wants to prescribe a narcotic painkiller, an additional security verification step is required. In Massachusetts, where I used to work, a law was passed to limit narcotic prescribing to a seven-day supply after a surgery or injury.

But the truth is, a deep cultural shift within our health care system is needed. Physicians need to know that if they don’t prescribe a narcotic because it’s not clinically indicated, or worse yet, because the patient already has an addiction problem, that they have the backing of administrators at every level, from their own department to the head of the hospital all the way up to state officials. If patients are seeking narcotics and have a documented history of doing so — and become combative or refuse to leave after discharge — they may need to be escorted out of the emergency room by security and their treatment terminated to avoid interrupting the care of other patients.

What my patient said to me that Saturday morning is right: We health care providers created the problem. Now it’s up to us to take steps to try to solve it. Beyond these new prescribing laws, on-site drug counseling ought to be in place. Drug rehabiliation programs need to be expanded, and dedicated staff should be available in the emergency room to enroll patients into them directly. But it begins with doctors not jumping immediately to prescribe narcotic painkillers — and a health care system that allows them to say no.

Helen Ouyang is an emergency physician at NewYork-Presbyterian Hospital and an assistant professor of medicine at Columbia University.

In Hospitals, Smoke-Free Doesn’t Mean Abuse-Free

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Credit James Yang

The substance user and the hospital are bound by the most ambivalent of relationships. Heavy users — of tobacco, alcohol or harder drugs — see far more of the wards than the average citizen and, it is safe to say, like them even less.

They need hospitals. They hate hospitals. Hospitals make them well and sick at the same time. We are their doctors and nurses, their parents, their arresting officers, parole officers, judge and jury. Needless to say, we are not trained for the last five roles, nor are we particularly good at them.

A single principle guides us: You cannot use your drug of choice on our premises, no matter how much you may need it and prefer it to our proffered alternatives. Around that immutable core swirl large clouds of negotiation, compromise, duplicity, manipulation and general misery for all involved.

On some days it seems as if we spend all our energies managing not the conditions we are trained to manage but the addictions that complicate them.

One patient is tying his shoes as we make our rounds in the morning, and tells us cheerfully that he is going out for a smoke. He’ll be right back. We inform him, not without sympathy, that in our hospital smoking breaks are not allowed. If he leaves for even half an hour he will officially be considered discharged. His bed will be given to someone else, and to resume his medical care, he will have to go back to the emergency room and start the cycle all over again.

We propose a nicotine patch instead, but the nurses have already given him a patch, to no effect. Few other compromises are possible between the smoke-free hospital and the hard-core, implacable smoker. The discussion grows heated. We wind up discharging him on the spot, just a little sooner than we had in mind.

The patient in the next room has been in the bathroom for almost an hour. We need to examine him. We knock on the bathroom door. He yells out that he’s fine.

When he finally drifts out, drowsily readjusting the dressing covering the intravenous line in his arm, he doesn’t look fine. He looks as high as a kite, and come to think of it, the two visitors lounging by his bed do, too. We sigh. No easy compromises will be possible for him.

It was back in the 1980s that most American hospitals became officially smoke-free (and cigarette butts began accumulating in stairwells and side exits). The big exceptions were the V.A. hospitals: In fact, theVeterans Health Care Act of 1992 specifically required V.A. facilities to establish designated smoking areas for clients. In 2008, those areas were all moved outdoors, and most V.A. hospitals still have them.

This policy has been bitterly criticized as the worst kind of tobacco industry manipulation, but it does serve a useful function: It allows medical care to proceed without major interruption. Granted, that care is often for tobacco-related conditions, a cycle that strikes some observers as a common-sense, harm-reduction approach to the real world, and others as completely insane.

Still, smokers pose fewer challenges than intravenous drug users, like that young man who wandered out of his bathroom to face our interrogation. He has an infected heart valve, and is receiving high doses of antibiotics through an intravenous line in his arm, a portal to his bloodstream that is apparently proving too tempting for him to ignore.

He needs antibiotic treatment, and we have no oral options for him. Among other considerations, if his guests keep providing him with substances to shoot into that line, it may well become infected and unusable, and he will get even sicker than he is.

He promises never to do it again.

So now what? We have a set of programmed responses, none particularly satisfying or effective.

We can give him some methadone to keep him from withdrawing. We can screen his visitors or post a watcher at his bedside. Some hospitals transfer patients like him to an expensive intensive care bed for even more careful monitoring. Some make contracts and threaten to kick patients out for violations. (Can we really kick them out, as desperately sick as they are? I’ve never actually seen that happen.)

Addiction experts point out that hospitalizations offer an excellent opportunity to urge addicts into treatment. Unfortunately, inpatient acute care hospital wards are spectacularly ill equipped to provide that treatment, which would require a specially trained, dedicated team of medical and mental health professionals able to treat infection and addiction at the same time, in the same bed, on the same premises. It doesn’t sound like a particularly expensive proposition, but it must be one, because it’s another thing I’ve never seen happen.

Instead, we routinely plan for patients to be transferred to drug treatment programs when they are discharged. Quite a few don’t last that long. Our patient will prove to be one of them: After a few more days, he will suddenly be gone, well enough to walk out of the hospital (and take his intravenous line with him).

Presumably, he will try to make it out in the world until he gets too sick and lands in another hospital, where events will repeat themselves in yet another baffling health care cycle.

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