The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates nearly 2 million Americans abused or were dependent upon opioids in 2007 (OSA, 2009). Recently, the availability and abuse of illicit opioidi drugs (heroin, morphine, opium) as well as the non-medical use of opioid medications (fentanyl,  morphine, oxycodone) without prescription have considerably increased in the general population, causing profound negative consequences as well as significant challenges within behavioral healthcare. The prevalence of opioid use disorders and opioid- related admissions into addiction treatment ­settings are on the rise, with more Americans needing, seeking and receiving treatment for opioid-related problems than ever before. However, individuals still commonly find it difficult to access needed treatment services due to factors, such as limited treatment capacity in their region; insufficient insurance coverage/program cost; lack of awareness and bias of providers; and social stigma/discrimination related to addiction.

Optimistically, major improvements have been made around how treatment of opioid use disorders is being delivered, while new medications and treatment protocols (office-based buprenor- phine treatment) have facilitated a huge increase in treatment capacity. This article—the second is a series focusing on medication assisted recovery—presents a concise overview of medication assisted treatment (MAT) of opioid use disorders and opioid pharmacotherapy options currently available in the United States.

Opioid use disorders
Opioid use disorders (OUD) include: opioid use (abuse and dependence; addiction); opioid-induced (intoxication and withdrawal); and opioid-related disorders. These disorders are generally considered high severity conditions which typically require long-term treatment, ongoing monitoring and multiple treatment episodes (CSAT, 2004; 2005; 2006). Globally, consensus now exists that opioid addictionii is a medical disorder which responds effectively to treatment when counseling/behavioral therapy and opioid pharmacotherapy are combined to promote recovery. This is not to suggest the role of psychological, spiritual and social factors are not critically important in recovery planning as much as it is a refutation of the antiquated notion that opioid addiction is a moral defect/character flaw best responded to as a criminal matter (CSAT, 2005; 2006).

For many with OUDs, repeated use of opioids (four to six times per day) is motivated almost entirely by the intense desire to avoid withdrawal symptoms (nausea, vomiting, diarrhea, anxiety, physical pain and insomnia) which occur within hours of the last opioid use. Most individuals become trapped in a constant cycle of opioid use/withdrawal which creates an endless loop that consumes most of the person’s energy, attention and activities. Although many with OUDs will openly admit that they initially used opioids to get “high,” most report the primary objective quickly becomes avoidance of opioid withdrawal. Count­less people in recovery have shared that personal choice to use opioids is quickly replaced by the necessity to get “normal” or avoid withdrawal.

The recovery process for many individuals with OUDs is complicated by comorbid medical issues such as HIV and hepatitis; co-occurring mental disorders; stigma and discrimination; and considerable economic, social and legal challenges. However, research clearly demonstrates that many can and do recover from these debilitating disorders when they receive indi­vidualized recovery support services and effective integrated treatment which includes pharmacotherapy and ­counseling.

Pharmacotherapy
Determining the appropriate pharmacotherapy treatment option for a person is a complex process based upon numerous factors, as all MAT options have benefits and challenges. The selection of MAT options for each person should be a collaborative process between family members, significant others, medical and addiction professionals knowledgeable of MAT and others interested in promoting the recovery of the individual.
Currently, three medications are used widely in the treatment of OUDs as maintenance medications: metha- done, buprenorphine and the combined buprenorphine formulation which includes Naloxone. (Table 1 lists these, as well as some of the medications used in detoxification programs to treat OUD symptoms.)

Methadone: Viewed as the “gold standard,” methadone is a full opioid agonist that assists individuals reduce opioid cravings and withdrawal as well as block further opioid effects. Methadone is one of the most widely available, inexpensive and effective treatment options available. Strictly regulated, it may be dispensed for the treatment of addiction only in approved opioid treatment programs (OTP).

Buprenorphine: Approved in 2002, buprenorphine is a partial opioid agonist medication with similar benefits as methadone. Unlike methadone, bu-prenorphine can be dispensed by prescription from federally approved physicians and does not require individuals be treated in OTPs. Buprenorphine has a “ceiling effect” which reduces the misuse potential of the medication. Now widely available across the United States, buprenorphine can be a costly, yet effective treatment option that has assisted many in their recovery.

Buprenorphine and Naloxone: Like buprenorphine, this medication is taken sublingually and combined with Naloxone to further reduce diversion potential. Research indicates the bu- prenorphine medications may be equally effective in treating OUDs as methadone.

Naltrexone: An opioid antagonist medication with no narcotic properties, naltrexone is typically used as an aversive treatment since it immediately produces opioid withdrawal if opioids are ingested. In some cases it is used to induce withdrawal to determine if an individual has OUDs.
Clonidine: Frequently used to treat OUDs withdrawal symptoms, clonidine is viewed as superior to methadone for detoxification purposes since it provides no opioid effects and can be dispensed without special program licenses and with fewer complications (CSAT, 2006).

Marshall Rosier, MS, CAC, LADC, MATS, CDP-D is the Executive Director of the Connecticut Certification Board (www.ctcertboard.org) and is a published author, consultant and lecturer specializing in medication assisted recovery and co-occurring substance use and mental disorders. Marshall obtained his graduate degree from Yale University and over the last 20 years has worked in diverse academic and treatment settings.

References
CSAT (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: (SAMHSA).
CSAT (2005). Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06–4214. Rockville, MD: (SAMHSA).
CSAT (2006). Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06–4131. Rockville, MD: (SAMHSA).
OAS (2009). Results from the 2008 National Survey on Drug Abuse and Health: National findings. HHS Publication No. (SMA) 09-4434. Rockville, MD: Office of Applied Studies (SAMHSA).
(i) Many use the term opioid and opiate interchangeably. However, opioid refers to all opiates/opioids whereas the term opiate is meant to refer only to the natural derivatives of the poppy/opium plant (ii) The term opioid addiction is commonly used to refer to opioid dependence

The February 2010 issue of Counselor contained an article by William A. Rule titled “Self-Disclosure in Addictions Counseling: To Tell or Not to Tell.”  We are grateful to Rule for addressing the therapeutic advantages and disadvantages of counselor self-disclosure and for his contribution to the continued discussion of counselor boundaries.  However, we disagree with Rule’s statement in the final paragraph of his article, “Therapists and counselors who are also recovering addicts and alcoholics and who wish to be considered professional and effective should not, under any circumstances, self-disclose to his or her client that they are in recovery.”

We believe that a recovering counselor’s selective self-disclosure of their recovery can be an effective tool in promoting client recovery. We share our observations with the goal of promoting much-needed dialogue of this important subject.
Further, an interesting question that may be asked is why we are singling out the question around recovery when other questions might also be asked, such as “Are you married? Do you have any children? Have you ever experienced depression ______________________ (fill in the blank)?” Granted, the issue of recovery is unique in the addiction field. One would not likely ask an OB/GYN if she had a baby. But, the question of recovery may typically arise. However, we need to be careful not to focus just on the question of recovery as self-disclosure.

This article we will offer information about (1) Counselor Self-Disclosure in General; (2) The Question Behind the Question; and (3) Guidelines for Effective Self-Disclosure.

Counselor self-disclosure in general
Discussions of whether recovering addiction counselors should “Tell or Not to Tell” are not new.  Dr. Shelia Bloom’s article on the “Role of the
Recovering Alcoholic in the Treatment of Alcoholism” is testament to such concerns 33 years ago. The 1978 “Counseling Alcoholic Clients: A Microcounseling Approach to Basic Communication Skills” training module developed by the National Center for Alcohol Education, includes a section with strategies for training addiction counselors in the use of counselor self-disclosure. Today, most effective entry-level addiction counselor training courses contain structured opportunities to explore the subject, often resulting in lively debates on the “pros” and “cons” of self-disclosure.
Unfortunately, there is not consensus on the subject. It is regrettable that the 2006 publication, TAP 21:  Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, does not even mention the skill of counselor self-disclosure. When estimates of the number of recovering counselors working in this field range from 45 to 60 percent (by self report), we believe more clarity on this subject is essential to effective client care.

A good entry point to our discussions is Gutheil’s (2008) suggestion that referring to the issue as one of self-disclosure is simplistic since there are inescapable revelations by clinicians, spontaneous self-disclosures, shared affiliations, non-verbal communications and implicit communications (such as marital status indicated by a ring on the finger or pregnancy of a counselor). Gutheil concludes it is an over-simplification to merely flatly assert, “no-self-disclosure,” and states that “decisions about the therapeutic use of self-disclosure need to be made on a case-by-case basis in the content of the type of therapy offered.”  We agree with his statement.

The question behind the question
The decision by a recovering counselor “not to tell under any circumstances” when asked if they are in recovery ignores the nature of what often prompts the client to ask the question. The question behind the question is the issue of counselor competency.  When a client asks a counselor if they are in recovery, the inquiry is often an attempt by the client to establish trust in the relationship, and confirm that his counselor is able to help. If the counselor responds appropriately, the ensuing dialogue can encourage the client to explore the nature of the therapeutic client/counselor relationship, fundamental boundaries and counseling ­expectations.

 For instance, if the counselor responds to the question, “Are you in recovery?” with “That’s a very good question. Thanks for asking. I wonder what prompted you to ask that?” the client could perceive the counselor response as an invitation to explore deeper their motivation for asking the question. This could be an occasion for the client to clarify their assumptions and expectations about the counseling process. Then, based on the work done by the client in the session, the counselor can decide “to tell or not tell” based on an informed judgment as to what’s best for the client.

A study by Barrett and Berman (2001) found “that clients in the increased disclosure condition reported less symptom distress, and like their therapist more than clients in the limited disclosure condition.” The study found that “self-disclosure by therapists can in fact strengthen the therapeutic alliance and improve treatment outcomes.”

Guidelines for effective self-disclosure
Decisions about the therapeutic use of self-disclosure are appropriate and need to be made on a situation-by-situation basis, based on what’s best for the client. It is beneficial for clients to explore the “question behind the question.”  Here are suggested guidelines for therapeutic self-disclosure (Gutheil & Brodsky, 2008):
 1. More is Less; Less Is More. Limit your self-disclosure to information that you believe will be helpful to the client by sharing the “mountain tops” of your experience, not the “valleys.” You do not want to shift the focus to yourself for too long, but rather, keep the focus on the client.

2. Maintain Appropriate Boundaries. ecide for yourself what information you will not share with the client. This information might include your financial condition, sexual preference, past legal problems, conflict with employers, etc. Firm boundaries will create safety in the relationship for the client.
 
3. Remember Which “Hat You Are Wearing.” If you are in recovery and thereby are subject to a “dual relationship,” always be aware of which relationship you are in. For instance if you see a client at a 12 Step meeting, remember that you are not acting as a professional counselor in
that setting.
 
4. There are Different Levels of Self-Disclosure. Remember, there are different levels of self-disclosure which are often associated with differing results. For instance, sharing you once received a traffic ticket for speeding might have a far lesser impact upon your relationship with a client than sharing you were once incarcerated for DUI. 

5. Remember the principle of “cui bono,” which benefits from this disclosure. Is dis-­closure serving the needs of the counselor or the client? Is it
being done for the sake of the client, to build the therapeutic alliance, to enhance the therapy process? Does it work?

In conclusion, we encourage continued debate and discussion on this issue, and we thank Rule for raising the important question of appropriate self-disclosure.


References
Barrett, M.S., Berman, J.J. (2001). Evidence Based Mental Health. Is Psychotherapy More Effective When Therapists Disclose Information About Themselves? Journal of Consulting Clinical ­Psychology. August; 69: 597–603.
Blume, S.  (1977) Role of the recovering alcoholic in the treatment of alcoholism. In B. Issin & H. Begliester (Eds.) Biology of Alcoholism, Volume 5: Treatment and Rehabilitation of the Chronic Alcoholic. New York:  Plenum Press 545–565.
Gutheil, T. & Brodsky, A. (2008). Preventing Boundary Violations. Guilford Press.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services ­Administration (2006). Addiction Counseling Competencies, The Knowledge, Skills, and Attitudes of Professional Practice, TAP 21.

Addiction counselors always seem eager to know what client variables predict treatment outcome, and that is the focus of this column.
Treatment prediction variables are  a set of factors (internal or external) that explain how clients associated with these variables will do in treatment. It is important to note that these variables only predict or forecast an outcome. They are not, in and of themselves, the cause of a treatment outcome, but can identify client groups who have alleged poor factors. Once identified, these clients can be targeted for special treatment so they don’t fall through the cracks.

To gain some perspective on prediction variables, we will review some past attempts to find predictive patterns of treatment outcome, followed by a look at a recent systematic piece of research (Adamson, Sellman & Frampton, 2009) that examines 30 years of prediction research, to see what new patterns have emerged.

Around 1977, a meta-analysis of 45 studies, completed by Gibbs and Flanagan, found a few stable predictors of better treatment outcome, including: a steady work history; low psychopathology; a history of fewer arrests; and a history of Alcoholics Anonymous (AA) attendance. About 20 years later, Brewer, Catalano, Haggerty, Gainey and Fleming (1998) identified a number of predictors of future drug use, including: high levels of drug use before entering treatment (in this case, opioids); associated depression; higher levels of stress; employment problems; socializing with substance abusing peers; and leaving treatment before completing the ­program.  

Just a few years later, McKay and Weis (2001), in a similar analysis, found pretreatment levels of substance use and psychiatric severity were
predictive of poorer outcomes, while stronger motivation and better pro­gress in treatment generally indicated better treatment outcomes.
While informative, these past findings are dated; therefore, more recent research and stricter statistical analysis was needed to assess the current state of predictive treatment outcome variables. By following a rigid set of statistical guidelines and reviewing more than 60 research papers, Adamson, Sellman and Frampton (2009) were able to identify several reliable predictors of treatment outcome, including:
• Self-efficacy, or a belief in one’s confidence to do well in treatment. The most consistent predictor found, this basically translates to the more confidence a client has in the recovery process, the better he or she does.  
• Motivation, or the level of inspiration or enthusiasm the client
has toward recovery. The more ­motivated a client is, the better the treatment outcome.
• Treatment goal, or achieving specified recovery plans goals within the span of treatment. Those who achieved their recovery goals did better.
• Dependence severity, or the more severe the substance dependence, in terms of duration and intensity, the poorer the treatment outcome.
• Psychopathology ratings, or the higher the levels of comorbid psychopathology (e.g., depression, anxiety) the poorer the outcome.
Interestingly, some variables that one might have thought to be important did not make the grade, including: income; gender; religion; co-existing anti-social personality disorder; other personality disorders; the onset of alcohol misuse; a family history of drug or alcohol problems; and associated alcohol related problems (e.g., work, social, health and family).

Try it
The Adamson et al. (2009) study provides information that can be easily applied to an existing program.
In terms of the self-efficacy, the counselor’s job is to build confidence so clients can have faith in their ability to complete treatment, and do well in recovery. How do you help someone who comes into your program with a defeatist attitude? How do you help someone gain “I can do this” attitude? Most modern addiction counseling books don’t have much to say about this. Yet, one can achieve overall confidence by first succeeding with small, very manageable steps or goals, which can be used to go after bigger things. A rough illustration of this might be, cutting down one cigarette per day, and using the small dose of confidence to further cut down to two, and so on.

The counselor should help the client achieve and maintain change. While there are several studies on the dynamics and course of motivation, there is limited information on actually doing it. The best available instructions are the traditional reinforcement theories that give rewards for good behavior; negative rewards for not so good behavior; and modeling.

Sometimes putting things into a moral perspective is useful; convince the client that treatment is the right thing to do. Others respond better to inspiration, such as seeing a fellow client or sponsor do well and aspiring to do the same. The counselor’s job is to get creative and come up with things that motivate the individual client.

Treatment goals should be easily achievable so that clients are more likely to reach them. In turn, an achievement would generally elicit motivation. Regarding dependence severity and psychopathology levels, a good clinical intervention should pay close attention to these folks upon admission by: providing them with more counseling time; building a stronger rapport; and watching for craving spikes, as well as spikes in depression or psychotic symptoms.

It is important to create a plan to offset these depressive or psychotic episodes by determining how the client made it through past spikes, and use that in the treatment plan. For example, I worked with a client who had paranoia elevations on the weekends that would land him in the local hospital emergency department. We tried a number of different things that ­didn’t work. Then we started to pay attention to the weekends when he had diminished levels of paranoia. We discovered that he had simply gone to the beach to talk with his friends, and entertained pleasant thoughts of his daughter. By encouraging him to use just these two behaviors, he was able to get through weekends without going to the emergency department. It helped his self-efficacy as well.

Research you can do
For our purposes, you can do a quick and dirty pre/post test by comparing your past program outcome results to doing treatment just a bit differently, using some of the information provided by the Adamson et al (2009) study. Encourage the staff, or yourself, to place more emphasis on the five main findings listed above. For instance, place more effort on a current sample of clients to raise self-efficacy. Then three and six months after that sample has left treatment, measure how well they did on say total abstinence days, hospital visits, arrests, etc. Compare those results to a matched past sample from your program.

As always, I remain interested in your findings.

Mike Taleff has written numerous articles, several books, teaches at the college level, and conducts trainings and workshops (e.g., the latest treatment practices, Critical Thinking and Advanced Ethics). He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References
Adamson, S.J., Sellman, J.D., & Frampton, C.M.A. (2009). Patient predictors of alcohol treatment outcome: A systematic review. Journal of Substance Abuse Treatment, 36, 75–86
Brewer, D.D., Catalano, R.F., Haggerty, K., Gainey, R.R., & Fleming, C.B. (1998). A meta-analysis of predictors of continued drug use during and after treatment for opiate addiction. Addiction, 93, 73–92
McKay, J.R. & Weis, R.V. (2001). A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-up. Evaluation Review, 25, 113–161.

As an occasional viewer of the reality series Celebrity Rehab, I have lately become concerned that those involved in the production of the show might have a blind spot regarding the clinical efficacy and ethical ramifications of conducting addiction treatment on what is essentially a sound stage. For readers who may be unfamiliar with the program, Celebrity Rehab with Dr. Drew (VH-1, Thursdays, 10:00PM) is an hour-long reality show on VH-1, now in its third season.

Filmed at the Pasadena Recovery Center (PRC), Celebrity Rehab is based on a simple enough premise: a group of career-challenged celebrity addicts, paid by the week to appear on the show, place themselves under the care of Dr. Drew for treatment of their substance addictions. Dr. Drew is, of course, Drew Pinsky, MD, a board certified internist and addictionologist who brings to Celebrity Rehab over 25 years of experience in blending medicine and entertainment. Dr. Drew has recently emerged onto the public scene as a 21st century Marcus Welby—concerned, cool and caring—the fashionably hip public face of addiction medicine.

Hoping to revive flagging careers as actors, porn stars and reality show personalities, Dr. Drew’s celebrity addicts jockey with each other
for camera time using theatrics, tantrums and other kinds of self-created drama. Appearing self-absorbed and self-promoting, cast members seem intent on creating a depiction of treatment that is likely to leave some viewers wondering whether what they are seeing on Celebrity Rehab is really addiction treatment or just a source of narcissistic nourishment and heady fuel for the celebrities’ desire for attention and adulation. In one episode after another, Celebrity Rehab patients, eager for media exposure they hope will ­revive moribund careers, barter on-camera angst, vulnerability and catharsis for hoped-for career viability and a chance at becoming America’s Next Top Recovering Addict.

As hard as Celebrity Rehab sometimes is for me to watch, I frequently catch myself admiring Dr. Drew’s clinical skills. To my ears, his therapeutic interventions sound nuanced and well timed and his counsel always compassionately and skillfully delivered.  Watching him work, I often feel a sense of bemused envy. I find myself thinking, Hey, nice reframe Dr. Drew, while noticing that, sometimes, when a particular therapeutic intervention works, it works dramatically.  

Many of us who have conducted addiction treatment have witnessed first-hand the drama of the treatment environment, perhaps most vividly expressed in expressive and emotive therapy sessions. If there was ever a doubt about the dramatic potential of the therapeutic milieu, the success of Celebrity Rehab has erased it. So, for someone like Dr. Drew, with credibility in the spheres of both addiction treatment and entertainment television, the allure of making TV gold out of the dramatic ore of the therapeutic environment must be powerful. In working with their high-profile ­patients, the temptation for Celebrity Rehab therapists to choose interventions high on the drama scale, in favor of more mundane but clinically effective practices, is likely ever present. Viewers of the show, especially those of us who work in the field of behavioral health, may be forgiven for wondering if a given clinical decision is an expression of the therapist’s professional judgment or just their show business savvy. The temptation to coax drama out of the therapeutic process at the possible expense of weakening it is, I think, the essence of the ethical dilemma inherent in treating addicts in front of TV cameras.

Examples of Celebrity Rehab’s efforts to stack the deck in favor of drama are not hard to find. Considering the fact that Dr. Drew’s patients are paid to appear on the show leads to the obvious presumption that contracts between the show’s producers and cast were executed at a time when cast members’ judgment was impaired by their use of drugs.  Celebrity Rehab also has ignored an established rule observed by credible treatment centers, by knowingly admitting to the same small treatment community, two recently romantically involved individuals. In the Statement of Medical Ethics of the American Society of Addiction Medicine (ASAM), arrangements like these run counter to accepted ideas of milieu safety. More­over, practices such as these are verge on exploitation and run explicitly counter to ASAM’s ethical guidelines.  

 The stakes couldn’t be higher, as the recent history of celebrities who have publicized their recovery from addiction tells a troubling story. Taking
 one’s struggle at becoming clean and sober into the public realm, it seems, rarely turns out well. A regrettable record of tabloid-splashed celebrity relapses illustrates this grim truth. It is not by accident that anonymity has evolved as a governing principle of most treatment programs and of the 12 Step fellowships. Anonymity has long been considered an indispensable principle of recovery not only because it helps shelter recovering alcoholics and addicts from potential ostracism that comes with having a stigmatized disease, but even more importantly, because anonymity keeps in check the often outsized egos of many people struggling to find a place in recovery. Ask anyone in AA and they will tell you that addicts who fail to achieve at least a modicum of humility usually use again—and some of those who use, die. Shrinking the ego is a hard and painful undertaking, in or out of treatment, and is something that just can’t be accomplished by someone who is preoccupied with playing to the gallery. Whether they are celebrated or not, when addicts are in treatment and fighting for their lives, the last thing they need is an audience.

Jeffrey C. Friedman, LISAC is a primary therapist at Cottonwood Tucson where he works with chemically dependent patients. He may be reached at jeff.friedman @cottonwoodtucson.com.   

The common denominator connecting the deaths of celebrities Heath Ledger, Anna Nicole Smith and Michael Jackson is prescription drug abuse triggered by chronic sleep deprivation.

Sleep deprivation, caused by insomnia or sleeplessness, is one of the most common heath complaints, and can lead to impaired mental and physical heath, or even death. After periods of reduced sleep, brain neurons may begin to malfunction, visibly affecting a person’s behavior. In sleep-deprived subjects, there is no activity in the temporal lobe of the cerebral cortex, which is associated with the processing of language (Ledoux 2008). Sleep-deprived individuals may exhibit slurred speech, stuttering, speaking in a monotone voice or speaking at a slower pace than normal.
They often experience behavioral or mood changes, such as anxiety, depression, fatigue, lack of interest or motivation and social or vocational dysfunction, leading to increased errors or accidents; decreased attention span; and tension, headache or stomach symptoms (Peters 2009). Extreme anxiety cause by poor sleep patterns may contribute to irrational and dangerous behaviors.

Heath Ledger
The late actor Heath Ledger—who received critical acclaim for his roles in The Patriot and Monster’s Ball, and a best actor nomination for Brokeback Mountain—suffered from chronic insomnia and anxiety. Furthermore, as his career soared, he was contending with the pressures of success and demands for increased creative output, while also dealing with a tumultuous personal life. Just prior to his tragic overdose in January 2008, the sleep-deprived and physically exhausted actor is believed to have been fighting off effects of walking pneumonia. The actor died from an accidental overdose of prescription medications, including painkillers, anti-anxiety drugs and sleeping pills.

Specifically, the New York City medical examiner’s office determined his death to be the result of “acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine.”

Ledger’s prescribed medications included painkillers, Vicodin (hydrocodone) and OxyContin (oxycodone); anti-anxiety drugs, Valium (Diazepam), Xanax (Alprazolam); sleeping agents Restoril and Euhypnos (Temazepam); and an over-the-counter antihistamine, used as a sleep aid (Doxylamine). Unconfirmed reports allege that Ledger also engaged in heavy drinking and used heroin and cocaine (Biskind, 2009).

Anna Nicole Smith
Because traditional sleep medications such as Ambien were ineffective, television reality star and former Playboy Playmate of the Year Anna Nicole Smith was prescribed the sedative chloral hydrate, which proved to be her undoing.

A seven-week investigation into Smith’s death in February 2007, found that the actress had died of “combined drug intoxications,” with the sleeping medication chloral hydrate being the “major component” in her death. The medical examiner reported a total of seven prescription drugs, usually prescribed for anxiety, depression and insomnia, were found in Smith’s bloodstream (CNN.com, 2007).

Smith reportedly had developed an increased tolerance to the sedative chloral hydrate and took about three tablespoons per dose, whereas the normal dosage is between one and two teaspoons. Synthesized in 1832, chloral hydrate, also known as “Mickey Finn” or “knockout drops” was developed for the specific purpose of inducing sleep. When used properly, and without the introduction of alcohol or other depressants, chloral hydrate is effective in easing sleeplessness due to pain or ­insomnia.

Today, the use of chloral hydrate has declined as other agents, such as barbiturates and benzodiazepines, have largely replaced it. In the death of Anna Nicole Smith, chloral hydrate became increasingly lethal when mixed with four prescription benzodiazepines: Klonopin (Clonazepam), Ativan
(Lorazepam), Serax (Oxazepam) and Valium (Diazepam). In addition, Smith had taken Benadryl (Diphenhydramine) and Topamax (Toprimate) and  an anti-convulsant GABA agonist, which likely contributed to the tranquilizer effects of the chloral hydrate-benzodiazepine combination (Furek, 2008).

Although the individual levels of any of the benzodiazepines in her system would not have been sufficient to cause death, their combination with a high dose of chloral hydrate led to her fatal overdose. The autopsy report indicated that chloral hydrate was the “toxic/
lethal” drug, but it is not known whether the chloral hydrate alone would have killed her. On Oct. 12, 2007, the Drug Enforcement Agency and California authorities served eight warrants in connection with Smith’s death. The investigation revealed that Dr. Khristine Eroshevotz, Smith’s personal psychiatrist, had written all 11 prescriptions, later called “pharmaceutical suicide” by a pharmacist who refused to fill one of Eroshevotz’s prescription order (Duke, 2009).

Smith’s former boyfriend Howard K. Stern and physicians Eroshevotz and Sandeep Kapoor were charged with “illegal conspiracy to prescribe, administer and dispense controlled substances to an addict.” Stern faces 11 felony counts, while the doctors were charged with six each (Duke, 2009)

Michael Jackson
Michael Jackson, the “King of Pop,” was the most recent celebrity in this tragic cluster. His death—reckless, senseless, irresponsible—has been ruled a “homicide” by the Los Angeles County coroner, who concluded that the 50-year-old singer died of an overdose of propofol, a powerful sedative given to help him sleep. Michael Jackson’s personal physician, Dr. Conrad Murray, administered Jackson the propofol prior to the singer’s death on June 25, 2009 (Duke & Simon, 2009).

Propofol (Diprivan) is an extremely dangerous drug that is administered intravenously in operating rooms and some office procedures as a general anesthetic, according to manufacturer AstraZeneca. The drug works as a depressant on the central nervous system, however, once the infusion is stopped, the patient wakes up almost immediately. Reportedly, Dr. Murray had been treating Jackson for six weeks prior to his death, administering 50 mg of propofol diluted with the anesthetic lidocaine via an intravenous drip to treat the singer’s insomnia. Concerned that Jackson may have been developing an addiction to the drug, Murray claims that he was trying to wean Jackson off the propofol by combining it with other drugs to help him sleep.

In the nine-hour period, prior to Jackson’s death, Murray administered the following drugs to Jackson: Valium, Ativan, Versed and propofol. In addition to his very public struggle with his own self-image, Jackson also apparently was privately struggling with drug problems. In 2007, according to the Associated Press, an L.A pharmacy sued him, claiming he owed $100,000 for two years’ worth of prescription meds …” (Gates, 2009).
Spanning three unique demographic groups, the careers of Michael Jackson, Anna Nicole Smith and Heath Ledger touched our lived in unusual ways. All were gifted and talented, but in the end, their lives intersected at the juncture where sleep deprivation and drug overdose defined their final days. Like a perverse reality show this tragic saga continues. Each decade we observe our iconic celebrities self destructing in full view of their fans and a curious public—note the deaths of Elvis Presley, Marilyn Monroe, Janis Joplin, Kurt Cobain and countless others. We need to stop the madness and view this as a “teachable moment” where we renew our commitment to treatment and carry the message of recovery to those who need it most.

Maxim W. Furek, MA, CAC, ICADA, is a Director of Garden Walk Recovery, an organization “promoting wellness through drug  prevention and education.” He is the author of The Death Proclamation of Generation X: A Self Fulfilling Prophesy of Goth, Grunge and Heroin. He can be reached at www.maximfurek.com.

References
Biskind, P. (2009). “The Last of Heath.” Vanity Fair. Issue No. 598.
Brain Activity is Visibly Altered Following Sleep Deprivation (2002). UC San Diego Medical Center. Retrieved from http://www.ask.com/bar?q=sleep+
deprivation+research&page=1&qsrc=0&ab=4&u=http%3A%2F%2Fhealth.ucsd.edu%2Fnews%2F2000_02_09_Sleep.html
Duke, A. (2009). New charged filed in investigation of Anna Nicole Smith death. CNN.com/entertainment.
Retrieved from http://www.cnn.com/2009/SHOWBIZ/music/08/24/michael.jackson.propofol/index.html
Furek, M. (2008) The Death Proclamation of Generation X: A Self-Fulfilling Prophesy of Goth, Grunge and Heroin, i-Universe: Bloomington, IN.
Furek, Maxim W. (April, 2009). “What Really Killed Anna Nicole Smith?” Counselor, The Magazine for Addiction Professionals. Vol. 10, No. 2.
Gates, D. (2009). Finding Neverland. Newsweek. June, 27, 2009.
Green, B. (2009). Michael Jackson, Elvis Presley, and Anna Nicole Smith: Death is the Prescription, how many more? Retrieved at http://www.articlebrain.com/Article/Michael-Jackson—Elvis Presley—and Anna-Nicole-Smith—Death-is-the Prescription—how-many-more-/34674
Ledoux, S. (2008). The Effects of Sleep Deprivation on Brain and Behavior. Retrieved from http://serendip.brynmawr.edu/exchange/node/1690
Peters, B. (2009). What is Acute Insomnia? About.com: Sleep Disorders. Retrieved from http://­sleepdisorders.about.com/od/commonsleepdisorders/a/Acute_Insomnia.htm
Source: Jackson’s doctor gave drug authorities believe killed him. Retrieved from http://www.cnn.com/2009/SHOWBIZ/Music/07/27michael.jackson/index.html

Aging and addiction is prompting increased concern among addictions professionals.  This stems in part from the overall “graying” of the population, together with changing use patterns among older adults accompanying aging of the baby boomer generation.  This two-column series will address specific considerations in applying the wellness and recovery model to the growing number of senior and elderly clients seeking treatment.

Substance abuse in older adults
Substance abuse is often difficult to detect in older adults for a number of reasons: they usually drink at home alone; they generally don’t suffer work-related problems; and abuse in this population often involves prescribed medication. Memory loss or confusion accompanying substance abuse may be confused with symptoms of dementia and other age-related conditions. In addition, family members are often reticent to admit that “grandpa or granny” may be having a problem with alcohol or drugs (Colleran & Jay, 2002).

Older substance abuse patients are more likely to be both physically and psychologically fragile, and generally require more medically intensive care during withdrawal, together with more intensive counseling to assist them in overcoming entrenched self-destructive behavioral patterns (Battaglia, 2010).

“Older adults and seniors age quickly when suffering from alcoholism and/or addiction to mood-altering prescription drugs,” state Carol Colleran and Debra Jay, in their book, Aging and Addiction. “They lose their health, mental clarity and their ability to live independently years earlier that other people their age. The good news is that older adults are more successful in treatment that any other age group.”

Wellness and recovery applications in treatment
We become more health conscious as we grow older and personally experience health-related consequences that inevitably come with age. Unlike younger patients, who often act as if they were invulnerable, older patients entering treatment are acutely aware of existing physical ailments and the toll they have taken on their bodies and psyches. It stands to reason that many of these patients will be amenable to a wellness-oriented treatment approach. Indeed, the wellness and recovery model, when integrated with an active  12 Step recovery focus or immersion in an alternative recovery program, guides the patient along a holistic pathway to recovery that holds promise to dramatically improve his or her overall health status and quality of life. Below are some applications of three key components of wellness and recovery in treating older adult patients.
Nutritional Foundations: Persons entering recovery generally have a lot of clean-up work ahead of them in the realm of nutrition. This is especially true for many older patients whose bodies and brains have been ravaged by malnutrition stemming from decades of substance abuse. Many of these patients also suffer from chronic conditions such as diabetes and heart disease, which call for basic dietary changes as an integral component in restoring the body to optimal health.

As is the case for everyone entering recovery, older patients need to focus on transitioning to a healthy diet, preferably working in concert with a skilled nutritionist grounded in nutritional issues relating to recovery. Medical counsel is indicated for patients suffering from diet-related health conditions. A sound diet, combined with regular exercise, promotes improved energy and alertness and can have a powerful rejuvenating effect.
Many nutritionists working with persons in recovery advocate a balanced diet that is high in vegetables, fruits, grains and other complex carbohydrates, together with quality sources of protein, and low on fats, sugars and meats. Components of this diet are illustrated in the Mediterranean Healthy Diet Pyramid, which can be downloaded from www.oldwayspt.org. (Be sure to download the pyramid without the wine!)  
Older people living in isolation may have fallen out of touch with meeting their basic nutritional needs, and will require motivational counseling and instruction to get them back on track in preparing or selecting fully nutritious meals. It is particularly important that they be taught to minimize their consumption of “nutritional stressors”—especially sugar, caffeine and high fat, highly processed foods.

(The topic of nutrition and recovery is treated more fully in my book The Wellness-Recovery Connection (Health Communications, Inc.) as well as in my workbook/instructor’s manual Nutritional Foundations for Recovery, available from Gorski/CENAPS ®.)

Fitness and Recovery: Regular exercise is important to everyone in promoting cardiovascular fitness and optimal health. Unfortunately many older persons with substance abuse problems lapse into overly sedentary lifestyles as they “retire from life.”

For seniors entering recovery, regular exercise can become a powerful “positive addiction” to help fill the void when one discontinues drinking and drug abuse. It can also serve as a valuable rejuvenating agent while boosting one’s self esteem.  

Vigorous exercise promotes release of endorphins—powerful chemicals that stimulate the pleasure centers of the brain—helping combat post-withdrawal depression as well as depression experienced by many older people stemming from loss and grief issues. Regular exercise also benefits many older patients by providing an important social outlet via participation in group activities (e.g., walking, running or biking clubs, yoga classes, tai chi, etc.).

Older patients, especially those with serious health problems, should seek medical guidance in adopting an exercise regimen tailored to their special needs. A fitness trainer with geriatric experience can be of tremendous help here. Walking is often a good core exercise, and water aerobics may be the exercise of choice for persons suffering from severe arthritis. Yoga and other flexibility exercises are excellent in promoting both physical and mental agility, and muscle toning exercises should not be ignored. The latter are particularly important in combating atrophy of muscular tissue that accompanies the aging process.  

Freedom from Nicotine: Alcoholism and nicotine addiction are co-addictions, and the greater majority of persons initiating recovery are moderate to heavy smokers. Smoking is a definite causative factor linked to heart disease, lung cancer, emphysema and many other serious conditions, and is the leading cause of death for people in recovery.

Older people entering treatment often have a fatalistic view regarding their nicotine addiction—“After all, I’ve been smoking for so many years—the damage has probably already been done.” Such pessimism needs to be effectively countered by treatment professionals. Quality of life benefits of quitting, including increased energy and ability to engage in pleasurable activities such as hiking and sports, need to be emphasized.    Even for long term smokers, the risk of heart disease is often drastically reduced within a relatively short time after quitting. Modern imaging technology provides sophisticated screens (e.g., the EBT lung scan, that can detect lung cancer in its early stages when the disease is often highly treatable).  
Medical guidance is essential in identifying and following through with an appropriate quitting strategy, which may entail supervised use of pharmacological agents. Stop smoking Quit Lines (call 1-800-QUIT NOW) can be highly effective, especially if one links up with a counselor experienced in coaching older persons on kicking the habit.

The next column will focus on qualitative aspects of wellness and recovery—including life satisfaction and central purpose—as they apply to older persons entering recovery.  Until then—to your health!

John Newport, Ph.D. is an addictions specialist, writer and speaker based in Port Townsend, Washington. He is author of The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction, and is currently completing a Wellness and Recovery Work­book Series in collaboration with the Gorski-CENAPS® Corporation. For ­further information on The Wellness-Recovery Connection, visit www. wellnessandrecovery.com. For information on the Wellness and Recovery Work­book Series, visit www.relapse.org

References
Battaglia, Emily (2010). “Baby Boomers: The Changing Face of Older Adult Addiction” (posted on www.4therapy.com).
Colleran, C. & Jay, D. (2002). Aging and Addiction: Helping Older Adults Overcome Alcohol or Medication Dependence. Center City, MN: Hazelden.
Newport, J. (2004). The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction.  Deerfield Beach, FL: Health Communications, Inc.
Newport, J. (2009). Nutritional Foundations for Recovery (workbook and instructor’s manual). Independence, MO: Herald House/Independence Press.
“Trends in Treatment: Substance Abuse in Older Adults” (posted on www-drugaddiction.com/senior_
treatment.htm)

“There is no difference between an inappropriate orgasm and a recovered alcoholic taking a drink.” —“Gerard,” 45, sober 10 years.

“We (sex addicts) detox too. We are addicted to the endorphins. Our withdrawal is pretty intense.” —“Sharon,” 37, member of Sex Addicts Anonymous, sober six-and-a-half years.

“Desire, at the end, was a malady, or a madness, or both . . . .I ceased to be Lord over myself. I was no longer the Captain of my Soul.”
—Playwright Oscar Wilde

Thanks to the headline grabbing falls from grace of a golf icon and late night TV host, sex addiction is the new/old frontier in 12 Step recovery. Some see sex addiction as the diagnosis du jour for men behaving badly. But long before Tiger Woods and David Letterman, the quintessential sex addict was famed lothario Casanova. To this day a serial seducer is known as a “real Casanova.”

Behind such “success” is a compulsion that destroys marriages, embarrasses and horrifies adult children and results in the transmission of diseases. Like addiction to alcohol and other drugs, sex addiction is an equal opportunity destroyer.

Tracing the roots
As with many addictions, sex addiction is often rooted in childhood trauma. In interviews with three self-proclaimed male and two female sex addicts, patterns of dysfunction and trauma emerged. The males range in age from 17 to 57. A priest sexually abused the eldest and another said he switched addictions from alcohol and cocaine. The teen said he couldn’t resist the advances of girls seeking sex via sexting—the sending of X-rated photos via cell phones and raunchy phone calls. The women felt their sex addiction made them bad persons. So desperate was “Faith” that she “took a razor blade and etched the sign of a cross on my inner thighs, thinking that would stop me from leading this double life.” For each of the five, the pain of addiction led to confusion, self-loathing and lives that spiraled out of control.  

“It’s about core issues, about pain. Tiger’s addiction probably has something to do with his father and pain that he never dealt with. I read that his dad had multiple affairs,” said Marshall Lipscomb, who has gone public with his sex addiction. Lipscomb expressed this insight: “What would trigger it (sex with strangers) was anger, loneliness, fear of failure, unworthiness, unstructured free time, fear of rejection … It would temporarily make my negative thoughts and feelings go away” (Merli, 2010).

“Gerard” said he pursued sex with prostitutes “not because it felt so good and I enjoyed it so much but because I had to have it. It was a part of me I could not surrender to God.”

“Sharon,” a 37-year-old business owner, said her husband finding graphic e-mails she had written to her lovers precipitated her bottom. Her embarrassment was exponentially exacerbated when he shared the “damning evidence” with her family. She traced the roots of her addiction to self-esteem. “I had an enormous ego and it was fragile,” she said. “My whole life drive was to keep it inflated and keep it from being harmed.”
While in treatment “Sharon” was put on a “no male contact contract, which was so hard for me.” She wore a “NO MALES” placard around her neck. In response she fantasized about flirting with the barista at Starbucks to get a free cappuccino. “My whole identity was talking to men, flirting with men,” she added.

Assessing the cost
Sex addiction treatment often costs more than inpatient programs for other dependencies, but the emotional, mental and spiritual devastation of sex addiction exacts a cost that can’t be calculated.

Sex addiction terminology and treatment has grown widely since Patrick Carnes coined the phrase in the late 1970s. According to Carnes, sex addiction often co-occurs with alcohol dependence, and it is a fallacy to assume that recovery from alcohol dependence will resolve sex addiction (Scott, 1988).

The role of creativity in recovery
Creative approaches in treatment are often key to long-term recovery and an improved quality of life. “Faith” said expressing her feelings via role-playing and journaling helped her deal with being emotionally shut down and codependent. Art therapy also played a critical role in Faith’s recovery, and she noted that although she initially perceived disturbing sexual images in her drawings, these were eventually replaced with more positive images. In her first year of recovery Faith drew nearly every day; she now uses the soothing, modern-day personal Rorschach exercise 15 times a year.

Saddled with PTSD from repeated childhood sexual abuse of forced oral sex on her father, Faith reported a disturbing flashback this year. While at the dentist she was given a numbing agent for a procedure. She said that “goop going down my throat” made her want to jump out of the chair and flee the office but, “I didn’t do anything, I was frozen and later cried ­hysterically.”

“Gerard” voiced the unresolved anger and self-loathing felt by many sex addicts. “God is not doing what I want Him to do to help me resolve this addiction and sometimes I’m pissed off by it,” he said. Gerard’s predilection is oral sex procured from prostitutes. “I’m 10 years sober from alcohol and cocaine and I don’t have a mate,” he said. “If I can’t find a mate, screw it, I’m just going to go out and buy one.” He referred to his sexual pursuits as a compulsion, one that “synthetically fills that sexual part of me.” “Gerard” said sex with prostitutes, some of whom he tried to help get sober, led to him contracting herpes 20 years ago. He said he is giving his sex addiction to God because his life is “unmanageable” and preventing him from finding the “right woman” he so desperately seeks.

Recovery’s fulfillment
The redemption of reclaiming her life from the suffocating embrace of sex addiction is a gift “Faith” gives thanks for every day. Next year she will celebrate 25 years of sobriety. Today “Faith” does not act on sexual compulsions. “I don’t react or go on auto pilot. I have serenity, peace, joy and excitement about life,” she said. “God is calling me to share my story.”

For “Sharon,” ritual and 12 Step recovery were critical elements of getting well. In treatment she created a “chalk” outline of her prone addict on paper. She dressed and burned in effigy the representation of her former self. “She looked like the melting witch in the Wizard of Oz, with her limbs flailing as she curled into the fire,” she said.

“Sharon” reports a “fantastic” sex life with her current husband. “It’s so important to not go from being a sex addict to having a lame sex life, or worse than that to having no sex life,” she said. “That’s a recipe for relapse.”

Thomas M. Greaney, MEd, LADC, CCDP, provides his private practice clients in CT and RI with creative ways to view and overcome addiction. He facilitates groups for 18-24-year-olds at an agency in southern CT. Tom presents seminars on creative approaches to group therapy. Contact him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 860-912-2944.

References
Merli, M. (2010). Recovering sex addict hopes openness will help others. The News-Gazette. Champaign, Ill. Feb. 7, 2010.
Scott, N. (1988). Sexual addiction and chemical
dependency: an interview with Patrick Carnes.
Alcoholism & Addiction Magazine. Vol. 9, no, 2. p.45 (3)

The chemical dependency treatment profession has become more research-oriented, yielding evidenced-based treatments and increased knowledge on the neurobiology of chemical dependency. Harm-reduction treatment approaches and a variety of recovery-based support groups also have contributed to the profession’s growth by providing more treatment options to the patient population.

Information and research related to chemical dependency treatment professionals and their ethical standards, however, is limited. All licensed/certified chemical dependency treatment professionals are required to adhere to a code of ethics. However, ethical guide­lines may be complicated and abstract due to inconsistencies. One ethical issue that is common within the counseling profession but not addressed, is sexual attraction. Although sexual exploitation of patients is viewed as both harmful and an ethics violation, the issue of sexual attraction within the counselor and patient relationship has been understudied. This article discusses the taboo topic of sexual attraction within the counseling relationship, including risk factors associated with counselor engagement in a sexual relationship with a patient; and professional interventions that counselors can utilize to help minimize the risk of any negative impacts on the therapeutic relationship.

Sexual attraction is not uncommon in the counseling relationship; most chemical dependency treatment professionals have experienced sexual attraction to a patient at some time in their career (Corey, 1996). Unfortunately, this sexual attraction is often ignored or not processed due to the taboo nature of a counselor viewing his or her patient as sexually attractive. This lack of acknowledgement and awareness of a common human response can have potentially harmful consequences on both counselor and patient. Sexual attraction to a patient is the first indicator of an increased risk for engaging in a sexual relationship with a patient. This does not imply that sexual attraction will result in sexual behavior; rather, that counselors who experience sexual attraction to a patient may benefit from a professional intervention. Processing the experience with a supervisor or consulting with other professionals could be beneficial.

Several personal and professional characteristics may be associated with an increased risk of a counselor engaging in a sexual relationship with a patient, including: physical attraction; lack of self-awareness of physical attraction; non-therapeutic use of self-disclosure (usually about current personal problems); longer sessions (extending time beyond what was initially agreed); intimate touching or hugging; therapy session becomes less clinical and more social; preoccupation with the client; preoccupation with your appearance; looking forward to seeing the patient; special fee arrangements; unsatisfactory relationships in your own life; loneliness and isolation (Reamer, 2003; Sarkar, 2004).

Identification with any of these characteristics should be handled with caution, as it does not necessarily mean that sexual exploitation is inevitable. These characteristics only provide knowledge to assist chemical dependency treatment professionals in becoming aware of potential behaviors that may contribute to ethical violations.

Sexual exploitation of patients has gained attention recently, primarily because it contributes to a majority of lawsuits for counseling professionals and because of the harmful nature of the ethics violation (Reamer, 2003). The chemical dependency treatment profession does not see the ethics violation of sexual exploitation of patients at an alarming rate. According to the Texas Department of State Health Services Licensed Chemical Dependency Counselor Program, only five percent of ethics violations for Licensed Chemical Dependency Counselors from 2005 to 2008 were for sexual misconduct (Texas Department of State Health Services, 2009). Although this percentage is low compared to other ethics violations, there are still important interventions – such as the use of supervision and availability of a peer assistance program—that can be implemented within the profession to help eliminate the sexual exploitation of patients.  

A counselor who is sexually attracted to a patient may experience shame, guilt, remorse and confusion. Receiving clinical supervision surrounding these feelings is a responsibility of the counselor and an essential part of practicing ethically. Additionally, supervisors should provide a safe, confidential environment in which these sensitive issues can be discussed. Without this safe environment and the competency and skill of an effective supervisor, a dialogue on sexual attraction is unlikely.  

In addition to supervision, the availability of a peer assistance program is conducive to ethical practice. For example, Licensed Chemical Dependency Counselors in Texas are now required to have access to a peer assistance program. The Texas Addiction Professionals Peer Assistance Network (TAPNET) was designed to assist chemical dependency treatment professionals who experience symptoms related to substance abuse and mental health disorders. TAPNET realizes that chemical dependency and mental health disorders can be chronic conditions, and professionals are not immune to relapse of these chronic disorders (TAPNET, 2009). Advantages of peer assistance programs include: early detection and intervention of symptoms, which can minimize the impact that these symptoms have on personal and professional life; the opportunity for the professional to maintain his or her license/certification once treatment goals are met; aftercare support for the professional returning to the work environment; and confidential treatment, which may increase the likelihood of professionals being willing to seek out treatment for a substance abuse or mental health disorder (Fletcher, 2001).  

The availability of peer assistance programs is evidence of the continued growth of the chemical dependency treatment profession, and these programs can offer another intervention to assist the counseling professional in maintaining appropriate boundaries with the patient population. When more intensive intervention is needed, peer assistance programs may be the resource needed to help the counseling professional who is experiencing some of the aforementioned risk factors associated with engaging in a sexual relationship with a patient. Given the success of peer assistance programs in other disciplines and the potential benefits that these programs can offer, all national and state licensing/certification boards should consider peer assistance programs for credentialed chemical dependency treatment professionals.  

Lastly, professionals who train others in ethics are responsible for providing a thorough educational experience that facilitates meaningful discussion on the many taboo and often overlooked areas of ethics. This will increase awareness of sexual attraction within the counseling relationship, thereby resulting in the potential for increased dialogue among professionals and reduced ethics violations for the chemical dependency treatment profession as a whole.