The youngest drug abuser psychiatrist Dr. Sheldon Greenberg has detoxed and treated was a 14-year-old boy. He remembers the boy well: “a cocaine addict, and at the time he was brought to the hospital he was also drunk. He had allegedly attacked a policeman and was subsequently shot in the eye. He had to go through detox while he was in surgery. It was awful.”
After 25 years as a psychiatrist specializing in addictions medicine, Greenberg has treated everyone from teenagers to septuagenarians. They come from all social classes, from city and suburb–even overseas. They are addicted to all manner of substances and activities: crack cocaine, gambling, alcohol, sex, heroin, pain pills, marijuana, PCP and more.
One thing he learned long ago is that stereotyping addicts is impossible.
“I’ve treated the entire gamut of people from blue collar all the way up the social scale to professional athletes, nurses, doctors, lawyers and captains of industry,” he said.
One patient was a member of the clergy so prominent in his denomination as to be conducting seminars in other states. Unfortunately, the man found his marriage increasingly boring and empty, so he got himself into a relationship with a dependent, exploiting woman.
“He needed that gleam of adoration in her eyes,” Greenberg said. “He also needed the crack cocaine she introduced him to. A few hits was all it took. He was hooked.”
He has treated a couple–a husband who was buying heroin for his wife so that she would stop turning tricks to get money to buy her own drugs.
And there was a man who came in to detox after he saw a woman at a drug house permit deviant sexual acts to be performed on her so she could obtain drugs. He told Greenberg, “I can’t stand what I’ve become.”
Greenberg, 51, is the medical director of Lifeline, a residential substance abuse rehabilitation facility located in Louis A. Weiss Memorial/University of Chicago Hospital on Chicago’s North Side. He is also the medical director of Gateway Foundation-Kedzie House, a halfway house on the West Side. Lifeline is one of a chain of two; the other facility is in Detroit. He is also a medical review officer for a number of industries, helping them monitor the ongoing sobriety of employees with prior addictions.
Greenberg did not arrive at this psychiatric specialty immediately. Though he had some experience treating heroin, alcohol and hallucinogen users before and during his residency at Northwestern University’s department of psychiatry in the early ’70s, he had been in private practice and held several administrative positions before he was approached with the idea of becoming the medical director of a cocaine program 10 years ago.
“In 1985, my colleagues and I had no awareness of–I don’t think we could have dreamt at the time–the extent and severity of the drug-using population that was developing in this country,” he said. “Neither could we have predicted the development of freebase cocaine, nor the salesmanship, marketing, transporting and distribution systems that would develop in this country.”
When a patient enters residential treatment at Lifeline (a large percentage are crack cocaine addicts) the goal is twofold: to detox the patient with a minimum of physical withdrawal pain and to teach the patient how to deal with “urge states” once released from residential care.
After completing residential treatment, Lifeline, like other drug treatment facilities, offers free after-care–which can include counseling sessions, group support meetings, and crisis family intervention sessions–for a period of at least two years.
The length of time a recovering addict must be hospitalized varies greatly from person to person depending on the state of detoxification they are in, or the level of their urge states. “There are certain individuals who may literally need to be in a safe, supportive environment,” he said. “The main thing is to have the appropriate level of sequestration and treatment that is required.”
If there is anything typical about drug addicts, he says, it is that many of them have underlying severe depression, anxiety states or personality disturbances which must be treated along with the addiction. (Personality disturbances, he says, include unusual sensitivity to rejection, abandonment, deprivation, entitlement and anger. It also includes avoidant tendencies, paranoia, impulsivity, aggression, “acting out” and sociopathic tendencies.)
Of primary importance in gaining an addict’s trust and allegiance in the therapeutic process, he says, is the doctor’s willingness and ability to enter the “inner world” of each addict.
“One has to get into the mind, heart and soul of the individual to understand why the person was attracted to their particular drug of choice. What I do is put myself in their shoes and try to understand–with empathy–what they want and need so I can work with them to guide them away from that drug,” he said.
Indeed, over the years he has learned to do this so effectively that some patients have asked him if he, himself, was ever a drug addict. (The answer is no.)
“When you do join them in exploring their psyches, what you see is a mass of impulses, where people often have extreme difficulty containing emotional states, handling psychological pain; people who have unusual degrees of reactivity when their `buttons’ are pushed,” he says.
Fighting the urge
Greenberg requires that his recovering addicts become members of the “recovery community,” meaning they must attend meetings–which are held on premises–of one of the classical “Anonymous” program interventions which have “worked for years,” as he says.
In contrast both to the strict no-drugs-of-any-kind philosophies of these groups and the beliefs and practices of medical directors of other addictions facilities, Greenberg sees no harm in having patients continue using some medications; Revia, for instance, a drug that blocks opiate receptors, has recently been found effective in diminishing craving for alcohol.
After detoxification, Greenberg works to develop successful new methods for coping with sudden strong emotional swings and sudden cravings when they return to their lives outside rehab.
“Addicts have to rehearse every situation that could lead to drug relapse as if they are soldiers about to go into battle,” he said. “The main principles are activation/desensitization rehearsal before they leave, of every situation that might trigger them to use drugs. This is the essence. This is the new challenge now in treatment.”
With each patient, Greenberg custom-designs special imaging techniques that have earned him national recognition in the addictions medicine community. (He has lectured about these methods at meetings of the American Society of Addiction Medicine Specialists, and the Illinois Academy of Family Physicians.) His innovations include music, laser lights and tape recordings of addicts’ children to amplify their innate inner strength to shrug drugs.
“I am prepared to be totally flexible in treatment,” he said, “because what works for one person may not work for another, even if both have been using the same drug. Some individuals need exquisite nurturing; others need to be challenged.”
And all this is done, of course, with one eye on the clock, because insurance companies are very much concerned with issues of cost containment, and desire fast results. There are many levels of care, including inpatient, partial hospitalization and outpatient.
“Obviously, in the managed care environment, one has to work very effectively and intensively, while at the same time preparing the patient for further psyschological exploration and treatment in the future,” Greenberg said.
Getting his point across
“The critical thing that patients must learn is to be aware of their thoughts, feelings and emotions in that critical period when they may be unconsciously leaning toward relapse–before they are even conscious of having drug use fantasies or urge states.
“For example: By suggesting to an addict that he is walking briskly away from, or riding a bike away from his drug of choice, seeing the drug recede into the background, addicts may report that their urge for that drug is diminishing.
“I have helped individuals by placing my hand on the small of their backs and physically guiding them away from drugs and drug paraphernalia. While we are walking, I ask them to imagine that their loved one, or someone they care about, or someone supportive, is with them, encouraging them, being proud of them for every step they make away from the drug.
“I also work with a laser pointer. I have the patient focus his energy–his being–on that one dot. Then I have him imagine that within that dot is that part of himself that wants to make it. I tell him to put that dot into himself and make it grow, that he can feel it becoming warm and strong within him. This can literally imbue a person with such strength that at a given crucial moment, the person may be able to overcome cravings with this technique.
“Sometimes I suggest to patients that they tape a piece of music that is inspirational to them to listen to and perhaps add their own voice or the voices of significant others saying words of encouragement. Then they can listen to it to help them over moments of craving.”
After a patient has become familiarized with these and other techniques, Greenberg holds rehearsal situations, sometimes one-on-one, sometimes in a group setting so the recovering addict can practice coping with stressful situations.
“If I know what the patient’s trigger states may be,” Greenberg said, “I might have him go through specific experiences where we activate his urge states–by putting drugs and paraphenalia in front of him. I then help him learn ways of literally calming down–to teach him how to have a sense of mastery over his feelings, where the cravings diminish and he feels some confidence. Then he has a tool for mastering similar situations.”
Though it may sound almost laughable to people accustomed to picking up a paperback or going out to shoot hoops during bland hours of the day, Greenberg says he sees many individuals who “feel they cannot be bored without it being conceived of as a painful experience.” Among these are gamblers, drug dealers and sex addicts.
“Gamblers are individuals who are addicted to action and the adventure. They may almost have a need to put themselves in self-defeating situations, because their `rush’ is to put themselves at the brink of defeat, and then be able to walk away. Drug dealers tell me their world is one of adventure, intrigue, joy, power, dominance and control.
“There are certain individuals who could not conceive of having a sexual experience unless they add drugs to it. After they become accustomed to having sex while using cocaine, having sex any other way, for them, leads them to feel . . . deprived. Still others find power and control in certain sexual practices.”
Some don’t make it
Despite the techniques and self-confidence patients learn from Greenberg and his colleagues, there are relapses. He does not know how many, because some patients simply disappear. Others relapse and return for further treatment.
“The greatest problem I have in after-care treatment of the severe addict is: Will he call me if he starts to get in trouble?” Greenberg said. “We now know that, at the moment a person is having extreme distress, if he obtains some comfort and human support, his pain will be lessened to some degree.
“The commitment that I and other addictions medicine professionals make is that we are available. Patients know they can call us if things are starting to get too difficult for them.
“I believe that if we’re able to help people stay sober, by whatever means, through the initial critical period–perhaps six months or so–their prognosis is greatly improved. This becomes a major issue in society with drug testing being mandated for so many industries. We try to impress upon addicts that there are societal consequences of continuing to relapse. The world is becoming a harder place. Drug addicts are a problem in society that people are running out of patience with and just wish would go away. Addicts are perceived as having almost willful behavior that they could have and should have changed.”
The life addicts return to can be extremely stressful; often it involves angry, resentful significant others and considerable financial loss. Greenberg has had to counsel families on the vital importance of their ongoing love and kindness to the recovering person. Although they may feel otherwise, he tells them to be patient for several months because they may see the emergence of great strength, will power and character as their recovering addict overcomes his chemical dependency.
Though the chorus calling for legalization of some drugs–notably marijuana and heroin–is growing, Greenberg strongly opposes legalization. Though he sympathizes with those who wish to reduce drug-related murders, muggings and break-ins, he says the easy availability of drugs would be just too tempting to great numbers of people. The drug with the highest relapse rate is alcohol, he says. Why? “It is ubiquitous.”
“What I have found from my experience is that if a person is sensitized to one particular drug and likes it, he may want more of it.” And, enjoying the sensation of being high, the person may be more willing to try another drug. “Rather than take a chance that a person may be introduced to a particular drug, it is best not to have it.
“I went into this knowing that there would be a high rate of frustration, but the challenge is exciting and the rewards are tremendous. A few years back a recovering female cocaine addict promised me she would name her baby after me if she made it sober through her pregnancy and young motherhood. About three years later, she came in and proudly introduced to me to baby Sheldon. I still have his picture on the wall.”
