Our medical school hosts a weekend curriculum for lay community members, many of whom are retired or have relatives working in medicine.  It is spread across several months, and I was asked to speak last week about substance use in the elderly. After the event, I was thrown more than a dozen questions.   My responses did not satisfy me in several instances, but you do what you can do when you're standing at a podium in front of 100 potential donors to the school.  The show must go on.  I don’t expect all in the readership to agree with my answers – after all, a good many of you are certainly smarter than I, or at least more cautious.  Here are a few of the audience’s Q & A items:

Q – I assume that for any treatment for SUD to work, the abuser must really be motivated to change self-destructive behaviors. So, if the person is not motivated, what can friends do except accept their limitations, listen to their problems, and watch the physical and mental deterioration taking place?

A –   The tone of the question suggests that you have had unfortunate experience in this respect, and I sympathize. But maybe part of the answer is that, to the person with the substance use disorder, the perception is not of self-destruction. They cannot or will not readily see that.  So, a big part of motivational enhancement therapy (MET) consists of bringing them by stages to understand their own part in the illness.  …Meanwhile, your question is what friends can do. As alcohol and drugs are not free, and as the requirements of daily living are not easily met by the person with addiction without well-intended help from others, the first order of business is to identify and interrupt all sources of enablement.   No intercession on their behalf with employers, no calling in sick for them. No money. No listening to endless hours of complaint about how the world is treating them.  Something that I did not mention in the presentation was that this illness pervades, and it enlists the family and friends in its malignancy. The original basis for Al-Anon (not AA) was, "save yourselves." When the time is apparent to provide help by getting them to the help, you will then still have resources.

Q – Can MAST be used for other substances, rather than just alcohol? What about things like compulsive shopping, gambling, eating, etc.?

A –  Sure, although you would obviously have to change the wording. But it would be an un-validated test, and really only useful for initiating a conversation about compulsive behaviors. Ultimately that’s the best use of any screening test  One site that identifies such tests for gambling is NCPG’s, https://www.ncpgambling.org/help-treatment/screening-tools/ . An example is the BBGS:  https://www.icrg.org/resources/brief-biosocial-gambling-screen

Q – Is there such a thing as an addictive personality based on genetic and environmental factors? Can you test for that before an addiction occurs?

A – You are asking two questions, really. One is about genetic influence, and there is ample evidence supporting that contention (Mark Schuckit and colleagues at University of California San Diego); but as with any genetic influence, the genes are not the whole story. More to the point, is that it is not necessary to have a hereditary component to develop alcohol use disorder. You can do that by diligent application to serious drinking… 😊

…As to whether there is actually a personality disorder which in some way condemns an individual to development of the compulsive use disorder we call alcoholism, the answer is no. A better explanation of this is in the linked paper by Littlefield and Sher, really quite readable even if just in the first few pages, where some of the long-term work by George Vaillant and others is acknowledged. George spent half a century looking at two populations, greatly dissimilar, from Cambridge, Massachusetts, and was able to put this one to rest.  (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002230/ )

Q – Please comment on caffeine addiction.

A – The DSM5, the text identifying criteria for psychiatric disorders, omits its consideration as a substance use disorder while including caffeine use as a research category, and while it does recognize caffeine intoxication.  I do not agree with the DSM5’s writing committee’s reluctance in this. It fulfills all of the SUD criteria in my view although perhaps less dramatically than may be experienced with heroin or with alcohol. But a more scholarly, comprehensive response may be found in this citation:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777290/   And in the continuing spirit of self-disclosure, my own one remaining substance use disorder (SUD) is in fact with caffeine; I justified it when I entered a new residency program at the tender age of 43 and found myself having to stay awake several nights in a row and somehow manage to learn new material. But that's the case with most substances of addiction, they have utility, at least initially.

…There is of course a long answer to this bearing on what the adverse effects of caffeine use are in your life or for your family. To the extent that it may in fact cause irritability or insomnia, those are obvious examples. But certainly caffeine withdrawal is a miserable experience and is accompanied by headaches that have clinical resemblance to migraine, as well as of course profound fatigue and dysthymia. Getting off caffeine is not an exercise for the faint of heart.  [Good news?  Once you get through the withdrawal, most folks enjoy long-term recovery.]

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM