By looking into the field of the neurosciences, we can understand that addiction holds its power mainly because endorphins––our natural opioids––are released in the brain. From repeated behaviour, the ‘primal’, reward-driven part of the brain quickly learns to overpower the more evolved, more rational part of the brain (known as the prefrontal cortex) to get that endorphin rush.
After taking a deep dive into trying to understand alcohol addiction and available treatment models, Elliot Stone found himself returning to the science again and again. He made calls to leading researchers in the field and eventually used his MBA to bring together a seasoned team of clinicians to develop a treatment program that incorporated evidence-based medicine, psychotherapy, and therapeutic interventions like CBT all into a reliable platform to turn to in times of distress. We talk with him about the resulting ALAViDA program and why he's excited by the work being done in addictions.
Tracy: Why don't you start with the Alavida medical assisted treatment program. Give me a breakdown of how it works and what it incorporates.
Elliot: It works by combining the best evidence-based practices in two worlds that are close but that don't often intersect. These are the world of psychotherapy and the world of medicine. We combine those two things and we use technology to empower the process, making it easier for everyone to collaborate. On the medical side, we're using medications in line with best practices and the leading research to help people. We use them as a tool for helping to basically retrain the brain and to just make the process of pairing down your drinking easier, from a biological sense.
On the therapy side, we're using tried and true approaches like CBT and motivational interviewing; we put the patient first and guide them in a very practical way through successive achievements of small goals in order to get long-term success. The technology we use allows access to the program from wherever you are, and also makes communicating very easy; it also makes being in the program and being under our care simple. You're not taking half of your day off work to go to a meeting and you're also not leaving for 30 days to go to inpatient treatment. Rather, you're clicking a link on your mobile phone and queueing up your physician or your therapist. Otherwise, you're sending them a message straight through it or scheduling a group meeting as well. You're also tracking yourself on a daily basis through the platform, so it's something that drives awareness and shares really helpful information with your care team.
Anyone who has ever been in therapy knows that you can have a whole bunch of things you were going to talk to your therapist about until you actually get into therapy. But if you had a daily contact point where you were taking notes on what was going on and your therapist was able to read that in advance of your session, it makes framing that session a heck of a lot easier, especially if you're diving into one particular problem. What we do is pretty specific, but it makes the whole thing a bit more efficient. It makes the best use of everyone's time and it gives people what they need without what they don't need.
Tracy: We're seeing a lot of success with hugely popular apps like Headspace that have similar aspects. It gives the user or subscriber somewhere to turn in those very narrow times of duress. For those who say, "I would love to jump into a session right now and I can't," it gives them the chance to keep in touch.
Elliot: I use Headspace. Yes, that's the basic idea.
Tracy: We know that stimuli surrounding the act of drinking (sights, smells, sounds, etc.) trigger a dopamine release. Dopamine is the 'drive' neurochemical, which heightens your energy and narrows your focus on a substance. Is the medication that ALAViDA uses something to block dopamine receptors so that that intense focus on something isn't experienced?
Elliot: We use a few different medications but the primary, frontline medication is often Naltrexone. Naltrexone is an opioid antagonist so it blocks the opioid receptors. So that's part of how the medication we use works.
Tracy: [Opioids are otherwise known in the brain as endorphins. They deliver that feel-good, relaxing, 'Ahhhh' sensation activated in the reward center of the brain. This is commonly the desired effect of most addictions.] I see. It's less so negating the driving factor of addiction (dopamine), and more so negating the reward factor (endorphins).
Elliot: Yes, it's breaking that cycle. If you don't get that neurochemical reward, then you aren't as inclined to [seek the substance that delivers it]. If you're able to block that reward for a period of time in specific circumstances, it can pull someone out of that compulsive cycle and give them a bit of space to make decisions. And that space is where we really double down on the therapy.
Tracy: Awesome. On the therapy-focused side, do you work with therapists or physicians?
Elliot: Everyone is a Master's level therapist; either an RCC, Registered Clinical Counselor or MSW, Masters level social worker. They're all trained in addiction work and we provide our own comprehensive training as well.
Tracy: In terms of the business side, you mentioned earlier that you have plans to get this program offered in HR for corporate offices?
Elliot: What we're starting to do now is talk to organizations in terms of broadening their wellness packages. Yes, we can take people on the severe end of the spectrum, but the reality is, 'severe' doesn't exactly look like what most people think it looks like. Oftentimes, it can be the person sitting next to you in your cubicle. We're talking to companies about integrating into their wellness platforms or their EAP; not only offering treatment, but actually engaging people and helping to assess the problem at an earlier stage. It's about engaging, educating, and then treating with an appropriate treatment based on where the person is at. This, as opposed to waiting for them to explode, then giving them the worst-case-scenario treatment. That's where a lot of our focus is at the moment. The impact we want to have as a company is to make evidence-based treatment available on a broad spectrum. We want to change the conversation around addiction treatment.
Tracy: A lot of companies might have no idea what to do. For example, if they see an employee--often who they highly value--on the brink of a drinking quandary, they typically approach the employee saying, "Maybe you should see someone or go to a meeting." Because they have no idea what to do, what's appropriate. The addiction industry has changed a lot, but general knowledge in the workplace hasn't evolved enough.
Elliot: The challenge is they don't have any other options. They don't know about other options.
Tracy: In your own endeavouring to understand addiction, why did you continue past the notion that AA is the only answer? AA is a program that is notoriously rigid and often psychologically torturous to some without any scientific evidence, but many just stop there: AA, that's the answer.
Elliot: I think the statistics are really clear. AA is a great program, and the 12 steps have helped a lot of people, but a lot of people doesn't equal most people. Helping the one million people seeking treatment, even if they were all doing really well--which they're not--would still be only a drop in the bucket of the people who actually have this problem on a daily basis and aren't getting help. Part of the reason they're not getting help is because what [they're being] offered isn't working, or it doesn't resonate with them. When we're talking about healthcare, we shouldn't be offering only one thing. The more I got into researching it, the more I just couldn't believe how behind-the-times this specific area of medicine was. Personally, experiences with friends and family who have had problems made me [decide on] getting more educated myself. When I did, I realized I was a bit ashamed of some of the things I said in years past. Pretty much everyone makes the mistake [of saying], "Oh, you've got a problem? It's 12 step time." It's not a bad thing to say, but it's an uneducated thing to say.
I've also always wanted to do work that no matter how bad of a day it is at the office, what we do at the organization is something that's en masse 'good' in changing lives. You can't get closer to that than working in addictions. This is a way for someone with my profile--which is not a Doctor or a therapist--to do that. I can facilitate bringing the right people into the room; sometimes those people are in different countries and sometimes they're in different industries, but because my background is pretty mixed in terms of having worked a lot of places, lived a lot of places, I communicate well across-boundaries. That's where I saw myself having an impact. Changing things when you know you're changing them in a positive direction is also fun--so are the crazy developments that are happening in healthcare. It's a cool place to be working.
Tracy: With every decade there comes a new wave of awareness, and I think you guys at ALAViDA are definitely doing your part in changing that. It's great to say, 'Hey, I've looked at the science.' We see that with Johann Hari, Dr. Gabor Maté, and Dr. Carl Hart; also Maia Szalavitz and Zachary Siegal. So many great thinkers and leaders are saying there are better ways to tackle addiction.
Elliot: Part of the challenge is that everyone wants to [tote the one 'cure']. We even see it with break-through things, and frankly, we were guilty of this when we first came out as well. It's how you get in the news: someone says something sensational about you. The problem is that every new thing that comes out, or every new discovery is sold as 'the cure'. But the reality is that it's a lot of things. There need to be options. The real cure is in being able to pull the components that someone needs together; assess them and adjust to what the person needs in real-time. You're effectively giving them exactly the best thing possible for them. [The solution is] not just an app for drinking; it's not just a medication; it's not just a certain kind of therapeutic approach or a certain person providing you with therapy. It's either all of those things, or some of those things depending on what the person is needing.
It's the same as the larger problem in medicine: things overlap and people don't communicate because they're working in silos. People die of cancer in between appointments for a skin infection. You're going around to the different specialists and they're working with your skin irritation and not paying attention to the cancer that has just started growing faster. That's a general problem that we're sorting out now though; I'm really hopeful about the way things are changing in healthcare in general. What we're able to do at ALAViDA [in terms of addressing the same problem], is pull some of those components together and then continue to be a source of help. The goal here is to move research into practice almost in real-time, as opposed to the 30-year lag. You have research where something is published, reviewed, and we're literally putting it into practice within six months. I don't think that's done often enough, unfortunately. Look at the best practices that just came out from the American Psychiatric Association. That was put out in January; we've been doing that for two years and still, it will be another 10-15 years before it makes it into the mainstream clinical population.
Tracy: Education is key. Definitely in medicine, but also in journalism. Trying to address the question of why an addiction forms in an individual, many disagree on the causes with most still holding the belief that it's just the substance that causes addiction. But there are deep-rooted elements like childhood trauma [its effects on the nervous system], behavior conditioning, not feeling connected to your community, etc. You might need to address them all, but you might also only need to address one. You've said before that you like the idea of harm reduction: you don't always have to fix every single issue to halt the behaviors within addiction. Want to explain this again in your own words?
Elliot: Yes, exactly. In harm reduction, it's not letting 'perfect' get in the way of 'good'. Just because you can't fix a person down to their core by helping them work through all of their childhood issues or whatever may have happened to them--maybe they went to Afghanistan [and have trauma from that]. The person may not want to [address] that, which is a large part of actually being able to do the work. It doesn't mean you can't help them get to a better footing with a substance. Most people are receptive to that. An addiction to exercise can be unhealthy, but it's a heck of a lot better than heroin.
Tracy: Very true.
Elliot: That's not the answer, but along the way of sorting out the person's problem with a certain substance, you can really give them tools that keep other addictions from arising. Even if you don't fix the underlying issue or cause. We see people living better lives all the time and there are plenty of people getting results that have trauma. They may be working through it with someone else, they may not be working through it right now, or they may have already worked through it in the past. I don't think the two are tied so tightly.
Tracy: Looking at the power of behavior repetition, or conditioning, it's a very powerful aspect of addiction. Willpower alone can't get you out of those ingrained behaviors. "Neurons that fire together wire together" as they say. You're essentially working out the 'muscle' that is the reward center of the brain, building up its capacity to override the careful thoughts and planned actions of the more rational prefrontal cortex. The field of neuroplasticity has proven though that we can change and relearn that. Why did you choose to focus on this aspect?
Elliot: I was going down a path of looking at different treatment modalities. I wanted to know what it looked like to go into an inpatient facility in BC, in Washington State, in Nebraska, in France, in Finland--and I wanted to know what outpatient treatment looked like. So in walking in a patient's shoes and talking to them, I realized some things. I was doing a lot of research on what language was being used and what it was based on. What do [these programs] say their success rates are? What kind of people work there? What are their credentials? Somewhere along the line during that research, you just keep coming back to the same names over and over again.
For me, those names got me into the history of Finland. Specifically, how they went through a prohibition period and outlawed alcohol. They then reopened it to the public, but only through an alcohol monopoly (so kind of like BC Liquor, but on a federal level). Then later--during the 50s sometime--they carved off a few percent and essentially funded a massive alcohol research program. Some pretty amazing things came out of that program like the first AA rats. They bred the first rats that could be used as proxies in an alcohol use disorder testing, or alcoholism testing. I started calling people [who had conducted that research] and effectively, they answered the phone. Dr. Hannu Alho, had been doing this work since the 60s and put it into a clinical practice and were getting very good results. There was just something immensely trustworthy about it, maybe it's a white lab coat and an old scientist [laughs], but the research was long, the people were open and progressive, and everything about what they were doing was different than what you see here [in North America]. There are pockets of people doing similar work now and I found some of them, but they weren't as accessible and it wasn't such a clear line of following the research, the names, and then going into a clinical practice. To me [Dr. Hannu Alho and his cohorts] just made sense. I went over to see them and it made sense in person as well. So here we are.
Tracy: What stood out the most about this line of action?
For us, it was a system of doing all the right clinical things in conjunction and delivering it in a lighter and longer approach. It was great! It made sense to me because that's the whole objective: give people what they need and not a whole lot of extra stuff. There is a crucial additional layer that we developed around how to make it simple and accessible. How do you make it easy for people to, first, find you, then for them to start and be able to finish? We want them to be able to get the change they want. Now we're using multiple medications, sometimes no medications, there are a variety of therapeutic approaches there are other services that we can provide like bringing a loved one into the process of change.
Tracy: You mentioned earlier that you're "just" an MBA, but it's nice to have that bridge. Someone who is saying, 'Okay this is going on over here, this is going on over there. Let's combine these things and work together.' ALAViDA focuses on alcohol. Currently, a lot of news is centered on the illicit opioid overdose crisis. Have you felt recently that alcohol has been lost in the dialogue surrounding addiction?
Elliot: It's the same challenge that you have with diabetes. It's really, really hard to get someone to change an behaviour today in order to prevent a potential health outcome years down the road. I guess we all have a little rebel in us.With alcohol, there are very few people who are in acute distress, where they need to quit drinking today or they might die tomorrow. And even then it's very hard for someone to actually believe that. Whereas with opioids, if you've got people dying at parties because they had a bad [poisoned or improperly dosed] batch, that's a very real threat. You don't just get sick. [With alcohol] someone tells you that you have a problem, and then you have a chance to get better. But [with opioids] you die, immediately in many cases. It's human nature that people are focusing on that. Alcohol is a bigger cost in terms of lives, yes. It's a bigger cost in terms of productivity and to the economy; car accidents, DUIs--the whole economy of heavy alcohol use, or problematic use is huge when you look at what actually goes into treatment. So no, I don’t think alcohol is getting the attention that it should, but I think it will. That's coming around. People are also getting smarter: we're moving down a better path. Mental health is starting to be appreciated, HR is in C suite, and there's a general movement in the right direction. It's just going to take time.
Tracy: Looking at the pharmaceutical hysteria we're experiencing in response to the overdose crisis, there are many people saying, 'To hell with pharmaceutical companies'. Additionally, a lot of blame is landing on GPs and MDs. With the medication element of the ALAViDA program, have you been able to say, 'Hey, this isn't a prescription opioid, this isn't oxycodone or fentanyl.' Have you faced challenge in communicating that your medicine is an opioid blocker, not something that should cause fear?
Elliot: It's something that we get fairly commonly, but it's not hard to educate people out of that. The simplest way is to explain how none of the medications we use are addictive. They're different than suboxone, methadone, or maintenance therapy. People are upset about people dying and opioid addiction is a very serious thing, so again, it's a natural thing. Also, here have certainly been some pretty gross misjudgments across the table--not just from pharmaceutical companies, but from GPs who were overprescribing as well. It may have been those who were just uneducated, or perhaps some people were truly being negligent. But it's not a blame that lies with any one person, and I think the idea that all drugs are bad is naive and it’s our collective responsibility to educate people. The case with all of the medications that we use is also that of the difference between suboxone and methadone. What people like is that you don't take it forever. As you start drinking less, you'll start taking less medication. With some of the medications, it's just a regimen: it's not going to be taken for a long period of time. That's something that people generally like to hear. People don't want to take medications if they don't need to.
Tracy: I've spoken to some in the field who say that after just 30 days, (although some experts say 60 for long-term effects), that stimuli, or cue, or trigger--whichever you choose to call it-- loses its power. The bright, fluorescent, liquor sign that seems to make you turn your car into the liquor store parking lot starts to lose its control over your mind and actions. If that sign doesn't equal that reward (from drinking), your ability to regain control over your behavior returns. With 'reward' blocking medication, you don't have to remove yourself from the stimuli by going into a treatment center. This way, you can have the same effects while you continue to work and live at home. If it can assist you in getting past that time-frame where it's automatic behavior, then that can be a good thing.
Elliot: Yes absolutely. The challenge is that it's a very complex topic. Stimuli can be visual cues [that trigger your focus on getting a drink], but there are a lot of layers to it. After 30 days without drinking, you may be past most of the visual cues, but what about the smell of beer, or having a slice of rum cake? Do you avoid everything that has a potential cue? That's one of the things that we're doing with naltrexone: the real, physical stimulus is still there, so you're working with that. The whole process and the entire situation is there: the smell of the bar, the taste of the drink, the clink of the glass. But you're blocking the the brain's response to all of those things [changes].
Tracy: You're working within the environment.
Elliot: You're sitting there like 'uck!'. After a period of time, none of those things have power over you anymore. If you were able to quit drinking for 30 days on your own by avoiding your normal social scene or what have you, that's great, but there are still certain stimuli out there that when you just let it touch your lips one time, for example, then you're back to drinking a whole heck-of-a-lot again. They call it the alcohol deprivation effect; there's a study published by Dr. David Sinclair of the Sinclair method. One of his first scientific discoveries was when they were using mice in the lab and gave them alcohol for a period of time. They were doing different tests to see how mice would respond, but when they finished the experiment, put them back in the cage, and took away the alcohol, once he took them out to do a different experiment, he realized that when alcohol was back in the cage, the rats drank more than they'd ever seen them drink before. The stimuli were brought back and their natural response spiked. This is the same thing that happens with people who "fall off the wagon" or all of the other bad language that goes along with that. The point is that the pattern is more biological than we once realized. It was chalked up to willpower for centuries, but now we understand it on a research-based level.
Tracy: It's the same thing that so many have experienced after going through a rehab center program. They'll feel so good at the end of it, but the minute you're back and walking past your neighborhood bar after a stressful workday, and you fall back into your old habits again.
Elliot: That's exactly it.
Tracy: Any final comments?
Elliot: I’d just conclude by saying that I am hopeful. Alcohol poses an enormous public health problem, but we are better equipped today than we have ever been before and I am optimistic about getting personalized evidence-based treatments in the hands of those that need it. It’s not just ALAViDA, there is an army of people out there doing amazing work and people are starting to take note. There’s a wind of positivity in the air