How does TMS work?

Basically, a TMS device allows a trained physician to use an electromagnet to noninvasively stimulate the brain of a patient. A rapidly changing magnetic field created by a magnetic coil causes weak electric currents in the brain through electromagnetic induction. By stimulating different areas of the cortex, it is possible to elicit a therapeutic response. For example, studies have shown that applying stimulation to the left prefrontal cortex increases activity below the stimulation site and produces a statistically significant reduction in depressive symptoms. TMS can currently target sites in the brain to within a few millimeters.

What is electromagnetic induction?

In TMS, magnetic induction is when current is produced in the brain through changing magnetic fields produced by the TMS stimulation coil. Induction was discovered by Michael Faraday in 1831.

What does TMS stand for?

TMS is short for transcranial magnetic stimulation. rTMS, which is a newer form of TMS, stands for repetitive transcranial magnetic stimulation. rTMS improves on TMS by allowing for multiple magnetic pulses per second. The word “transcranial” simply refers to the fact that the magnetic field passes noninvasively through the head and no surgery is required.

Where has TMS been researched?

TMS was developed in England and is currently being actively investigated at major universities throughout the world such as Harvard, Yale, Georgetown University Medical Center, The Medical University of South Carolina, Stanford University, Helsinki University Central Hospital, and the University of Sydney.

What are the benefits of TMS?

NeuroStar TMS Therapy is the first and only non-systemic and non-invasive depression treatment to be cleared by the FDA It is indicated for adult patients who did not achieve satisfactory improvement from prior antidepressant medication therapy. Those patients received a median of 4 treatment attempts, 1 of which was of adequate dose and duration. In clinical trials, 1 in 2 patients had significant improvement in symptoms and 1 in 3 had complete symptom resolution Since it’s non-systemic, it doesn't have side effects such as weight gain, sexual dysfunction, nausea, sedation, dry mouth, etc.

Is TMS therapy a good alternative for patients who are fearful of the side effects associated with antidepressant medications?

NeuroStar TMS has been cleared by U.S. FDA for the treatment of patients with depression who have failed to achieve satisfactory improvement from prior antidepressant treatment. NeuroStar is non-systemic, so therefore it is a good alternative for people who are fearful or intolerant of side effects and are otherwise approprate for treatment. Like any treatment option, including TMS, patients and clinicians should work together to find the most appropriate treatment option for each patient

How effective is TMS therapy compared with drugs?

NeuroStar was not compared in head-to-head studies with antidepressant medications. It is difficult to compare NeuroStar vs. drugs, because they have been studied in different patient populations The patients for which NeuroStar has been FDA-cleared had failed multiple treatment attempts, one of which achieved an adequate dose and duration Almost all antidepressant medications have been studied and approved for 1st-line treatment. In the NeuroStar randomized controlled trial, almost 3x the number of NeuroStar-treated patients had a significant improvement in symptoms compared to placebo.

Finally, it is also important to consider safety and tolerability. TMS is non-systemic, so it doesn’t cause side effects such as weight gain, sexual dysfunction, nausea, dry mouth, sedation, etc.

Is TMS Therapy intended to replace antidepressant medications?

No, there is a significant unmet need in the treatment of depression. Currently there are few options for patients who have had an inadequate response to previous antidepressant treatments. They are often faced with choosing between a complex regimen of multiple drugs or, for more severe cases, more invasive procedures. While TMS Therapy is a new treatment option, we do not believe it will displace the need for other antidepressants. Based on its excellent safety profile, NeuroStar TMS Therapy may be used earlier in the treatment algorithm than antidepressant drug classes that carry a significant safety/tolerability burden.

Can TMS patients also take an antidepressant(s)?

NeuroStar TMS Therapy was studied as a monotherapy without additional antidepressants in the controlled clinical trial so the efficacy with additional antidepressants (i.e., as adjunctive therapy) is not known NeuroStar TMS Therapy was safety administered in conjunction with medication antidepressants and this replicated what has been shown in the many literature-based single center trials of TMS In clinical trials, patients were administered antidepressant medications during the taper phase at the end of two of the acute studies. In the maintenance of effect study, patients who were being treated with antidepressant monotherapy and also had periodic reintroductions of TMS Therapy

If patients have to go back on drugs anyway, then what’s the point?

NeuroStar is used for the acute treatment of patients with depression who have not received satisfactory improvement from prior antidepressant treatment Most patients who benefited from TMS were able to retain effect for up to 6 months on only one antidepressant medication at a minimal dose These patients had failed a median of 4 antidepressant treatment attempts, one adequate treatment In the open-label trial, which is most like the real world, among NeuroStar-treated patients, 1 in 2 achieved a significant improvement in symptoms and 1in 3 had complete symptom resolution Since NeuroStar is non-systemic, these results were achieved without side effects such as weight gain, sexual dysfunction, nausea, dry mouth, sedation, etc.

Does NeuroStar TMS hurt?

The most common adverse event related to treatment was scalp pain or discomfort at the treatment area during active treatments, which was transient and mild to moderate in severity. The incidence of this side effect declined markedly after the first week of treatment. Less than 5% of patients discontinued the study due to any negative side effect.

Does NeuroStar TMS cause brain tumors?

No, TMS Therapy uses the same type and strength of magnetic fields as MRIs, which have been used in tens of millions of patients around the world and have not been shown to cause tumors. The amount of magnetic field exposure for a full course of TMS Therapy is a small fraction of just one brain scan with an MRI.

Does NeuroStar TMS cause memory loss?

NeuroStar TMS Therapy was systematically evaluated for its effects on memory The clinical trials demonstrated that NeuroStar TMS Therapy does not result in adverse effects on memory or concentration

What are the long-term consequences of TMS treatment?

TMS is an acute therapy. With regard to long-term safety, TMS uses the same type and strength of magnetic fields as MRIs, which have been used in tens of millions of patients around the world and have not been shown to cause long-term consequences. The amount of magnetic field exposure for a full course of TMS Therapy is only a small fraction of one brain scan with an MRI. If a patient had multiple courses of acute TMS, the magnetic field exposure would be less than exposure from a few MRI sessions.

What is the FDA-cleared indication and what does it mean?

NeuroStar TMS Therapy is indicated for adult patients with major depressive disorder who failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. The important points are:

Does clearance of NeuroStar TMS Therapy mean that all TMS devices are cleared for use in major depression within the United States?

No. NeuroStar TMS Therapy is the first and only TMS device to have been evaluated in a large, multicenter, controlled clinical trial NeuroStar is the first and only TMS device to be cleared by the U.S. FDA for the treatment of major depression Any other TMS Device that is claimed to be “FDA-approved” is not cleared for the treatment of depression and has not been shown to be safe and effective

Has TMS been mentioned by the news media?

TMS is frequently mentioned in the news. There have been recent articles in Time Magazine, New Scientist, The New York Times, MSNBC, Newsweek and the BBC. The MIT Technology Review has also written a summary of TMS. It is widely looked upon as having great potential to improve the quality of the lives of many who are currently suffering from mental illnesses. As the science improves over time, it is likely that TMS will be receiving more attention from the public news media. From time to time TMS creates a flurry of excitement in the media. One example was in May 2007 when the University of Wisconsin announced that they were able to induce oscillations in the brain which appeared to be equivalent to slow wave sleep. While they were only able to do this in subjects who were already asleep, it is possible that TMS may one day be turned into a method for helping people have a good night’s rest.

Is TMS safe? What problems do patients commonly report?

TMS was introduced in the mid 1980s. It is generally agreed to be free from side effects when proper procedures are followed. Over the years since introduction, safety guidelines have been developed which minimize risks. The main complaint from a small percentage of patients is headache during and immediately following the stimulation session. This can be alleviated with over-the-counter pain medications such as aspirin or ibuprofen. It is believed that these headaches are caused by the inadvertent stimulation of nearby muscle groups, which results in tension headaches. Another common problem is ringing in the ears caused by the noise of the stimulating coil, so earplugs are typically worn during the procedure. Seizures are the major possible risk associated with TMS, although they have only been encountered in several patients thus far. While TMS safety guidelines established in 1993 and revised in 1996 go a long way to reducing the chances of seizure, the possibility still exists. It is therefore necessary that TMS laboratories and physicians be prepared to deal with diagnosing and treating a seizure. All seizures thus far have been experienced either during or immediately following TMS treatment, during which time a patient should be closely monitored by the attending physician.

What are the risks of TMS therapy?

NeuroStar TMS Therapy is contraindicated (should not be used) in patients with implanted metallic devices or non-removable metallic objects in or around the head. It also should not be used in patients with implanted devices that are controlled by physiological signals such as pacemakers, etc.

Are there other patients for whom NeuroStar TMS Therapy could pose a risk?

Depression is a lethal disease and, as with all antidepressants, patients treated with NeuroStar TMS Therapy should be monitored for signs or symptoms of worsening depression. The efficacy of NeuroStar TMS Therapy in patients with depression who have failed 2 or more antidepressants has not been proven and it has not been studied in patients who have had no prior antidepressant treatment in the current episode.

What is the sensation like during TMS treatment?

Patients can hear a loud clicking noise when the magnetic pulse is applied, so earplugs are normally worn to avoid discomfort. There is also a tingling sensation which can be felt in the scalp to a greater or lesser degree by patients. It is rarely uncomfortable. Some patients even report that they become so accustomed to the feeling that they can tell when the physician is stimulating the correct spot.

How does TMS compare with ECT (Electroconvulsive therapy)?

TMS is a noninvasive method of stimulating the brain through the use of magnetic fields. The stimulation coil does not make contact with the patient’s head as it induces a weak electrical current in the brain through electromagnetic induction. TMS has not been shown to cause memory loss or loss of consciousness. It does not require anesthesia nor does it cause seizures. TMS undoubtedly has a superior side effect profile to ECT. ECT was developed in the 1940s and 50s, albeit with later refinements, while TMS was invented in the mid-1980s.

Are there any long term risks associated with TMS?

According to The International Society for Transcranial Stimulation, in an article ‘Managing the Risks of Repetitive Transcranial Stimulation’ published in CNS Spectrums, “The long-term risks of rTMS are not known. However, the limited data available at this time (2002) from repeated application of high intensity, time-varying magnetic fields to humans, as in magnetic resonance imaging, do not suggest that they are significant.”[2]

What is Brain Stimulation?

Brain stimulation represents a new discipline in psychiatry focused on using magnetic or electrical energy to improve brain function. These techniques are used both for research and for treatment in major psychiatric disorders that do not always respond fully to conventional treatments, such as medication or psychotherapy. Stimulation with electrical or magnetic energy interacts with neurons, causing them to release chemicals called neurotransmitters, and possibly also helping form more healthy synapses, or connections, between nerve cells. Repeated stimulation can modulate or “reset” the activity of specific regions of the brain to exert significant changes. Brain stimulation therapy uses both traditional and brand new methods of applying energy. It is not a replacement for medications, but it may be added onto medications to improve outcome. As with other treatments, brain stimulation has a risk of side effects that should be discussed thoroughly with your doctor before making a decision.

All Approved Brain Stimulation Techniques

Electroconvulsive Therapy (ECT) has been modernized substantially since it was first introduced over 70 years ago. ECT remains the most effective and rapidly acting treatment for severe treatment-resistant depression and other disorders. Modifications in ECT technique, electrode placement, and dosage can dramatically affect the side effects and tolerability of the treatment. NewYork-Presbyterian Hospital and the New York State Psychiatric Institute have long been recognized as leaders in the field of ECT research and clinical practice. We specialize in individualizing ECT dosage to each patient’s needs, and in selecting treatment parameters that research has shown have the lowest risk of side effects.

Transcranial Magnetic Stimulation (TMS) was approved by the United States Food and Drug Administration in October, 2008, for the treatment of major depression that has not responded to at least one adequate trial of an antidepressant medication in the current episode. Columbia was one of the main research sites that demonstrated the safety and efficacy of TMS prior to its approval, and is the first location in the New York area to offer it now for treatment. TMS is a non-invasive form of brain stimulation that modulates brain activity using focused magnetic pulses. To treat depression, this stimulation is delivered to an area of the brain linked to depression in 30-60 minute sessions administered on an outpatient basis. Treatment typically occurs daily (Monday - Friday) for 4-6 weeks. TMS is not a replacement for antidepressant medications, but may be added onto existing medications. More information about TMS can be found at the Division of Brain Stimulation and at Neuronetics.

Vagus Nerve Stimulation (VNS) was approved by the FDA for the long-term treatment of chronic major depression that has not responded to antidepressant treatments. VNS is performed with an electrical device like a pacemaker that is implanted in the chest. Electrical leads are connected to the vagus nerve in the neck. The vagus nerve sends impulses to the brain. VNS is indicated for the adjunctive long-term treatment of chronic (more than 2 years) or recurrent depression for patients 18 years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments. VNS is not a replacement for medications or electroconvulsive therapy (ECT), but it can be added onto other treatments for adjunctive therapy and long-term management.

Future Directions

The TMS community is actively engaged in research with experimental forms of brain stimulation to help identify safe and effective treatments for medication-resistant depression and other disorders such as obsessive-compulsive disorder (OCD), anxiety disorders, and autism spectrum disorders. Areas of research include transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), deep brain stimulation (DBS), and transcranial direct current stimulation (tDCS).

What illnesses has TMS been successful in treating?

TMS is currently being studied as a potential treatment for many disorders including depression, schizophrenia, posttraumatic stress disorder, obsessive-compulsive disorder, migraine headaches, autism, stroke, and chronic neuropathic pain. Numerous studies have been published in peer reviewed journals which indicate that TMS is even useful in treating cases of depression which are untreatable with any other therapy. Some have called TMS a “life saver.” When used as a treatment for depression, TMS typically takes several weeks to work. But results are sometimes experienced after only one session.

Does TMS ever take some time to work? Is it possible that it may not work until a month after the treatment?

In a small number of patients, the positive response is seen after a short delay after therapy. The hippocampal neurogenesis theory of antidepressant action could possibly explain a delayed response time, but it is currently very difficult to prove.

What advances in science and technology led to the development of TMS?

In 1831, Michael Faraday discovered the principle of electromagnetic induction. This phenomenon allows for the induction of current through the use of a changing magnetic field. It was already known, thanks to Galvani’s experiments of the 1700s, that the nervous system had an electrical component. For decades in the early 1900s, physiological experiments were done using huge magnetic coils. Although the state-of-the-art in electromagnets at the time was very crude, investigators managed to produce subtle psychological effects in test subjects. These experiments led to an eventual breakthrough where it was finally possible to stimulate the human eye into seeing phosphenes – the sensation of light. It was in 1985 that magnetic stimulation finally entered the clinic through the work of P.A. Merton at the National Hospital in London. Since then, advances in capacitors and other electronic components have made precise repetitive TMS possible. In 1987, the IEEE awarded the Prize for Innovation to the developers of the British group from the University of Sheffield which developed TMS.

How can TMS help scientists to further understand the nature of human cognition and intelligence?

In 2006, Professor Snyder of the Australian National University in Canberra published research in the journal Perception entitled “Savant-like numerosity skills revealed in normal people by magnetic pulses.”[15] The paper begins by explaining that some autistics have mathematical abilities which far surpass those of most people. By stimulating the left anterior temporal lobe, the researchers were able to temporarily induce some surprising abilities in people who were not autistic. These test subjects were far more likely than their non-stimulated counterparts to be able determine the number of dots flashed on a computer screen. Such studies will allow scientists to understand not only the autistic brain but the non-autistic brain as well. It has also been shown (as mentioned in New Scientist) in May of 2007 by Fortunato Battaglia at the City University of New York that stimulating the brains of mice can cause neuron growth, a process referred to as neurogenesis. It is possible that this phenomenon can be used to treat patients who are currently suffering with Alzheimer’s.

Is it true that many instances of depression cannot be treated with drug therapy alone?

According to a paper in The Lancet, “Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study”, depression will be the second leading cause of disability worldwide. Drug resistant, or refractory depression, occurs in up to 30% of cases. These patients have often tried every currently available pharmaceutical intervention and are still unable to return to a normal and healthy life. It is in these cases, estimated at around 4 million in the US alone, that TMS presents the possibility for greatest benefit.

Depression and TMS

What is Depression?

Depression or depressed refer to both expected and pathologically chronic or severe levels of sadness, perceived helplessness, loss of interest or pleasure, and other related emotions and behaviours. A depressed mood is often reported as feeling depressed, sad, helpless, and hopeless. In traditional terms "depressed" is often synonymous with "sad," but both clinical and non-clinical depression also refer to a combination of more than one feeling. Such a mixture can include (but is not limited to) anger, fear, anxiety, despair, guilt, apathy, and/or grief, in addition to what many people would describe as typical "sadness". It is harmful for the human body and can affect proper functioning of the brain. Extended depression can lead to suicidal tendencies.

Depression is a serious medical illness affecting more than 14 million American adults every year. It results in a persistent state of sadness that may interfere with an individual's thoughts, behavior, mood and physical health. Symptoms can include: While the exact cause of depression is not known, the leading scientific theory is that depression is caused by an imbalance of the brain’s neurotransmitters. Neurotransmitters are chemical messengers that send signals between brain cells. Depression is most often treated with antidepressant medications. It is believed that antidepressant medications work by increasing the levels of these neurotransmitters. Although antidepressants can be effective for many patients, they do not work for everybody. Additionally, since antidepressants medications are typically taken by mouth, they circulate in the blood stream throughout the body, often resulting in unwanted side effects such as weight gain, sexual problems, upset stomach, sleepiness, and dry mouth. More than 4 million patients do not receive adequate benefit from antidepressants and/or cannot tolerate the side effects caused by them.

What defines Major Depressive Disorder (MDD)?

Major depression is a common and serious medical illness affecting more than 13 million Americans, or approximately 6.6 percent of the population in a given year. Unlike the normal ups and downs of everyday life, Major Depression is persistent and can significantly interfere with an individual's thoughts, behavior, mood, and even physical health. Mental illness is the leading cause of disability in the U.S. often impairing social, academic and work functioning and causing significant emotional distress. Depression is the most predominant illness within the mental health arena. Women are almost twice as likely as men to suffer from depression. However, some experts feel that depression in men is significantly under-reported. Major depression can occur at any age, including childhood, the teenage years and adulthood. Major depression has no racial, ethnic, or socioeconomic boundaries. About two-thirds of those who experience an episode of depression will have at least one other episode in their lives. It is not unusual for depression sufferers to have more than one episode in any given year. Major depression, also known as unipolar depression, is only one type of depressive disorder. Other depressive disorders include dysthymia (a type of chronic depression) and bipolar depression (the depressed phase of bipolar disorder or manic depression). Individuals suffering from bipolar disorder experiengce both depression and mania in a cyclical fashion. Mania often involves abnormally and persistently elevated mood or irritability, elevated activity, grandiosity, rapid speech and racing thoughts.

What Causes MDD?

Scientists have not yet determined the root cause of major depression. However, there is strong evidence there may be several contributors to the illness. Psychological, biological and environmental factors may all contribute to its development. Whatever the specific causes, research has firmly established that major depression is a biological brain disorder. Serotonin, norepinephrine and dopamine are three neurotransmitters (chemical messengers that transmit electrical signals between brain cells) thought to be involved with major depression. Several theories attempting to explain depression are based on an imbalance of these chemical messengers. It is thought that most antidepressant medications work by increasing the availability of neurotransmitters or by changing the sensitivity of the receptors for these chemicals. Scientists have also found evidence of a genetic predisposition to major depression. There is an increased risk for developing depression when there is a family history of the illness. Not everyone with a genetic predisposition develops depression, but some people probably have a biological make-up that leaves them particularly vulnerable to developing depression. Life events, such as the death of a loved one, chronic stress, and alcohol and drug abuse, may trigger episodes of depression. Some illnesses such as heart disease and cancer and some medications may also trigger a depressive episode. Often, however, depressive episodes occur spontaneously and are not triggered by a life crisis or physical illness.

What are the symptoms of MDD?

The onset of the first episode of major depressive disorder may not be obvious if it is gradual or mild. The symptoms of this disorder characteristically represent a significant change from how a person functioned before the illness. The symptoms of depression may include:

• Feelings of worthlessness, hopelessness, helplessness or guilt
  
• Persistently sad or irritable mood
  
• Pronounced changes in sleep habits and energy levels
  
• Pessimistic feelings about the future
  
• Trouble making decisions
  
• Significant weight gain or loss
  
• Difficulty thinking or concentrating
  
• Low libido
  
• Increased agitation
  
• Lack of interest in or pleasure from activities typically enjoyed
  
• Recurrent thoughts of death and/or suicide
  

When several of these symptoms occur at the same time, last longer than two weeks, and interfere with ordinary functioning, individuals should seek professional advice and treatment. If left untreated, major depression can lead to attempted suicide.

What are other treatments used to treat for MDD?

Several types of treatment for major depression are available, and the type chosen depends on the individual and the severity of their illness. There are three basic types of treatment for depression in common use today: psychotherapy, medications and electroconvulsive therapy (ECT). They may be used singly or in combination. NeuroStar® TMS Therapy is currently testing a fourth type.

TMS and Brain Anatomy

What is the cerebral cortex?

The cerebral cortex is the outermost layer of the brain, measuring 2-4mm thick. It is important in many functions, ranging from memory to emotion and is larger in humans as compared to other animals.

What is the motor cortex?

The motor cortex, as its name suggests, is pivotal in motor functions. It is part of the cerebral cortex. Early TMS research revealed that stimulating the motor cortex can cause the conduction of nerve impulses to the spinal cord. The motor cortex is currently used as a gauge to determine the appropriate strength of TMS pulses in a given subject. Researchers will stimulate the motor cortex and check for muscle movement. They will then note the setting required to induce this muscle movement, and use a lower setting (sub-motor threshold) to stimulate other parts of the brain as required by the study/treatment protocol. This is an important safety practice which greatly reduces the risk of seizures.

What are neurotransmitters?

Neurotransmitters are chemical messengers. They are responsible for facilitating communication between neurons (nerve cells). The prevailing hypothesis behind depression is that it is caused by a deficiency in monoamine neurotransmitters, markedly serotonin, dopamine, and norepinephrine.

How do other mental disorders coexisting with drug addiction affect drug addiction treatment?

Drug addiction is a disease of the brain that frequently occurs with other mental disorders. In fact, as many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs—i.e., tobacco and alcohol. For these individuals, one condition becomes more difficult to treat successfully as an additional condition is intertwined. Thus, patients entering treatment either for a substance use disorder or for another mental disorder should be assessed for the co-occurrence of the other condition. Research indicates that treating both (or multiple) illnesses simultaneously in an integrated fashion is generally the best treatment approach for these patients.

Why do drug-addicted persons keep using drugs?

Nearly all addicted individuals believe at the outset that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve longterm abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences—the defining characteristic of addiction.

What happens to your brain if you keep taking drugs?

Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine's impact on the reward circuit of a drug abuser's brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high - an effect known as tolerance.

Why do some people become addicted to drugs, while others do not?

As with any other disease, vulnerability to addiction differs from person to person. In general, the more risk factors an individual has, the greater the chance that taking drugs will lead to abuse and addiction. "Protective" factors reduce a person's risk of developing addiction.

What factors determine if a person will become addicted?

No single factor determines whether a person will become addicted to drugs. The overall risk for addiction is impacted by the biological makeup of the individual - it can even be influenced by gender or ethnicity, his or her developmental stage, and the surrounding social environment (e.g., conditions at home, at school, and in the neighborhood).

Which biological factors increase risk of addiction?

Scientists estimate that genetic factors account for between 40 and 60 percent of a person's vulnerability to addiction, including the effects of environment on gene expression and function. Adolescents and individuals with mental disorders are at greater risk of drug abuse and addiction than the general population.

Is there a difference between physical dependence and addiction?

Yes. According to the DSM, the clinical criteria for "drug dependence" (or what we refer to as addiction) include compulsive drug use despite harmful consequences; inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including even appropriate, medically instructed use. Thus, physical dependence in and of itself does not constitute addiction, but often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, where the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.

What is drug addiction treatment?

Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, in many different forms, and for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. For many, treatment is a long-term process that involves multiple interventions and regular monitoring. There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy (such as individual or group counseling, cognitive therapy, or contingency management), medications, or their combination. The specific type of treatment or combination of treatments will vary depending on the patient's individual needs and, often, on the types of drugs they use. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach. Finally, people who are addicted to drugs often suffer from other health (including other mental health), occupational, legal, familial, and social problems that should be addressed concurrently. The best programs provide a combination of therapies and other services to meet an individual patient's needs. Specific needs may relate to age, race, culture, sexual orientation, gender, pregnancy, other drug use, comorbid conditions (e.g., depression, HIV), parenting, housing, and employment, as well as physical and sexual abuse history.

How effective is drug addiction treatment?

In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient's problems, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and his or her treatment providers.

Is drug addiction treatment worth its cost?

Substance abuse costs our Nation over one half-trillion dollars annually, and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated health and social costs by far more than the cost of the treatment itself. Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person.

How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various rates, so there is no pre-determined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum, and some opioid-addicted individuals continue to benefit from methadone maintenance for many years.

What helps people stay in drug addiction treatment?

Because successful outcomes often depend on a person's staying in treatment long enough to reap its full benefits, strategies for keeping people in treatment are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention typically include motivation to change drug-using behavior; degree of support from family and friends; and, frequently, pressure from the criminal justice system, child protection services, employers, or the family. Within a treatment program, successful clinicians can establish a positive, therapeutic relationship with their patients. The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services should also be available.

Can exercise play a role in the treatment process?

Yes—exercise is increasingly becoming a component of many treatment programs and has shown efficacy, in combination with cognitive-behavioral therapy, for promoting smoking cessation. Exercise may exert beneficial effects by addressing psychosocial and physiological needs that nicotine replacement alone does not; attenuating negative affect; reducing stress; and helping prevent weight gain following cessation. Research is currently under way to determine if and how exercise programs can play a similar role in the treatment of other forms of drug abuse.

How can families and friends make a difference in the life of someone needing treatment?

Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy can also be important, especially for adolescents. Involvement of a family member or significant other in an individual's treatment program can strengthen and extend treatment benefits.

Does relapse to drug abuse mean treatment has failed?

No. The chronic nature of the disease means that relapsing to drug abuse is not only possible, but likely, with relapse rates similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components. Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does not mean treatment failure. For the addicted patient, lapses back to drug abuse indicate that treatment needs to be reinstated or adjusted, or that alternate treatment is needed.

What Is Relapse Prevention Treatment?

Relapse prevention teaches patients to recognize signs of relapsing. Recovery is abstinence from the drug (while being able to function socially and psychologically). There are usually warning signs before a relapse. One of the most important of these warning signs may include emotional distress, which causes recovering addicts to turn to drugs for relief.

What are the unique needs of women with substance use disorders?

Gender-related drug abuse treatment should attend not only to biological differences but also to social and environmental factors, all of which can influence the motivations for drug use, the reasons for seeking treatment, the types of environments where treatment is obtained, the treatments that are most effective, and the consequences of not receiving treatment. Many life circumstances predominate in women as a group, which may require a specialized treatment approach. For example, research has shown that physical and sexual trauma followed by post-traumatic stress disorder (PTSD) is more common in drug-abusing women than in men seeking treatment. Other factors unique to women that can influence the treatment process include issues around pregnancy and child care, financial independence, and how they come into treatment (as women are more likely to seek the assistance of a general or mental health practitioner).

How does heroin abuse affect pregnant women?

Heroin abuse during pregnancy and its many associated environmental factors (e.g., lack of prenatal care) have been associated with adverse consequences including low birth weight, an important risk factor for later developmental delay. Methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse, although infants exposed to methadone during pregnancy typically require treatment for withdrawal symptoms. In the United States, several studies have found buprenorphine to be equally effective and as safe as methadone in the adult outpatient treatment of opioid dependence. Given this efficacy among adults, current studies are attempting to establish the safety and effectiveness of buprenorphine in opioid-dependent pregnant women. For women who do not want or are not able to receive pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be accomplished with relative safety, although the likelihood of relapse to heroin use should be considered.

What are the unique needs of adolescents with substance use disorders?

Adolescent drug abusers have unique needs stemming from their immature neurocognitive and psychosocial stage of development. Research has demonstrated that the brain undergoes a prolonged process of development and refinement, from birth to early adulthood, during which a developmental shift occurs where actions go from more impulsive to more reasoned and reflective. In fact, the brain areas most closely associated with aspects of behavior such as decisionmaking, judgment, planning, and self-control undergo a period of rapid development during adolescence. Adolescent drug abuse is also often associated with other co-occurring mental health problems. These include attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct problems, as well as depressive and anxiety disorders. This developmental period has also been associated with physical and/or sexual abuse and academic difficulties. Adolescents are also especially sensitive to social cues, with peer groups and families being highly influential during this time. Therefore, treatments that facilitate positive parental involvement, integrate other systems in which the adolescent participates (such as school and athletics), and recognize the importance of prosocial peer relationships are among the most effective. Access to comprehensive assessment, treatment, case management, and family-support services that are developmentally, culturally, and gender-appropriate is also integral when addressing adolescent addiction. Medications for substance abuse among adolescents may also be helpful. Currently, the only Food and Drug Administration (FDA)-approved addiction medication for adolescents is the transdermal nicotine patch. Research is under way to determine the safety and efficacy of medications for nicotine-, alcohol-, and opioid-dependent adolescents and for adolescents with co-occurring disorders.

Why is adolescence a critical time for preventing drug addiction?

As noted previously, early use of drugs increases a person's chances of more serious drug abuse and addiction. Remember, drugs change brains - and this can lead to addiction and other serious problems. So preventing early use of drugs or alcohol may reduce the risk of progressing to later abuse and addiction. Risk of drug abuse increases greatly during times of transition, such as changing schools, moving, or divorce. If we can prevent drug abuse, we can prevent drug addiction. In early adolescence, when children advance from elementary through middle school, they face new and challenging social and academic situations. Often during this period, children are exposed to abusable substances such as cigarettes and alcohol for the first time. When they enter high school, teens may encounter greater availability of drugs, drug abuse by older teens, and social activities where drugs are used. At the same time, many behaviors that are a normal aspect of their development, such as the desire to do something new or risky, may increase teen tendencies to experiment with drugs. Some teens may give in to the urging of drug-abusing friends to share the experience with them. Others may think that taking drugs (such as steroids) will improve their appearance or their athletic performance or that abusing substances such as alcohol or Ecstasy (MDMA) will ease their anxiety in social situations. Teens' still-developing judgment and decisionmaking skills may limit their ability to assess risks accurately and make sound decisions about using drugs. Drug and alcohol abuse can disrupt brain function in areas critical to motivation, memory, learning, judgment, and behavior control. So, it is not surprising that teens who abuse alcohol and other drugs often have family and school problems, poor academic performance, health-related problems (including mental health), and involvement with the juvenile justice system.

Are there specific drug addiction treatments for older adults?

With the aging of the baby boomer generation, the composition of the general population will expand dramatically with respect to the number of older adults. Such a change, coupled with a greater history of lifetime drug use (than previous older generations), different cultural norms and general attitudes about drug use, and increases in the availability of psychotherapeutic medications, may lead to growth in the number of older adults with substance use problems. Although no drug treatment programs are yet designed exclusively for older adults, research to date indicates that current addiction treatment programs can be as effective for older adults as they are for younger adults. However, substance abuse problems in older adults often go unrecognized, and therefore untreated.

Are there treatments for people addicted to prescription drugs?

The nonmedical use of prescription drugs increased dramatically in the 1990s and remains at high levels. In 2007, approximately 7 million people aged 12 or older reported nonmedical use of a prescription drug. The most commonly abused medications are painkillers (i.e., opioids: 5.2 million people), stimulants (e.g., methylphenidate and amphetamine: 1.2 million), and central nervous system (CNS) depressants (e.g., benzodiazepines: 2.1 million). Like many illicit substances, these drugs alter the brain's activity and can lead to many adverse consequences, including addiction. For example, opioid pain relievers, such as Vicodin or OxyContin, can present similar health risks as do illicit opioids (e.g., heroin) depending on dose, route of administration, combination with other drugs, and other factors. As a result, the increases in nonmedical use have been accompanied by increased emergency room visits, accidental poisonings, and treatment admissions for addiction. Treatments for prescription drugs tend to be similar to those for illicit drugs that affect the same brain systems. Thus, buprenorphine is used to treat addiction to opioid pain medications, and behavioral therapies are most likely to be effective for stimulant or CNS depressant addiction—for which we do not yet have medications.

What are the most commonly abused prescription drugs?

Although many prescription medications can be abused, the following three classes are most commonly abused:    Opioids -- usually prescribed to treat pain.    CNS Depressants -- used to treat anxiety and sleep disorders.    Stimulants -- prescribed to treat ADHD and narcolepsy.

Is the use of medications like suboxone simply replacing one drug addiction with another?

No -- as used in maintenance treatment, suboxone is a not heroin/opioid substitute. It is prescribed or administered under monitored, controlled conditions and is safe and effective for treating opioid addiction when used as directed. It is administered sublingually (i.e., under the tongue) in specified doses, and it's pharmacological effects differ from those of heroin and other abused opioids. Heroin, for example, is often injected, snorted, or smoked, causing an almost immediate "rush," or brief period of euphoria, that wears off quickly and ends in a "crash." The individual then experiences an intense craving to use again so as to stop the crash and reinstate the euphoria. The cycle of euphoria, crash, and craving -- sometimes repeated several times a day -- is a hallmark of addiction and results in severe behavioral disruption. These characteristics result from heroin's rapid onset and short duration of action in the brain.

Can a person become addicted to psychotherapeutics that are prescribed by a doctor?

While this scenario occurs infrequently, it is possible. Because some psychotherapeutics have a risk of addiction associated with them (e.g., stimulants to treat ADHD, benzodiazepines to treat anxiety or sleep disorders, and opioids to treat pain), it is important for patients to follow their physician's instructions faithfully and for physicians to monitor their patients carefully. To minimize these risks, a physician (or other prescribing health provider) should be aware of a patient's prior or current substance abuse problems, as well as their family history with regard to addiction. This will help determine risk and need for monitoring.

What are opiates?

Opiates are found in Poppy flower seeds, which contain Morphine and Codeine. There are also the synthetic derivatives of opiates (i.e., Hydrocodone, Oxycodone, and Heroin). Some synthetic opiates are used by doctors to treat pain. Opiates are used for pain treatment, anxiety and the euphoric state they are known to induce. Opiate addicts often end up sacrificing their entire lives: relationships, careers, and hobbies for their addiction. There is a high risk for developing diseases when using needles to inject drugs. The diseases that may develop are known to cause physical and psychological harm. Nerve receptors can adapt to resist opiates, which can cause the need for higher and higher doses. There is also a physical withdrawal when the drug leaves the body because the receptors have to re-adapt without the drug. Physical dependence is not the same thing as addiction. Patients can take a drug for pain and become physically dependent on it without becoming addicted. Treatment for addicts can be difficult. Many addicts go unnoticed to even their friends and family because of their ability to minimize or conceal it. The addiction is a disease that takes time, money, and effort. It cannot always be cured, and those who recover are always at risk for relapse.

What is the prevalence of opioid addiction?

Opioid dependence is more common than you may think. There are over one million opiate addicts in the United States today. Opioid dependence is not predictable -- it is a reaction that occurs in people who, for reasons that are not completely understood, are biologically and psychosocially vulnerable. Men and women of all ages, races, ethnic groups, and educational levels can become dependent on opioids.

According to the 2003 National Survey on Drug Use and Health:

4.7 million people ages 12 and older misused pain relievers in 2003 alone.

In 2001, almost 2.5 million people used pain relievers nonmedically (i.e., for recreational purposes) for the first time. This is a 335% increase from 1990, when only 573,000 reported using pain relievers nonmedically. (For more information, please see the NSDUH chart regarding the number of new users of pain relievers for nonmedical purposes among people ages 12 and older)

How does one detox from opiates?

Treatment for opiate addiction usually begins with detoxification, which is when a patient withdrawals from the drug under medical supervision. The withdrawal process can be very difficult and includes symptoms such as abdominal pain, agitation, nausea, diarrhea, sweating, insomnia, and vomiting. The magnitude and length of the withdrawal period is often related to the dose that the person has been taking. Heroin effects last 4–6 hours, while withdrawals from heroin can last for a up to one week. Medically administered Suboxone can greatly reduce or even eliminate withdrawl symptoms. Usually patients are able to return to work with 24-48 hours of induction.

What sort of treatment is utilized for opiate addiction?

There is no single path to an addiction-free life. It is extremely common for addiction to be comorbid with another mental health issue such as depression, anxiety, or ADHD. Therefore, a treatment plan must account for not only the addiction disorder, but also the underlying cause of one's tendency to abuse substances. The first goal of addiction treatment is to help the patient become independent of the substance. The primary medically-assisted method used at RecoverMD is Buprenorphine tapper. Buprenorphine is a synthetic opioid that is chemically similar to Morphine, Codeine, and Heroin; however it produces radically less euphoric ("high") effects. Buprenorphine is sold under the prescription brand name Suboxone. Taking Suboxone has been shown to dramatically reduce withdrawal symptoms. It is different from other opioids in that patients taking Suboxone usually feel more "clear headed" when taking it.

What is Suboxone/Buprenorphine and why is it important for the treatment of opiate addiction?

NIDA supported basic and clinical research led to the development of buprenorphine, a medication for the treatment of heroin addiction. These scientific discoveries spurred a collaboration with industry, which culminated in FDA approval of Subutex® (buprenorphine) and Suboxone® tablets (buprenorphine/ naloxone) in October 2002. Buprenorphine is a long-acting partial mu opiate agonist that acts on the receptor targets of heroin and morphine, but does not produce the same intense "high" or dangerous side effects. These properties also make it a good potential treatment for addiction to opiate analgesics. Buprenorphine's unique formulation with naloxone, an opioid antagonist (Suboxone), limits diversion by causing severe withdrawal symptoms in those who inject it to get "high", but no adverse effects when taken orally. Buprenorphine is taken under the tongue as a tablet. It occupies opiate nerve receptors and produces a mild opiate-like effect. Buprenorphine can cause withdrawal symptoms if a person is physically dependent on opiates. Doctors are allowed to prescribe Buprenorphine in their offices for patients to take home, which is helpful for addicts who prefer not to go to a Methadone clinic.

Is the use of medications like buprenorphine simply replacing one drug addiction with another?

No - as used in maintenance treatment, buprenorphine and methadone are not heroin/opioid substitutes. They are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed. They are administered orally or sublingually (i.e., under the tongue) in specified doses, and their pharmacological effects differ from those of heroin and other abused opioids. Heroin, for example, is often injected, snorted, or smoked, causing an almost immediate "rush," or brief period of euphoria, that wears off quickly and ends in a "crash." The individual then experiences an intense craving to use again so as to stop the crash and reinstate the euphoria. The cycle of euphoria, crash, and craving - sometimes repeated several times a day - is a hallmark of addiction and results in severe behavioral disruption. These characteristics result from heroin's rapid onset and short duration of action in the brain.

What is relapse prevention treatment?

Relapse prevention teaches patients to recognize signs of relapsing. Recovery is abstinence from the drug (while being able to function socially and psychologically). There are usually warning signs before a relapse. One of the most important of these warning signs may include emotional distress, which causes recovering addicts to turn to drugs for relief.

Where can I find additional resources about opiate addiction?

American Society of Addiction Medicine 301-656-3920 www.asam.org
Buprenorphine Information Center 866-287-2728 (toll free) www.buprenorphine.samhsa.gov
Narcotics Anonymous World Services 818-773-9999 www.na.org
National Institute on Drug Abuse 301-443-1124 www.drugabuse.gov
Smart Recovery 866-951-5357 (toll free) www.smartrecovery.org
Substance Abuse and Mental Health Services Administration (SAMHSA) 800-662-4357 (toll free) http://findtreatment.samhsa.gov/

Sessions with Dr. Edward Ratush

Dr. Ratush is invested in the patients he serves and strategically and collaboratively constructs treatment for each patient based the the specific needs and circumstance. Dr. Ratush believes that successful psychological and addiction recovery is best achieved when his patients make a lifestyle adjustment. For many this means adjusting diet, level of exercise, insight oriented activities such as therapy and a spiritual practice, as well as incorporating helpful medication both herbal and pharmaceutical into their daily lives. As you can imagine this is no small task and thus only those willing to take on such a comprehensive life change will benefit from it. This does not mean that Dr. Ratush will dismiss patients that are not 100% committed to working on all these fronts. Rather it is intended to clearly explain that those that benefit significantly from psychiatric and or addiction treatment put a lot of energy in making their recovery a reality.

Integral to the philosophy of RecoverMD is the concept of collaboration. Dr. Ratush cannot prescribe treatment to any patient without their involvement in the decision process. Such collaboration both empowers those in treatment as well as dramatically increases adherence to a treatment protocol. What this ultimately translates into is better treatment and better outcome. This is why direct honesty is the most effective way to get the help you need. Dr. Ratush chose this field because he believes in helping those who want to help themselves. Only when such a commitment is made real work can be done.

Collaboration is also integral between Dr. Ratush and any other treatment providers. While many services patients need can be obtained directly from Dr. Ratush it is common that Dr. Ratush will refer his patients for treatment with like minded colleagues or providers of your own choosing. In any of these scenarios it is vital to have all those involved in your treatment coordinated in a common direction with a unified goal.

For more information about Dr. Ratush, M.D. please email or call for a consultation.

Addiction Recovery for Co-occurring Disorders

Weekend Recovery for Co-occurring Disorders is more than a sole focus on the addiction, the co-occurring treatment model addresses the underlying factors which contribute to a persons substance use. As a trained specialist in the treatment of Addiction and Psychiatric disorders Dr. Ratush facilitates each patient’s recovery by customizing the interventions specific to each patient. Dr. Ratush is more then a prescriber of medications and therapist. He is every patient’s consiglieri, the central private and confidential consultant for Recovery. As such, he collaboratively with his patients devises treatment plans which utilize the interventions of complimentary modalities and other skilled practitioners ensuring synergy amongst proven evidence based approaches.

Addiction has many dimensions and disrupts many aspects of a person's life. Drug abuse and addiction lead to long-term changes in the brain's chemistry and anatomy. The changes in the brain cause those suffering to not only to lose the ability to control their drug use, but their addiction also affects all aspects of their lives. Addiction leads to isolation from family and friends and serious issues at work or school. In addition, the compulsive need for drugs can lead to significant financial and legal problems. The stigma of drug addiction needs to be lifted so individuals may receive proper medical treatment, similar to that for other chronic diseases.

Recovery with Buprenorphine

RecoverMD offers a comprehensively integrative approach to the treatment of opioid addiction, combining medical, psychological, as well as bio-psycho-social interventions. The cornerstone of treatment is outpatient detox and stabilization using Buprenorphine, a medication approved for the treatment of opioid dependence and motivational and cognitive behavioral psychotherapy. Once stabilized treatment focusses on relapse prevention and re-engagement with a healthy lifestyle.

Buprenorphine is sold as a brand name prescription medication name Suboxone. Taking Suboxone has been shown to dramatically reduce withdrawal symptoms. The medication is different from other opioids so the patient usually feels more "clear headed" when taking it.

The induction phase is the medically monitored startup of Buprenorphine therapy (Suboxone). Buprenorphine for induction therapy is administered when an opioid-addicted individual has abstained from using opioids for 12-24 hours and is in the early stages of opioid withdrawal.

The stabilization phase has begun when a patient has discontinued the use of his or her drug of abuse, no longer has cravings, and is experiencing few or no side effects. The Buprenorphine dose may need to be adjusted during the stabilization phase.

The maintenance phase is reached when the patient is doing well on a steady dose of Buprenorphine. The length of time of the maintenance phase is individualized for each patient and may be indefinite.

Currently the standard treatment plan at RecoverMD calls for a 16 week maintenance phase during which a patient will participate in a number of 'Choose your path' treatment activities. The length of the medically assisted treatment can be adjusted by the physician to fit the patient's treatment style.

Advantages of RecoverMD

Availability and Convenience - RecoverMD is located in the heart of downtown Manhattan. And unlike outpatient treatment centers and other clinicians Dr. Ratush is available both Saturday and Sunday. The reason for this is to give those people who are “functional addicts” and work during the week a real opportunity for treatment and recovery. Now for the first time work is no excuse!!!

Comprehensively Integrative - RecoverMD is committed to leaving no stone unturned when it comes to evaluating and treating addiction. RecoverMD combines group and individual therapy and peer support groups with medication management. RecoverMD also uses modalities considered alternative to the medical model such as acupuncture, hypnosis, biofeedback, and heart rate variability. Using these modalities in combination allows for a more robust clinical response. RecoverMD understands that many people addicted to opioids have a pre-existing or will develop a pain disorder when getting off opioids. Therefore the assessment of patients medical health is a vital component to designing a personalized treatment protocol.

Knowledge and Experience - RecoverMD realizes that 70% of addicted persons have a co-occurring mood or anxiety disorder. This is referred to as Dual Diagnosis or Co-occurring disorders. Dr. Ratush refers to this as Double Trouble because the #1 reason for relapse amongst addicted persons is untreated mood and anxiety disorder. This is a sobering fact because most clinician and facilities that claim to treat opioid dependence do not evaluate or treat the likely underlying psychological illness. This approach does not give persons in treatment the fighting chance they need to break the cycle. Therefore RecoverMD is committed to offer a full psychiatric evaluation and treatment when appropriate to all patients who seek addiction treatment with Dr. Ratush.

Creativity and Dedication - RecoverMD is willing to go beyond the conventional approach to opioid treatment. RecoverMD recognizes that the more interventions addicts use the higher degree of success in their treatment. The benefits of suboxone alone can be more then doubled when combined with additional interventions Thats why in addition to integrating complimentary treatments with the current standard, RecoverMD also rewards those patients that demonstrate their dedication to their own sobriety by offering financial incentives to utilize more treatment. The goal is to recognize the benefits of therapy and other treatment modalities and ultimately taper off the suboxone medication.