News & Politics

A Q&A with Dr. George Kolodner, an Expert on Substance Abuse and Addiction

The medical director of local outpatient treatment center Kolmac talks denial, celebrity deaths, and the signs of addiction.

Dr. George Kolodner. Photograph by M.H. Cohen.

Though the exact cause of Whitney Houston’s death may not be known for several weeks, there has been speculation about the cause being an overdose of prescription drugs. In a number of interviews, the Grammy-winning singer was candid about past abuse of alcohol, marijuana, and cocaine, and her stints in rehab. Some reports say prescription bottles of opioids were found in the Beverly Hills hotel suite where she died.

While celebrities get the attention for their drug and alcohol addictions, most rehab centers are filled with people who don’t get chased down the street by TMZ, who lead lives that aren’t routinely chronicled in tabloids. They have jobs and families, or are teenagers, and can’t afford the time or money to check into a rehab facility for three weeks of inpatient treatment. For these patients, there are places like the Kolmac Clinic, which serves as one of the Washington area’s leading outpatient rehab centers. It was founded in 1973 by Dr. George Kolodner and Jim McMahon with a concentrated focus on outpatient programs. Kolmac has treatment centers in downtown Washington, as well as in Towson, Gaithersburg, Silver Spring, Columbia, and Baltimore. Kolodner, Kolmac’s medical director, is a medical psychiatrist who specializes in addictions. He is a clinical professor of psychiatry at Georgetown University, where he oversees the teaching on addictions.

How many people do you treat in the DC metro area?

In Washington, we have about 600 patients, with another 270 in the Towson area and another 30 in Baltimore. We admit more than 2,200 patients a year.

And they are all outpatient?

It’s all outpatient, but at three different levels. One is outpatient detoxification, where people stay all day but not overnight. One is outpatient rehab, where they come for three hours a day, five days a week. Then there’s follow-up care, which is one time a week for two hours.

What types of addictions do you principally see in the Washington area?

Alcohol has always been the predominant one, though it’s become less exclusive. We generally get about 45 percent alcohol. Cocaine has gone down to our lowest number, about 20 percent from a high of 45 percent. What’s clearly gone up are prescription opioids [hydrocodone, oxycontin, methadone, oxycodone, heroin].

So you are seeing more prescription pill abuse?

Absolutely, especially among 18- to 25-year-olds. What we’re seeing is what you see nationally. There’s nothing different about Washington in that respect.

How much workplace substance abuse do you see?

Not all of our patients are working, but most are. Our primary treatment population is working addicts. Seventy-five percent of addicts are working at jobs. Whether they take drugs on the worksite is a slippery slope. There are some jobs where drug dealing is going on at the workplace. A lot of people will use before or after work, or they will drink during lunch or down in the garage. When it progresses to a certain point, they can’t go eight hours without it.

How many people come to you voluntarily?

We don’t keep numbers. But there’s a whole spectrum of formal versus informal. The people who come in truly voluntarily are miniscule. There are different degrees of pressure. There are cases where the spouse says, “I’m going to leave you if you don’t get treatment,” or there’s a spouse who is unhappy, or an employer who gives a formal warning. For example, we don’t get court referrals—there’s a whole world that does that—but the patient’s lawyer says, “Before you go before that judge, it would look good if you started treatment.” I assume there is some kind of external pressure.

Do you see a lot of denial?

We’ve moved away from using that term. Our approach is motivational interviewing. So we use the word ambivalence. It means they really want to stop using, but at the same time they really want to keep using. That kind of dynamic conflict is what we work with all the time. Even with people who look like they are in full recovery, there is some piece of them that is thinking about going back to using.

What is the main struggle with addiction?

When you use drugs addictively, you change the nervous system biologically in a way that favors the perpetuation of drug use. There’s certainly the physical withdrawal, but even after you get past the withdrawal, there are subtle changes in the brain. We have an expression, “Neurons that fire together wire together.” If you keep using drugs in a way that sets off impulses in your nervous system, your brain rewires. There are new physical connections. Instead of the playing field being level, it’s tilted.

Is it possible to use alcohol and drugs and have it under control?

Yes, and a lot of people do. There are folks who are genetically disadvantaged ahead of time, in ways we’re just beginning to document. It also depends on what your job is and where you live.

What’s the sign you don’t have it under control?

Ah-ha! That’s the question. It depends on your circumstance. There are circumstances where there’s much less opportunity. If you are a law enforcement officer or a school bus driver, you have to stay away from what’s illegal, meaning you have more space to get in trouble with alcohol than cocaine. Smoking a little weed is not a big issue for some people, but if you are going to lose your job, that’s a different circumstance.

What’s the tipping point?

There’s a process called decreased internal control. What it means is this: When most people decide to use a substance, the desire to use diminishes as they use. But with classic alcoholics, who have completely lost control, as they use, the desire intensifies and even explodes. We don’t know what that process is, but we hear about it so often.

For people who can’t stop, it’s like losing the brakes, though you might not have had a crash yet.

When a celebrity death is related to substance abuse, does your business increase?

Unfortunately, it happens so often it would be hard to track that. I can tell you something that is horrifying to me. We treat a lot of young adults, and a lot of them are involved in using opioids. They tell us their drug use really took off after a close friend overdosed. You think they would say, “That’s not going to happen to me.” But they tell me another story, the upside-down story. I can’t understand what’s going on there.

When you hear about a celebrity death from substance abuse, what is your reaction?

It can happen to anybody. If you start using, it is going to be more likely, because if you become addicted, you can’t control it like the rest of us can. It doesn’t matter your job or your income. If you are trying to recover and you are in the public eye, you have a real disadvantage. There’s a tendency to regard those people as addiction experts rather than addiction novices. Also, if you are successful, you are much more likely to get physicians to prescribe more liberally to you.

Are you surprised by the prescriptions patients can get?

I am horrified. My staff who are in recovery tell me they go to a doctor with a pain problem and say, “I am a drug addict in recovery,” and the doctors still insist that they take high-level addictive opioids. I have been involved in the battle to have more FDA control over prescription drugs. Some worry that doctors will become afraid to prescribe pain pills, and that there will be people in pain who can’t get what they need. The other side of the argument, from the addiction doctors, is that in order to prescribe these medications, a doctor should have to be able to prove some level of competence.

Is there a particular practice of medicine that is most egregious in prescribing narcotic pain meds?

It’s doctor by doctor. There’s certainly a range—dentists, orthopedic surgeons. I’m impressed by the potency of what they prescribe.

How quickly can a person become addicted?

With opioids, it is really quick.

At what point should a person come to a place like Kolmac?

When their attempts to stop or moderate a substance use have failed repeatedly. That’s when they ought to consider help from the outside. Most people either stop on their own, or they go to AA. For many people, that’s all it takes. Some people won’t go there, or it’s not enough.

What does it cost to come to Kolmac?

The retail price would be $5,000 for rehab. We work hard with insurance companies so nobody has to pay that price. The insurance companies pay half to most of that.

You believe it’s possible for a person to do rehab only during the day and go home at night?

That’s been my whole career. I started out in 1973 to show that residential programs are wonderful but not everyone can access them, and I’ve spent 38 years demonstrating that. We send people to inpatient who we think can’t make it on an outpatient basis. Outpatient has to be intensive.

Do you use any drugs in the detox process?

Absolutely. We use the same medications they use on inpatients, but we use higher doses. Our people have to be kept asymptomatic to come back the next day. I’ve got to make sure they are comfortable. We are on call 24 hours.

What is your success rate?

We have a crude measure: successful completion of our treatment program. The true measure is how you’re doing five years down the road.