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Addiction, Genetics and the Human Genome Project

“We cannot hope to fully understand the human brain and mind because the tool that we must use is the very thing that we want to understand.” – Doug Cwienk

I apologize for being MIA for so long.  I said that I would write again when I had something meaningful to say but the truth is, I have had something to say, just not the will to sit down and write it.  As you know, we lost our youngest son two and a half years ago to opiates.  Grief is an odd thing, just when I thought that I was handling things, it smacked me upside the head and stole much of my drive.  I am trying to take that control back now and get back in the habit of writing.

We know that genetics has a very strong impact on addiction, so understanding genetics can help us understand the impacts of addiction.  For that reason, I have been trying to understand genetics in a broad sense, so this post is somewhat scientific but not beyond the reach of anyone.  This then begs the question, “if we understand genetics so well, why can’t we fix the impact of genetics on addiction?”.  Actually, we have learned a lot about genetics but the more we learn, the less we understand.

I also want to point out that while I believe that genetics plays a large role in addiction, I do not believe that it is the only factor.  The likelihood of developing a substance use or behavioral disorder is also influenced by environmental factors, such as how and where we were raised, how we were treated and particularly trauma.  While genetics can help us understand a great deal about addiction, I do not believe that any one thing can solve the very complex riddle of addiction.

The Science Nerd Cannot Remain Hidden

I read an article about a professor of Neuroscience at Bucknell University that has also been in recovery for many years.  I reached out to her, hoping to get some good feedback about my blog but most of what she had to say was “read my book”.  I was disappointed, but I took her advice and it turned out to be very good advice.

Back in the spring, I finished the book titled “Never Enough” by Judith Grisel and I highly recommend it to anyone who would like to understand the impact of drugs on your brain.  Her book discusses the neuroscience of addiction with the added benefit of the perspective of someone who has experienced addiction.  I found the book and Dr. Grisel’s insights fascinating and enlightening.  I did not; however, write this post to gush about this book and its author.  Instead, I want to talk about some new insights that I have gained by reading this book and digging a little more into genetics.

The book supports the information that I have presented in this blog and it adds to that a more detailed discussion of the mechanisms by which many drugs impact your brain.  The author provides a good deal of information about marijuana (a topic that I have avoided because of controversy), a drug with which she had a very special relationship.  Near the end of the book, Dr. Grisel addresses the genetic component of addiction and our attempts to solve the addiction problem.  In this discussion, she addresses the human genome project, its promise, and why it failed to solve the problems we hoped it would.  This really struck me and got me thinking more about genetics, epigenetics, and how complex this really is.

Human Genome Project

Just to refresh your memory, the Human Genome Project (HGP) was a large-scale scientific undertaking that included many university researchers and laboratories from several countries.  The purpose of this project was to map the entire human genome, that is to take our genes apart and understand what each segment was controlling.  Before this project, we kind of looked at our genes from the whole city scale but this project would look at our genes on the individual address scale.  For example, instead of just knowing that there are segments of our genes that code for hair color and which colors were dominant, the HGP would tell us the addresses of those segments.  Armed with this information, we would then be able to identify genetically controlled conditions or diseases and “fix them” by editing the bad segments out.

The Human Genome Project was a huge success but rather than solve a world of genetically associated ailments, it showed us just how little we really know.  The project quickly achieved its goal of mapping our genes, but it turns out that the map revealed less of what we expected and more complexity in areas that we had not considered.

Just Enough About Genetics for Our Discussion

Our genes are in part, made up of strands of DNA that provide the instruction book for what each of us will be like.  Notice that I said “instruction book”.  Our genes do not define us because that instruction book is interpreted based on our experiences and environment.  The strands of DNA are made up of base pairs and there are three-part segments of these pairs that code for specific proteins.  They are called triplets.  There are also long sections of our DNA that we thought were inert, they didn’t code for anything.  This is likely to be comparable to your office, some people do the work and some just take up space.  Based upon the variability in humans, we were able to estimate the number of coding triplets that should be present in the DNA within our genes.  Identifying the location and purpose of each triplet is where we saw the tremendous promise of the HGP.  We would map all of these coding triplets and then set to work understanding each triplet and what it controlled. 

As we contemplated this undertaking the theory of epigenetics that had been developed in the 1940s came back to the forefront.  As we have discussed before, epigenetics tells us that our genes are not a rigid definition of who we will be.  We know that environmental factors (physical or psychological) can turn-on/turn-off some genes or cause them to make a different protein.  We also know that some of these changes can be passed on to our offspring in that altered state.  Epigenetics would complicate our understanding of the results of the HGP but this was not too great of a hurdle.

It’s Just Not That Simple

The first thing that we discovered from the HGP is that there were far fewer base pairs that form coding triplets than we thought.  In fact, we have many times fewer base pairs than a potato.  That was quite a slap in the face, surely, we are much more variable and complex than a potato.

We have discovered that some segments of our DNA that we thought were inert actual do code for a protein but not in the way that we understood.  Some areas in our DNA are simply repeating sequences and they do not repeat the same number of times in every person.  I do not think that we have discovered the actual mechanism, but we have learned that the number of times that the sequence repeats can cause differences in people.

An example of something we expected to learn from the HGP is sickle cell anemia.  We have identified the exact location within our genes that codes for sickle cell anemia and this could lead to genetically based treatment.  On the other hand, we found that multiple sclerosis is much more likely in individuals that have longer repeating sections in specific places in our genes.  We thought that these repeating sequences did nothing, like your coworkers, but put enough of them together and something bad happens.

Obviously, we overestimated the number of base pairs that form coding triplets because we though that they accounted for all of the variability.  In reality, there are things in our genetic code that we thought did nothing that actually code for proteins in ways that we did not predict.

In a way, I guess that we were arrogant.  The universe will not give up its secrets so easily.  Combine the complexities of genetics and epigenetics with the even greater, hidden complexities of the human mind and it is no wonder that addiction has proved to be such a powerful adversary.  BUT with support and understanding and very hard work we win sometimes.  As a friend of mine always reminds me, “People succeed in recovery every day.”

Stirring the Pot – Safe Injection Sites

“When you get into a tight place and everything goes against you, till it seems you could not hang on a minute longer, never give up then, for that is just the place and time that the tide will turn.”

— Harriet Beecher Stowe

Today, I want to pose a question about a controversial topic, “Should we have safe injection sites?”.  I have always been on the fence about this question, leaning toward “no, they are not a good idea”.  For those of you that are unfamiliar, the typical safe injection site is a place manned by medically trained personnel who give out new syringes and observe while a person injects themselves with the illicit drugs that they brought, typically opiates.  The trained personnel try to make sure that the individual does not die from an overdose and they may offer advice, help, social services, and other resources to try to get the individual with a substance use disorder (SUD) into treatment.

This issue has come to the forefront recently as the City of Philadelphia is trying to permit such a facility.  A non-profit called Safehouse has requested permission to operate a safe injection site in Philadelphia’s notorious Kensington section.  The City is in favor of the proposal, but the federal government has sued to prevent it. 

Raising the Issue

I recently attended a seminar about addiction and treatment, and someone asked the speaker his opinion regarding safe injection sites.  The speaker stated that he is in favor of such facilities because they save lives and you can’t get someone into rehab if they are dead.  That is a pretty straightforward argument that you would be hard pressed to refute.  I try to be a reasonable, open-minded person so when someone that I believe has more experience then I takes a position, I give it very serious consideration.  We all have our biases but I try to get past that and truly consider what has been said.

Our son was saved with Narcan and we got six months to see the kind of amazing man that he was when his life was not controlled by addiction.  I firmly agree that saving lives has to be one of our primary goals because as the speaker said, you can’t get into recovery if you are dead.  So therefore, I must agree that safe injection sites are a good idea.  Well, maybe it is not that simple.

My Thoughts

As I considered changing my mind, I tried to take inventory of why I initially thought that safe injection sites were not a good idea.  Then it hit me;

Suppose I said that I was going to provide my son with new needles and I would monitor him as he used, as long as stayed home so that I could give him Narcan if necessary.  I would be considered the worst kind of enabler.  I would be severely criticized and rightfully so.  Why then is it different if a non-profit or government agency does the exact same thing?

To my way of looking at it, it is not different.  It is enabling, facilitating this person’s addiction.  This is my answer, but it is kind of a cop-out.  I don’t address if the ultimate impact is better or worse, just that it flies in the face of conventional wisdom.

The Facts

Let’s be honest, everyone thinks that they have facts and common-sense on their side but they are mostly just opinions and suppositions.  Here are some of the “facts” and how I view them:

  • Providing clean needles reduces the incidence of infection, hepatitis, HIV, etc.  The data seems to show that this actually is a fact, but it cannot be viewed in a vacuum.  Are we trading this advantage for longer-lasting addiction and all that comes with it?   There is no valid way to measure that because we cannot know how the individual would respond or if there may be other outside influences.
  • Safe injection sites save lives.  This is a fact in the short-term because anyone who is saved with Narcan and otherwise would have died, is a life saved.  But we cannot know if the safe injection site makes it easier to continue to use, in which case we did not save a life, we just prolong it a little.  But isn’t it worth prolonging a life?  It certainly was in our case.
  • Safe injection sites promote drug use.  It seems like this should be true but this is one of those common-sense statements that is not a fact.  We have no way of knowing if the overall effect of safe injection sites is to promote drug use or to get more people into recovery by keeping them alive until find recovery.
  • Safe injection sites will destroy the neighborhood, attract drug dealers, and make a centralized location for dealers to find buyers.  This certainly seems like it would be the case, but it is not a fact.  We cannot know if this will happen and is it really that different from the way Kensington is now?
  • Our laws do not allow you to have a property where you allow illegal drug use (crack-house laws).  This is true but it is a law, not a fact.  Just like any other law, if it does not work, change it.  That is the job of Congress and we pay them quite handsomely for that job.
  • We should not spend time and money to keep people alive that don’t care about themselves.  Did your head explode?  Mine almost did just writing that sentence.  This is the worst kind of ignorance parading as common-sense.  People with a SUD do not choose that life.  They made a mistake early on and their brain has been overwhelmed.  Regardless of how far their life has sunk, they deserve our compassion.

So, it Looks Like I am Back Where I Started. 

I do not think that I can in good conscience support a safe injection site because it is enabling addiction on a large scale.  On the other hand, I do not think that I could oppose one either because there is a reasonable chance that it will save lives.  I would give anything to have my son back.  How can I deny something that might save someone else’s son or daughter?

FACT:  Safe injection sites are not the answer to our addiction crisis. They may be a reasonable stopgap measure, but they are not a solution.

Do you have thoughts, opinions, or experiences to share? Please comment, let’s work together and help each other to understand this problem.

Help, I Need Somebody

“Hiding in my room, safe within my womb

I touch no one and no one touches me

I am a rock

I am an island

And a rock feels no pain

And an island never cries.”  – Paul Simon

Today’s post is about what we can do to help ourselves and others.  As you may have guessed, I am running short on new things to say, so my posts are getting less frequent.  There is still much to address about addiction and I am always learning, so I will continue to create posts when I have something meaningful to add.

Reaching out

If you are one of the fortunate people that is not directly impacted by addiction, what can you do to help?  The best thing that you can do is understand what addiction is and how it affects the brain, either through my blog or other resources.  Armed with that knowledge, I would like you to find a better solution to this epidemic than the solutions that we have now.  Many people that are far smarter than me are doing this already and we haven’t found the magic bullet, yet.  So, the chances that you will be the one to find it are slim, but you may just be that person.  One thing I know is that this problem will not be solved by someone who doesn’t understand it. 

Let’s say that you are not the person that is going to uncover the answer to addiction’s hold on society.  There are other things that you can do that while not as profound, may be more rewarding and meaningful to you and to those around you.  Once you understand addiction, you can help by:

  • Not avoiding people that you know are struggling with family issues as a result of addiction.  You may not have time to talk or feel up to it, but a pleasant “hello” can mean a lot to someone feeling alone in a monumental struggle.  We do notice when you duck down a store isle to avoid us.  You don’t owe it to us to take time out of your busy day, but simply acknowledging us goes a long way.
  • Talking to us if you have the time.  The isolation that frequently accompanies this disease is awful.  Everyone is afraid to bring it up.  You don’t have to talk about the problem, just talk about anything and listen.  Trust me, you will not say anything that will make things worse.
  • Being aware of what you say in public.  I am not one of those people that believe you need to be politically correct nor am I overly sensitive about my situation.  It would be helpful if you keep in mind what you understand about addiction and speak accordingly.  There are many people that somehow think that they intuitively know all that they need to know about addiction, and they are looking for comrades.  Please don’t feed their ignorance by saying things that support the thought that “they must be from a bad family” or “they do it to themselves”.  You know better.
  • Getting involved in your community to help people who are struggling whether it be from addiction or some other problem.  If you can find the time and we all probably can find some time, help those less fortunate.  It very likely will help you more than it will help them.
  • Helping to educate people.  If you are one of those people that is good at conveying information or are naturally persuasive, talk to people about addiction.  Spread the knowledge.  Diminish the ignorance.

Caught in the Web

What if you are one of the many unfortunate people that are being directly impacted by addiction?  Well, if you enjoyed the Lord of the Rings movies, you probably remember when Frodo got tangled in the web of the giant spider.  Sometimes, that is what our life feels like.  When you have a loved one struggling with addiction that is what your life feels like most of the time.  Every move you make to free yourself from the web only seems to entangle you more.  So, you hide, you isolate, you suffer in silence.  That is probably the worst thing that you can do.

I have said this before, but it bears repeating, “Take care of yourself first.”  Find support groups.  Try them out and see which ones help you.  Some offer strength through religion.  Some offer a twelve-step program to guide your way.  Some offer a place to be heard and to meet others in a similar position.  Some are what I call “misery loves company”, where you can have a chance to feel sorry for yourself (rightfully so) and be around others that feel the same way and understand. Sometimes an exercise group is what you need. 

As I said above, helping others frequently helps you more than it helps them.  That is one of the major concepts in AA.  So, perhaps you should consider doing volunteer work, if you can find the time and energy.  Volunteering makes you feel good about yourself and it gives you something to focus on, other than your struggles.

Another way to help yourself is to share your experiences.  Part of the reason that the stigmas around addiction so stubbornly persist is that people only see the worst.   When people are not knowledgeable about something, they tend to take the limited observations they have and draw grand conclusions.  That is human nature, to simplify what we don’t know to make it easy to package away in our mind.  Help people see that what they observe is not the whole story.  Unsimplify their understanding!

Lead by Example – Tooting My Own Horn

This blog has been one way for me to give back and help move us closer to an answer to this addiction crisis.  But many times in this blog, I have suggested what you should do to help.  Just to let you know that I don’t just talk, I also walk the walk, let me tell you about what is happening in Lancaster County, Pennsylvania.

A few friends, my wife and I are establishing a support group called Storm Riders specifically for people who are dealing with a loved one’s addiction.  A flyer for this group is on this page.  This group will meet every 1st and 3rd Wednesday of the month, starting May 1st.  This group will provide a safe place to be heard and find help without any other agenda (commercial, religious, political, etc.).  The group will have no hierarchy or leaders.  Just a place to where people can end their isolation and find a sympathetic ear.  We are very grateful that Memorial United Methodist Church has offered us a meeting place, support, and hospitality, wanting nothing more than to help our community heal.

I have also given some short talks, leading to discussion, to educate the general public about addiction.  Middle Octorara Presbyterian Church was kind enough to sponsor three talks in March and April.  Memorial United Methodist Church has stepped up to sponsor a similar set of talks and discussion in April and May.  The flyer for these talks is on this page.  Both churches have recognized the need to educate the community and help the healing process.  As I have said in this blog, I believe that we need to get this information out to everyone who will listen. 

Local churches in southern Lancaster County are demonstrating their compassion and service to the community in ways that I hope will continue and spread.

Do you have ideas or experiences to share? Please comment, let’s work together and help each other to understand this problem.

Adaptation and Tolerance

“If one oversteps the bounds of moderation, the greatest pleasures cease to please.”  – Epictetus

One of the first posts that I placed on this blog was titled “Part II – The Dopamine Response, Addiction Stole My Brain”.  In that post, I addressed my understanding of the reason that the dopamine system exists in our brain and how it is hijacked by addictive behaviors or substances.  In that discussion, I stated that the brain starts shutting down dopamine receptors in response to the flood of dopamine and that is the cause of drug tolerance.  This is true although it is not the only cause of drug tolerance and I want to address that now.

Drug Tolerance Due to Turning Off Receptors

I think that nearly everyone is familiar with drug tolerance that occurs when someone abuses drugs.  In short, the more often and the more heavily you misuse a substance, the less your brain responds to it and the more that you require.  This is the reason that someone with a substance use disorder (SUD) requires more and more of their drug of choice as their active addiction continues. 

In an earlier post, I stated that your brain responds to the massive flood of dopamine caused by drug use by progressively turning off dopamine receptors.  Since the “high” that comes from drug use is the result of a huge release of this feel good chemical, dopamine, hitting dopamine receptors in your brain, the brain attempts to protect itself by progressively shutting down receptors.  With fewer and fewer receptors, the individual needs more drugs to prompt the release of more dopamine.  However, this person will never reach that first “good” high that they got when all their receptors were active.  I presented this explanation because I believe that it is true but there are other things going on that also contribute to drug tolerance.

Drug Tolerance – Less Dopamine

I believe that the brain of someone with a SUD cannot stop the flood of dopamine caused by misuse and that is why the brain resorts to shutting down receptors.  It is apparent, however, that there is a decrease in the amount of dopamine released.  It was explained to me that this decrease in dopamine release is the result of fatigue.  In other words, the individual’s brain is unable to keep up with the demand for dopamine created by the drug.  This does not completely explain our observations because it does not explain how increasing the amount of drug used would increase the response of a fatigued system.  It would, however, explain the observed, lower baseline dopamine levels in individuals suffering from addiction.

Adaptation

Tolerance can also be viewed as adaptation.  Adaptation implies that there is something more that results from ongoing misuse than just a change in the dopamine system.  That is, as misuse continues, your brain adapts more and more to the effects of the substances that you are misusing.  Therefore, your brain fulfills less and less of the role that the drug is providing and you require more and more of that substance.

This is the primary problem with prescribing opiates to control chronic pain.  As the brain adapts to the dose of opiates, the body requires more opiates to alleviate the pain.  If a doctor responds to continued pain with increased dose (as they were taught in the 1990s and 2000s), the patient is put on the fast track to addiction.

Adaptation is also very apparent when a person with a SUD experiences withdrawal.  It is my understanding that withdrawal is horrendous, and that heroin withdrawal is almost unbearable.  Since the brain has adapted to having the drug of choice, it ceases to provide the effects that the drug was providing.  When the drug of choice is no longer used, the brain is not immediately equipped to replace the effects that the drug provided.  For example:

  • Opiates provide pain relief and sedative/relaxation effects.  When someone who has been abusing opiates goes into withdrawal, they experience tremendous pain throughout their entire body, they cannot sleep, they cannot relax, and they experience panic-attacks.
  • Crystal meth and other methamphetamines hype you up.  They may keep you up and active for a few days without sleep.  Withdrawal causes individuals that misused these substances to sleep for long periods during the first few weeks that they are experiencing withdrawal.
  • Benzodiazepines, such as Xanax, Klonopin, Ativan, and Valium, are prescribed for anxiety, depression and as antiseizure medicines.  Withdrawal may cause insomnia, anxiety, panic attacks, and seizures.
  • Cocaine is a stimulant that causes euphoria.  Withdrawal from cocaine use may cause anxiety, depression, and fatigue.

Summary

There appear to be three different factors associated with drug tolerance while misusing drugs.  These include:

  • Dopamine receptors are turned off by the brain in an effort to protect itself from the excessively high dopamine levels caused by the use of addictive substances.  It is believed that the brain cannot control the dopamine release, so shutting down receptors is the only option.
  • The brain’s dopamine system may experience fatigue, meaning that the brain can no longer produce enough dopamine to satisfy the demand placed on it by the drug misuse.  This response does not explain all the effects of tolerance but it does fit the observed reduction in dopamine levels in the brain of a person suffering from SUD.
  • Adaptation causes tolerance by the brain adapting to the presence of the drug.  This becomes apparent during withdrawal.

Do you have ideas or experiences to share? Please comment, let’s work together and help each other to understand this problem.

Who’s to Blame? Revisited

“The secret of change is to focus all of your energy not on fighting the old, but on building the new.” ― Socrates

I know that I am late with this post but I wanted to finish an excellent book that was recommended to me before writing this post.  The truth is when I find the time to sit down and read, I don’t last long before I fall asleep.  The book is called Dreamland by Sam Quinones and it was recommended to me by a friend.  If you will recall, the last book that I discussed in this blog (Counterpoint – 9/10/2018) did not exactly agree with my understanding of addiction.  I wanted to update my views on “who’s to blame?” because of some recent revelations about Purdue Pharma and this book discusses the origins of the current opiate crisis.

I don’t like scapegoating because things are rarely that simple.  I don’t like massive lawsuits because I think that the money rarely goes where it belongs, rather it disappears into the pockets of attorneys and pet political projects.  I do, however, believe that people/corporations need to be accountable for their actions and if they got rich by creating a crisis, they should be penalized by losing some/most/all of those fortunes.  Given the lawsuit underway against Purdue Pharma, I wanted to get a better understanding of their role in the opiate crisis.

What did I learn from Dreamland?

This book gives a fascinating account of the origins of our current opiate crisis based on two parallel tracks.  One is the change in the way that opiate pain relievers and pain in general were viewed.  The second track involved the influx of black tar heroin from Mexico and the way it was “marketed”. 

Pain and Opiates

I like simple stories, but life rarely works that way, and this is the case with opiates.  Historically, doctors were afraid to prescribe opiates out of a fear of addiction.  In 1980, a letter to the editor was published in the New England Journal of Medicine that became known by its author’s names as Porter and Jick.  The letter was literally a paragraph and it said the data from one hospital revealed that less than one percent of patients that received opiates in the hospital became addicted.  This was a small set of data and not of profound significance.  

In the 1980s, there arose a distinct change in the way that we viewed pain.  The World Health Organization (WHO) declared that all people had a right to be free from pain, primarily based on the suffering of terminal cancer patients.  The field of pain management arose and pain became the fifth vital sign.  In addition to pulse, blood pressure, temperature, and respiratory rate, patients were asked to rate their pain on a scale of 1 to 10. 

By the late 1980s, some researchers had begun to conclude that opiates were not addictive if they were controlling pain and they cited Porter and Jick as evidence that less than 1% of patients would become addicted.  The concept that opiates would function differently if you are in pain sounds ludicrous given what we now know about addiction but it was accepted as truth back then.  Few if any of those citing Porter and Jick realized that this was not an extensive study of opiates and pain but rather a summary of the data from one hospital.  Around the same time, insurance companies began to exert more control of doctor costs including mechanisms like HMOs.  Doctors were getting squeezed by the need to see more patients in less time and the very time-consuming demands of chronic pain patients.  The concept that opiates could be freely given to fight chronic pain was a Godsend to doctors but many remained skeptical.

The company now known as Purdue Pharma (Purdue), in its earlier iterations had developed a timed-release opiate called Oxycontin.  Purdue’s owner had already revolutionized pharmaceutical sales by sending sales representatives out to aggressively lobby the use of their products.  As competition increased, pharmaceutical companies began to sponsor seminars and other percs for doctors.  Purdue saw the opportunity to market Oxycontin to doctors as a safe and easy (quick) means of dealing with chronic pain patients.  Seizing the concepts mistakenly attributed to Porter and Jick and the claim that Oxycontin could not be abused because of the timed-release mechanism, Purdue began a very aggressive and lucrative marketing campaign.

Less than scrupulous entrepreneurs combined with less than ethical doctors created an explosion of pain clinics, some of whose sole purpose was to prescribe opiates to anyone that felt they needed them, pill mills.  There was nothing wrong with prescribing opiates where needed but pill mills did not bother to diagnose the need.  Pill mills made massive profits based on volume sales.  People on public assistance or disability could get very large prescriptions of opiate pain relievers for very low cost.  It was not uncommon for a person on public assistance that had become addicted to opiates to regularly obtain large prescriptions in order to use half and sell half to supplement their income.  Some people would organize transportation and pay the copay for many people in that situation and they would receive half of the prescription so that they could sell it for huge profits. 

In addition to illegally obtained prescription opiates, opiates were often found by curious adolescents in their parent’s medicine cabinets or prescribed for pain such as injuries or wisdom tooth removals.

The initiation of the explosion in the use of prescription opiates can be seen as a huge misunderstanding about the addictive nature of opiates driven to exorbitant proportions by the marketing of Purdue.  Unethical medical practices on the part of pill mills used this somewhat innocent misunderstanding and created an addiction crisis of proportions that were never seen before.  As this crisis grew, it must have been obvious to Purdue that they were selling far too many opiates but greed can blind us to what we do not want to see.  The owners of Purdue and their families became billionaires..with a B.

That Purdue is in part responsible for the opiate crisis is in little doubt but to what degree is Purdue responsible is open to interpretation.  My interpretation is that they are not the Satan that they are portrayed but they do not deserve to have profited so handsomely from business practices that became unethical and caused misery and death on such a large scale.

Black Tar Heroin from Mexico

Traditionally, illegal drug importation and sales in the USA are controlled by foreign cartels and large gangs.  These groups flaunt their success and defend their territory with violence and murder. They are intentionally visible in order to scare off competition.  The heroin that these groups sold was grown and refined in Asia or Columbia and was generally a white or tan powder.  This heroin lost its potency every time it was cut/diluted as it passed through another middle man (stepped on). 

In a poor area of Mexico where the economy was largely based on growing sugar cane, the local residents discovered that they had optimal growing conditions for opium poppies.  Opium poppies are the raw material for producing opiates including heroin.  With minimal processing, they could make black tar heroin, a name that was an accurate description.  Being less refined, it wasn’t as potent as the Asian or Columbian heroin, but the Mexicans brought the black tar heroin to the USA and sold it directly.  So, without middlemen the heroin was not stepped on and the product on the street was more potent than the white powdered heroin. 

These black tar heroin producers kept a low profile, sold in less populated areas not controlled by cartels or gangs, targeted wealthier suburban buyers, and never carried much product or money on them.  They even delivered the heroin like pizza to buyers who did not have to go to dangerous neighborhoods and the dealers were not conspicuously waiting on a street corner for a buyer to come to them.

Being inconspicuous, they were less of a target for law enforcement and if a delivery man did get arrested, it did not matter because there was a large pool of poor farm boys wanting to come up north to make money.  These black tar heroin producers worked in small individual cells much as terrorists do, making it nearly impossible to eradicate them.  Instead, the cells expanded across the country virtually everywhere except large cities.  No one paid much attention to them or their black tar heroin until deaths by overdose began to climb dramatically in areas that had not previously had a major heroin problem.

Pill Mills and Black Tar Heroin Collide

I said earlier that Purdue claimed that Oxycontin was difficult to abuse because it was timed-release.  But everyone, especially the dealers and the addicts, knew that all you had to do was crush the pills and snort them to defeat the timed-release mechanism.  Being designed for a slow release, Oxycontin pills had high content of opiates in order to provide lasting relief.  As doctors became more comfortable with opiates, they were willing to prescribe more potent pills.  Eventually, it became obvious that prescription opiates were causing widespread problems with addiction and overdose.

Oxycontin and other opiate pain relievers such as Percocet generally cost about $1 per milligram of opiate on the street, so a 40 milligram pill costs about $40.  Heroin on the other hand costs about $10 per hit.  People addicted to opiates soon found that prescription opiates were harder to get in addition to being more costly.

Enter black tar heroin.  Whether by design or by chance, the producers/sellers of black tar heroin found themselves following the spread of pill mills.  As people addicted to prescription opiates were priced out of the market or their supply became unreliable, they rapidly turned to heroin.  As I have said in prior posts, the move from prescription opiates to heroin is typically an economic decision.

Heroin has always been available in big cities from dangerous gangs and cartels, so it was typically an urban problem of limited scale.  The producers/sellers of black tar heroin targeted wealthier suburban areas and made the transaction safe and easy.  For this reason, the opiate epidemic is roughly ten times greater than the crack epidemic of the late 1990s and 2000s and it includes all races and economic sectors.

Who is to Blame?

So how has everything that I learned from Dreamland and the current revelations about Purdue changed my view of who is to blame? 

  • I think that in my previous post I may have been too easy on big pharmaceutical companies.  Some companies got caught up in a misunderstanding about the dangers of opiates, but they were blinded by greed and ignored obvious signs.  They are not the entirety of the problem, but some had a significant role and profited handsomely.
  • Drug cartels are always going to be a problem, but the suppliers that caused this epidemic to grow to such large proportions were lots of relatively small-time producers with an incredible talent for giving their clients what they wanted.  Of course they are responsible in some way, but as I said before if there was no demand, there would be no supply.  They did exploit the situation and they expanded the market.
  • The Government?  Hell, they can’t even agree on how to tell what bathroom we should use.  I believe that we must continue to try to stop the influx of illegal drugs, but we cannot fully succeed.
  • As I said before, there are some bad physicians out there who overprescribe, run pill mills, but most doctors are conscientious and truly care about the well-being of their patients.  Doctors were under a lot of pressure and they were misled about the risks associated with prescription opiates.  But now that they know, a few doctors still over-prescribe.  Shame on them.
  • To my surprise, when I got to the end of Dreamland, the author said something very similar to my previous conclusion.  I said “Our expectations of the health care system are too high.  We want something outside of ourselves to “fix what ails us”, rather than putting forth the very heavy effort of working through it ourselves.”  Sam Quinones says something very similar, except he places the origin on the over-protectiveness of our society and our desire to never be uncomfortable.  I think that we are both right and that makes me feel like a cranky old guy, who walked 5 miles to school..in the snow..uphill both ways.

This post has been to some degree a short book report on Dreamland by Sam Quinones.  I highly recommend this book, it was incredibly insightful, and it was fascinating to read.  It is 362 pages long, so I clearly have left a lot of information out, but I tried to summarize the information that is relevant to this discussion.  I hope that Mr. Quinones will forgive me. I think that I will reach out for his feedback on how I did.

Mr. Quinones is probably too busy to answer me, but I hope that you are not.  Do you have thoughts to share? Please comment, let’s work together and help each other to solve this problem. r

Part Va – Nature and Nurture Revisited

 “Don’t be ashamed or proud of your genetics, for you have no contribution towards it.”  ― Mehnaz Ansari

It is often in the darkest skies that we see the brightest stars.”  ~ Richard Evans

I hope that I never stop learning and I hope that the same desire fills you. Way back in Part V of the Science of Addiction, I discussed nature versus nurture with regard to becoming an individual with a substance use disorder, the proper term for an addict.  I have learned more that slightly changes my discussion on the impacts of environment and heredity on the likelihood that an individual will become addicted.  Please join me in Part Va – Nature and Nurture Revisited.

Epigenetics

My education is in oceanography and geology and that is by design.  I studied oceanography because I wanted to be Jacque Cousteau, but that name was already taken.  I didn’t want to study living things, least of all people, because they have free will and are very confusing to me.  So, I focused on geological oceanography because rocks and sediments just do what physics says they must.  Therefore, genetics was not something that I had more than a cursory exposure to and that was fine with me.  But as I looked into the impact of genetics with regard to addiction. I encountered a concept that was new to me, epigenetics.  BEFORE YOU LEAVE THIS PAGE, BEAR WITH ME FOR A LITTLE, I WON’T GO INTO DETAIL.  Truth is, I am not sure that I understand the details.

My understanding is that epigenetics says the concept that genes are rigid, static things that determine what you will be like is not entirely true.  Genes cause proteins to be made that cells use to create an outcome, whether it be simple like eye color or more complex like an autoimmune disease.  We used to believe, based on Mendel’s research (Google it), that heredity was a static expression of certain genes.

I am sure you noticed (and were probably annoyed by) my use of the term static.  I used that term because the concept of epigenetics is not static, it says that the result of a certain gene is not predetermined.  This idea makes sense when we consider how diverse humans are, even within a given family.

Epigenetics says that certain genes may be “expressed” (turned on) or “silenced” (turned off) by environmental factors.  This makes perfect sense to me with regard to things like PTSD.  Some people develop PTSD from a trauma that appears to be much less than the trauma needed to cause PTSD in others, and still others don’t seem to develop PTSD at all.  If it was simply a static gene, either you would get PTSD from trauma or you would not.  Some people conclude that this means some people are just “stronger” than others but that doesn’t fit what we observe.  If the response is not a reflection of character but rather a gene that is turned on or not due to environmental conditions (trauma), that better explains what we observe.

Epigenetics says that it is even more complex than just “expressed or silenced”, that genes may interact.  It says that the protein made by one gene may change how another gene acts, either by turning that gene on or off or causing it to produce a different protein.  This is getting a little complex for me but what I get from it is that there is a lot more room for variability than allowed by the original concepts of genetics.  Also, epigenetics says that some changes may persist long after the thing that caused the change is gone.

Epigenetics and Addiction

Reading about epigenetics was a “holy crap” moment for me and I hope that I can do it justice for you.  Based on the model of epigenetics we can now understand some of the complexity of addiction.  My previous explanation said that your environment (your upbringing and possible trauma) could possibly put you on the pathway to addiction and heredity would determine at what point you will become addicted.  I had concluded that these two things both contributed to addiction, with heredity being somewhat more important. 

Now I see that heredity and environment interact, that each changes the other.  Instead of your experiences leading toward the path of addiction, I understand that your experiences my cause a gene that leads to addiction to be expressed or a gene that protects you from addiction to be silenced.  Some environmental risk factors, like trauma, abuse, neglect, etc., are well known but perhaps there are others that are less obvious, that may change whether a gene produces a certain protein, resulting in addiction.

We oftentimes talk about people who do not understand addiction and think that it is weak-will, a character flaw and we bemoan how wrong they are in that belief.  Part of their misconception comes from what they see. What we don’t see is the complex role that genetics, modified by environment, plays in addiction.  Addiction is far more complex than simple “common-sense”, and this is why people who have not experienced or been educated about addiction do not understand.  This is why we must educate people, so that we attack this crisis with knowledge rather than “common-sense” that is incorrect, due to a lack of information.

Epigenetics and Recovery

When I mentioned my newfound understanding of epigenetics to a psychiatrist friend, he challenged me to consider what that means for recovery.  Obviously, I do not suggest that we should move away from abstinence, support, and cognitive behavioral therapy (12-step programs).  In past posts, I did mention gene therapy and my concerns with editing genes to address addiction.  Instead, epigenetics says maybe we can find the gene or genes that are not in the correct state (on or off) and provide the correct chemical signal to change that state.  That is a long way off, but when we figure out how to isolate the genes and change their state, we could “turn off” the addiction.

If the concepts that I have shared with you in my discussions of how addiction changes your brain are correct, the pathways to addiction that you built would still remain.  Therefore, once you became an addict, you would still never again be able to use abusable/mind altering substances, but your daily battle would be much easier.  We might possibly be able to turn off your brain’s misinterpretation that you need your drug of choice to survive and thereby reduce some of the greatest hurdles to recovery, like cravings, triggers, panic attacks and drug dreams.

I hope that you made it this far and I hope that I succeeded in correcting my ideas of heredity and environment for you.  More importantly, I want you to see hope for the future and a possible pathway to success in the battle with addiction.

Analogies

“Never forget where you have been. Never lose sight of where you are going and never take for granted the people who travel the journey with you.”

Are you tired of thinking?  Tired of my long-winded discussions of addiction?  Take heart, because for today’s blog I am going to cheat and write several short segments.  I am going to revisit some of the analogies and thought experiments that I have presented before.  Some of these are my own and some I have borrowed from other people.  They will range from the relatively simple to more complex. 

I learned a great deal before I started writing this blog and I have learned more since.  One of the things that I have learned is that analogies are one of the most effective ways to explain the difficult and counter-intuitive concepts of addiction.

No Brakes – “Telling an addict to just stop is like telling someone driving a car with no brakes to just stop.  They want to, they just don’t have what they need.” – paraphrased from Dr. Nora Volkow, NIDA.  This is a wonderful analogy that is summed up with the statement that they want to, but they do not have what they need.  Don’t make the mistake of thinking that this statement implies a lack of willpower as many people suffering from addiction, our son included, have tremendous willpower.  This is explained with our next analogy.

One Hand Tied Behind Your Back – Individuals battling addiction are fighting their own brain with one hand tied behind their back.  Whatever willpower they have to fight the addiction, they also have to continue the addiction.  Furthermore, the part of the brain fighting to continue the addiction has access to both the conscious and subconscious while the part of their brain that is fighting against the addiction only has access to the conscious brain.  You are in a fight with one hand tied behind your back.  Remember someone attempting to conquer addiction is not battling the drug, it is just a chemical, it has no fight.  They are battling their own, altered brain.

Here is a visual analogy for you.

Why Addiction Typically Starts in Adolescence – This is more of a thought experiment than an analogy that I used to illustrate adolescent decision-making flaws that result from an incompletely developed pre-frontal cortex. 

Suppose you met someone in their mid-20s who did not have a lot of experience with substance abuse and you told them; “I will give you this powder and a straw so that you can snort it.  When you do, it will give you the best feeling you have ever had and ever will have.  It will last about 15 or 20 minutes, followed by a couple of hours of feeling very relaxed and peaceful.  There is just one catch, if you do this you may become addicted to this substance.  If that happens, obtaining more will become the only thing that matters in your life. You will lose interest in everything else. You will destroy your relationships. You will destroy your health. You will destroy your career.  Even if you manage to free yourself from the hold of this substance, you will never be completely free, the addiction will lie in wait for you to make a mistake. Do you want to try it?”.

The answer you will most likely get will be something like; “Why would I throw away everything that I have achieved and everything that I might achieve for this temporary feeling.  Get the Hell away from me.” 

If, however, you made the same offer to an adolescent, you may get an answer something like, “Best feeling ever? Hell yeah, bring it on. I won’t get addicted. That happens to other people, not to me.”

Cucumbers – Some analogies are quite simple but they paint a very clear picture.  I met a woman who is in recovery and she told me this analogy to show how addiction never completely leaves you once it has taken hold.  She said, “I used to be a cucumber but now I am a pickle.  I can never go back to being a cucumber.”  She is fine with who she is, she is a wonderful person, but she knows that if she tries alcohol again (tries to return to being a cucumber), she will fail.

Off-Switches – Similarly, a friend of mine explained the difference between my binge drinking in college then stopping when I hit the real world with his becoming an alcoholic.  He said to me, “You have an off-switch, I don’t.”

Dopamine and Pavlov’s Dog – Every time that Dr. Pavlov fed his dog, he rang a bell.  Soon, by merely ringing the bell the dog would act like he was fed.  He would salivate.  This is classical condition, very much like the dopamine system in your brain that gives you a little boost of the feel-good compound, dopamine, when you do certain things that are beneficial or were beneficial to the survival of the human race.  This is a brilliant design, we are prodded along to do things that help our species survive and we don’t even know it.  Just like Pavlov’s dog was not aware that the sound of the bell was making him salivate.

When we use addictive substances, we cause a veritable flood of dopamine in our brain.  This is what feeling high is and it is something on the order of 10 to 20 times the amount of dopamine released during good sex.  Wow, that is a whole lot of feeling good.  This hijacks that brilliant system designed to help us survive and it drives us very rapidly toward addiction.

Drowning in Dog Spit – So using the Pavlov’s dog analogy, how do we stop that flood of dog spit that is the rapid spiral to addiction driven by the hijacking of our brilliant internal design?  Pavlov couldn’t nag his dog to stop salivating, nor could be threaten it or beat it into stopping.  He had to stop ringing the bell.  When you remove the stimulus, the conditioning slowly begins to degrade.  Unlike Pavlov’s dog, we have an opposable thumb..we can ring our own bell.  We can go buy our drug of choice.  To begin recovery, we need help staying away from the bell.  We need inpatient rehab, we need a supportive community around us.

Roadways and the Neural Network – Neural pathways in our brain are the elaborate system of cells designed to pass messages through our brain.  It is most closely akin to a massive network of wires but also can be visualized as a system of roadways.  As our brain descends further toward addiction, a process called Neuroplasticity (See Part III of the science of addiction) literally begins building new neural pathways and interconnections to support the addictive areas of the brain.  Our brain is building highways to support our addiction and letting the roadways of our former self that would interfere with addiction, like morals and ethics, fall into disrepair. 

Recovery consists of getting off of the highways of addiction so that they can fall into disrepair and focusing on the roadways of the old, ethical you.  By doing this you are using neuroplasticity to undo the damage that was done.  Unfortunately, because the addictive behavior caused such an overwhelming response in your brain, your descent toward addiction was rapid but your climb out of it will be a long and arduous journey.  No matter how long you remain in recovery, the paths to addiction will still be present and it won’t take much of a slip to send you back down that road.

You NEED Air – The statement “Imagine trying to live without air. Now imagine something worse.” by Amy Reed is a wonderfully profound analogy to describe the driving force of addiction.  It describes how it feels when a part of your brain is certain that you need your drug of choice to survive and it is doing everything it can to drive you to get what you need.  It is my understanding that when you have truly become addicted, your brain has begun to believe that you must have your drug of choice to survive.  You intellectually know that you don’t need it, but powerful, primitive parts of your brain believe that you do need it to survive.  Survival is our most basic drive so your brain pulls out all the stops to make you use; vicious cravings, panic attacks, triggers, drug dreams, etc.

Finally, Narcan – If you were dying of thirst, literally DYING of thirst and you found some water would you drink it?  Suppose you almost died because it was contaminated but you survived. Now you are even closer to death. If you found more water but there was a possibility it too was contaminated, would you drink it?  Of course you would, you are about to die anyway.

Suppose your brain was certain that you had to have heroin to survive because you were suffering from addiction.  Suppose you overdosed and died but you were revived with Narcan. Narcan flushes the opiates off the receptors in your brain, so your brain is now even more desperate to get the heroin that it KNOWS you need to survive. Do you think that you would use again?

Now you know why someone who was just revived from an overdose, will go back and use again if they don’t have the help and support that they need.

Do you have analogies to add to this list? Do you have ideas to share or a disagreement with something I have posted?  Please comment, let’s work together and help each other.

Variability and Uniqueness

“Celebrate your uniqueness.  You are unique, just like everyone else.”

If you think that I have found the answers through science, I did not.  If you think that the solution to the addiction crisis should be simple, you are wrong.  People are complex.  They confuse me, that is why my degrees are in geology and oceanography.  Since my last post, the theme that seems to keep hitting me from all directions is variability.  Variability in the teenage brain, variability in our personal experiences with addiction, and variability in how we deal with addiction.  

I am afraid that I am giving the impression that there is a single model for addiction that we can use to solve the problem.  While addiction does cause changes to occur in an individual’s brain that are more or less universal, the brains that are being altered are not.  We can map the changes and we can interpret those changes to explain some of the confounding behavior of people with substance use disorders, but they are people, not machines.  We are destined to be stymied in our attempts to solve the addiction crisis if we do not account for the impacts of the thousands of other factors that shape human behavior.  So please join me in a discussion of some of the variability.

The Adolescent Brain

I started my discussion of the science of addiction with the place that addiction typically starts and that is the adolescent brain.  I asked a psychiatrist and college professor to review some of my writings and give me his thoughts.  He works with adolescents and given the limited time that he has, that was a good place to start.  If I can summarize the main theme of his comments, it is that what I said does not apply to everyone. 

The development of prefrontal cortex of the adolescent brain makes adolescents tend to make poor decisions because they rely more on emotion than logic.  That statement is true, but we all know (or knew) adolescents that made excellent decisions.  They were good at predicting the possible future risks and outcomes of their decisions.  Likewise, lower baseline dopamine levels and greater dopamine response tends to make some adolescents crave new experiences and take greater risks.  For some this means new experiences that help them mature while for others it may mean taking serious risks for fun.  To illustrate this variability, my son was the voice of reason among his friends in high school while he was considered the wild one in college..his behavior had not changed, his group of friends did.

The truth is that all of the physical and developmental issues that I discussed with regard to the adolescent brain are true and they make adolescents more prone to addiction.  BUT not everyone suffers from these issues and certainly they are not impacted to the same degree.  In fact, I think that it is safe to call this collection of issues risk factors.  Just as a reminder, these issues include:

  • The prefrontal cortex, responsible for executive functions (logic, self-control, risk evaluation, empathy, etc.), lags behind the development of the rest of you brain and does not catch up until your mid-twenties.
  • Adolescents are very socially-driven which makes the opinions of their peers, who suffer from the same underdeveloped pre-frontal cortex very important.
  • The adolescent brain appears to have a lower baseline of dopamine while at the same time it has an increased dopamine response to stimuli.  This helps in the transition to adulthood by seeking new experiences, but it may lead to greater risk taking and may also make the response to addictive substances more pronounced in adolescents.
  • During adolescence, the brain is going through a period of re-wiring.  Since the brain is already re-wiring itself in many areas, it may be easier for the changes to occur that support addiction as a result of substance abuse.

Behavior of People with Substance Use Disorder (SUD)

An author contacted me about a book that she had recently published, The Weight of a Feather by Lynda Hacker Araoz and I was excited to read someone else’s journey with a loved one suffering from SUD.  What I noticed was that her experiences, while occurring in a similar home life situation were very different from my own.  Her son caused a great deal of chaos in her house beyond just the fear and panic that accompanies the knowledge that your child is abusing deadly substances.  Her son’s actions were all too familiar; no consistent job, troubles with the law, disregard for other family members, coming home loaded, and failure to take rehab/recovery seriously.  Our experiences had none of that.  I refer to Nate as flying under the radar; good job, paid his bills, and worked hard at recovery but periodically relapsed. 

Was our situation an exception?  In my experience, exceptions are rarely the case and that applies here. I spoke with my psychiatrist friend and he said that our situation is very common.  I spoke with a woman that I met in a training class to become a Certified Family Recovery Specialist in Pennsylvania.  Her experiences were eerily similar to our own, even to the age at which our respective sons overdosed and died.

What does all of this mean?  The fact is that there is a broad spectrum over which families are affected by a loved-one’s addiction.  There is no typical and you cannot judge a family based on what they are going through.  There are mistakes that we make, see my post on Enabling/Accommodating, but the uniqueness of people and situations means that there really is no uniform basis from which to judge or fix the impacts of someone with SUD on themselves or their family.  Each plan must be individualized.  Each family must find their own way, hopefully with help and support from others that have been there.

Who has active addiction or is in recovery? Could be any one but chances are there is at least one in this group.

What We Do

As is discussed in my previous post much is said about enabling.  So much so that families suffering through a loved-one’s addiction feel that they are being blamed, that they are somehow making the addiction continue.  Lynda Hacker Araoz discussed in her book how she felt that the family was being left out of the discussion of addiction and how to attack the problem.  She does not put a definite timeframe on her experiences, so I am not sure when she encountered this.  Certainly, in the past there was an attitude that could best be summed up as “We are the professionals, we will tell you how it is and you just do what we ask of you.”  We did not encounter this attitude.  We did, however encounter some of the guilt for enabling, the pressure to use tough love, and the need to hit rock bottom.

My wife and I are like-minded and fiercely independent.  We listened carefully to what the experts said and made our own decisions.  Decisions that I am still comfortable with to this day, despite the outcome.

Fortunately, the concepts of leaving the family in the dark, of tough love and rock bottom are being tempered.  Not everyone must hit rock bottom to seek recovery and tough love is being replaced with the more complex but more useful self-evaluation of when you are accommodating the addiction.

One last thought.  I have heard numerous alternatives to 12-step programs and even some disparaging comments about AA and other 12-step programs.  I love the idea of alternative approaches, as I said we must account for the fact that we are dealing with humans in all their glorious uniqueness.  But AA and other 12-step programs have worked and continue to work for many people.  Let’s not throw out the baby with the bathwater.

Do you have thoughts or experiences to share? Do you think I am full of s**t?  Please comment, let’s work together and help each other.

Enabling or Accomodating

“With regard to addiction, enabling means to accommodate the addicted individual in order to protect them from facing the full consequences of their drug use.” (Lander, Howsare, & Byrne, 2013)

Loving someone struggling with addiction presents many challenges but none as great as differentiating between what is supporting and what is enabling.  It is heartbreaking to watch someone you love destroying themselves and not know if what you are doing is helping them or helping their addiction.  If I could provide you with the answer to this riddle, I would.  Many people try, they fail, because it is different for everyone and every circumstance. 

I have also been told not to use the term “enable” because it is too stigmatizing.  I agree, it implies that you are intentionally harming this person that you love and are trying desperately to help.  I don’t think that’s on you, even if you are making mistakes along the way.  Even if you are failing to do the things that your loved-one needs you to do to help them get into recovery because you are not emotionally strong enough.  You didn’t start their addiction.  You need to see the error in what you are doing, and you need change your behavior to help them. 

I think that I will use the term “accommodating” to replace enabling.

Take Care of You First

The idea that you have to take care of yourself seems selfish and counterintuitive.  You are fine.  You love them and would do anything for them.  They need the help, not you.  YOU ARE NOT FINE!  Whether you see it or not, you are suffering along with them and the more things that you tolerate, the more you tear yourself down.  You are limited in your ability to help by your own pain.  This may mean doing something that you think is cruel, like turning them out on the streets but it may be the only way to save you and them.  Keep them at arm’s length as you love and support them if that is what you need.  You want to avoid reaching the point where they have caused you such harm that you hate the person that they have become.

How Do I Know What to Do?

Most definitions of enabling/accommodating regarding addiction revolve around protecting the person in active addiction from the consequences of their own actions.  By that definition, I think that we parented our boys by avoiding enabling, because we felt that to become a responsible adult, they needed to experience the consequences of their actions. 

When our son didn’t prepare for a test, we didn’t let him stay home from school.  He went to school and struggled for his own poor planning.  When our son lost parking privileges at school for his behavior and he had “a solution”, we didn’t let him use it.  He was being punished for his behavior, so we made him take the punishment.  Unfortunately, we found out later that some of our son’s friend’s parents did not do the same.  We were considered the tough parents because we made our sons suffer the consequences.  No snowflakes at our house.  Oddly enough, we ended up having a son who died of an overdose, while those who coddled their children mostly did not.  Not really that odd when you consider that heredity is the single, strongest determinant for addiction, even more so than upbringing.

But I digress, when you accommodate addiction, you let your loved-one do as they please without suffering the consequences.  Some examples include:

  • Calling their boss to make excuses for their absence from work when they are hungover or going through withdrawal.  (You can’t have them lose their job.)
  • Cleaning up whatever mess they made.  (“They won’t do it”..not if you will do it for them.)
  • Helping them out financially. We know it is a bad idea to give someone with substance use disorder cash but if you cover other expenses, you are freeing up cash that they have used or will use to buy drugs or alcohol. (It is very difficult to find where you should be with respect to monetary help.)
  • Blaming others for your loved-one’s problems or behavior.  They don’t run with a bad crowd, they are the bad crowd.  Usually, they weren’t tricked into using, they went there willingly.  They need to own that.
  • You put off the things that you need to do to take care of yourself in order to protect or take care of them.  As a parent, we are wired to protect and care for our children.
  • You accept unacceptable behavior such as, physical or verbal abuse, stealing from you, ignoring reasonable house rules, etc.

Believe it or not, those were the easy examples.

I was contacted by Nicole at Reflections Rehab regarding an enabling quiz that they have. I took the quiz and while I think that we must look at things in the light of our own situations, it is consistent with my understandings. The quiz may be helpful for you to assess what you are doing and to start some discussion of changes you may wish to make. The quiz can be found at https://reflectionsrehab.com/program/family/#enabling

This Sucks

Our son had a great job with people that loved him, appreciated his work ethic, and demonstrated that.  What more could you want?  When he overdosed and had to go to rehab, we made him suffer the consequences of his actions, he had to call his boss and explain.  He did, his boss said, “Get better and your job will be waiting for you”.  Nate got better, his boss was true to his word and all was well until he overdosed and died six months after he went to rehab.  What did we do wrong?  That question will haunt me the rest of my life.

Here are some things that I have been told that I don’t think are as universal as they were presented but then what do I know, I failed to keep my son alive.

  • Take away their car and their phone, so that they have to spend their money on those things rather than drugs.  My view; a good idea under some circumstances but if you doom them to complete failure that is what you will get.
  • Don’t let them move back home because it is too easy, you are too easily manipulated, and very likely it is where they used (a trigger).  My view; a good idea but not always practical.  If they must move home, make it short and push them to be independent and in a supportive environment like:  halfway house, recovery house, sober house, etc.  Side note: when Nate died, we had just pushed him to move out of temporary arrangements at our house and into a sober house.

Tough Love

I think that the term tough love gets used way too much because it sounds good, but it is interpreted so broadly that it has no real meaning.  No one is asking you to be mean or spitefully.  If you are allowing them to suffer, it is so that they can get better.  I don’t like the term tough love because some people think that it means tough like a drill sergeant.  A drill sergeant tears you down to build you back the way the military wants you.  Your job is to sit back and watch as your loved-one tears them self down in the hopes that they will survive long enough to find the great person within and become that person.

In order to do what is necessary to help your loved-one you may have to do things that are very difficult, that seem like you don’t love them.  Just because you are being tough does not mean that you don’t love them, on the contrary you love them so much that you can make very, very difficult decisions in order to help them.  The toughest thing about so called “tough love” is how hard it is on you, not them.  Tough love is really:  massive love, thoughtful love, unconditional love, a love so great that you suffer tremendously watching them but yet allow them to fail in the hope that they can see what they need to do.

Rock Bottom

Those people or groups that advocate for the hardest line with your loved-one also tend to be those that push the idea that they have to hit rock bottom.  Once I was at a parent meeting for the latest rehab that our son was in and I was kind of a jerk but I was making a point.  When the staff member said that addicts need to hit rock bottom, I asked “what am I doing here, why don’t I just throw my son out in the street and speed his trip to rock bottom, so that he can then get better”. 
I was kind of an A-hole but he got my point and had no answer.

Rock bottom can be the most horrendous place imaginable.  If that was what would have saved our son, I would have driven him there myself.  I think that rock bottom is the place where you realize that you cannot sustain the lifestyle, the destructive, addictive, lifestyle that you are living.  I have listened to a guy who lived under an overpass in the Kensington section of Philadelphia for years before he came to that realization.  I have included a story in this blog of a man that came to that realization in his bedroom, when he met God.  I have read people’s stories of virtual death and resurrection with Narcan that brought them to recovery and those that were revived many times and did not find recovery until something else changed them.

Bottomline:  Take care of yourself first.  You cannot save your addicted loved-one no matter how hard you try.  That is work that only they can do.  You can prolong the process and ultimately make it more difficult for them by protecting them from the natural consequences of their actions.  BUT you are not responsible for their problems and you are not capable of fixing them.

My Best Answer to the Riddle:  Think about what you are doing and whether you are helping your loved-one or accommodating their addiction by letting them live consequence-free.  Make the best decisions that you can, re-evaluate your decisions, and accept that you did the best you could.  Forgive yourself for the errors that you make and forge ahead.  You are in an impossible situation, but you are not defeated. THERE IS HOPE.  THERE IS A LIGHT IN THE ADDICT.

Do you have thoughts or experiences to share? Do you think I am full of s**t?  Please comment, let’s work together and help each other.

Twelve Reasons

Even if you are a minority of one, the truth is the truth. – Mahatma Gandhi

Finding out that someone you love is addicted to hard drugs will wreck your world every bit as much as they are wrecking their own world.  I have learned, however, that many people caught in that nightmare (people in recovery and people with loved-ones suffering from addiction) have gained a very good, intuitive understanding of the changes that addiction causes in those trapped in its grip.  It is my wish that you could gain this understanding without having to suffer the pain that far too many of us have experienced.   I have made it my goal to educate people about addiction because I fervently believe that we do not stand a chance at success with this horrible disease until we first understand it..and that means everyone.

So, today’s post will take on one of the biggest stumbling blocks to solving this problem.  That is,the persistent belief that addiction is not a disease, it is a choice.  Please read the information below.  If you still do not agree that addiction is a disease, that’s OK with me.  At least you will have a better understanding of how addiction affects those in its grip.

“It is difficult to feel sympathy for these people. It is difficult to regard some bawdy drunk and see them as sick and powerless. It is difficult to suffer the selfishness of a drug addict who will lie to you and steal from you and forgive them and offer them help. Can there be any other disease that renders its victims so unappealing? Would Great Ormond Street (Children’s Hospital) be so attractive a cause if its beds were riddled with obnoxious little criminals that had “brought it on themselves?” 
― Russell Brand

from SandySwensen.com, “Where Love and Addiction Meet”

Twelve Things That Made Me Conclude that Addiction is a Disease

  1. Comparative brain scans show that addiction dramatically alters the response of the brain, particularly with respect to dopamine.  Dopamine is a feel-good compound that our brain makes to drive us to seek certain things or activities.  Addictive substances cause a flood of dopamine that overwhelms the brain.
  2. Comparative brain scans show that addiction causes significant changes in a very primitive part of the brain (the limbic system) that is responsible for automatic, survival-type responses such as hunger, thirst, fight-or-flight, etc. These changes can lead a person’s brain to conclude that the addictive substance is necessary for survival.
  3. The behavior of truly addicted individuals is illogical and incomprehensible unless it is viewed as a response to a need to survive.  If one considers that the primitive part of the brain of an individual suffering from addiction believes that using is essential for survival, then their actions are understandable.  (“Imagine trying to live without air. Now imagine something worse.” — Amy Reed, author)
  4. Things that happen when an addict stops using make sense as their brain attempting to protect them.  It is trying to force them to get the substance that it incorrectly “knows” that they need.  These things include:  intense, relentless cravings; drug dreams; thoughts that they can just use a little and control it; panic attacks; etc.
  5. There is a mechanism for the brain to change itself in response to what it perceives as important, that is, those things that it is thinking a great deal about. It is called neuroplasticity.  The massive dopamine response to addictive activities causes the brain to focus intently on the addictive substance or activity.  This results in neuroplasticity physically changing the addictive parts of the brain.
  6. There is no threat or reward that is great enough to cause someone to get to lasting recovery..not prison, not abandonment, not isolation, not a life of discomfort and misery, not even death.  I don’t believe that everyone has to “hit rock bottom”.  I believe that you have to genuinely come to the conclusion that your present path is unlivable and seek whatever help you need to stay away from abusable substances and reconstruct the great person that you were meant to be.
  7. Like many diseases, addiction has a very strong hereditary component.  In fact, some people may use and stop before ever becoming addicted, while others rapidly experience changes within their brain that are the very definition of addiction. 
  8. Heredity seems to be the more dominant factor controlling the point at which a person’s brain will shift into addiction.  There are, however, environmental factors such as their experiences growing up and traumas that they may have experienced that will make one susceptible to addiction.
  9. Addiction needs an initiating step (trying the drug) that the person suffering from addiction must accept their role in.  Once started, addiction rapidly spirals out of control and the addicted individual is not capable of stopping without help.  This is no different than many other things that we call a disease such as, smoking =>lung cancer or emphysema, poor nutrition and lack of exercise => heart disease, risky behavior => STDs, Hep C, HIV and many more.
  10. On average, people suffering from addiction enter into rehab eight times before they find lasting recovery.  Can you really believe that you are so wonderful, that you are so much stronger than all of those people?  That they are weak and can’t “just stop”,like you could.  That is a monumental level of arrogance..don’t you think?
  11. There is no period of remission (recovery) that is long enough to guarantee that there will not be a relapse.  This is because the changes to the brain,while healing in recovery, still leave a trail of breadcrumbs back to active addiction.
  12. Statements that I have heard or read from people suffering from addiction:
    1. I didn’t want to feel sick anymore but the drug always wins.
    1. When I was loaded, I was sure that I could stop tomorrow but when I started to withdrawal, I knew that there was no way that I could stop.
    1. It was like the drug knew what I was going to do to stop and it was just a little smarter than me. (Correct, except that the drug doesn’t want anything, it is a chemical. It is your own brain that you are battling.)
    1. I started using to take away the pain, soon it stopped taking away the pain but I could not stop using.
    1. I had used so much that I was always sick and depressed.  Using didn’t get me high anymore, it just made me feel normal.
    1. I didn’t even want to use but the next thing I knew, there I was with a needle in my arm.
    1. I wish that people saw the time that addicts spent alone. Thinking about everything they’ve done, every time they’ve lied or stole.
    1. I don’t have an off switch.
    1. “I call it stained-glass glasses…Like active addiction changes how you perceive life around you… makes you think every thing is fine when it is not…Makes you blame everyone else for every problem in your life…And mostly it convinces you that people hate you when they try to love you.”

I want to leave you with one final thought:

We used to believe that genetic markers such as hair color, eye color, facial features, or skin color indicated that some people were superior and that some people were inferior, less human.  We don’t believe that anymore(most intelligent people, anyway).  When will we stop seeing the genetic marker of a susceptibility to addiction as an indication that someone is inferior, weak, less of a human?  When will we find empathy and compassion for those less fortunate in genetic roulette?

A wonderful lady named Lynda Hacker Araoz reached out to me because she too is trying to educate people about addiction.  She has a blog, www.weightofafeather.com and a book “The Weight of a Feather, A Mother’s Journey Through the Opiate Crisis”.  I have not read the book, yet.  But her email was very articulate, and her book sounds fascinating.  I have no doubt that it will be excellent.