“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.
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.
“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.
“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
“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.
“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.
“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.
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
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.
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.
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)
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.
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.
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.
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.
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.
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.
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?
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.
Statements that I have heard or read from people suffering from addiction:
I didn’t want to feel sick anymore but the drug always wins.
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.
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.)
I started using to take away the pain, soon it stopped taking away the pain but I could not stop using.
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.
I didn’t even want to use but the next thing I knew, there I was with a needle in my arm.
I wish that people saw the time that addicts spent alone. Thinking about everything they’ve done, every time they’ve lied or stole.
I don’t have an off switch.
“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.
“The truth is, we all face hardships of some kind, and you never know the struggles a person is going through. Behind every smile, there’s a story of a personal struggle.” – Adrienne C. Moore
“A lie can travel half way around the world while the truth is putting on its shoes.” – Charles Spurgeon
Today, the greatest challenge that we face in addressing the addiction crisis is not preventing the creation of new addicts nor is it getting those already addicted into lasting recovery. Our greatest challenge lies in overturning the misconceptions, the stigmas, the misinformation, and the outright lies that continue to be repeated about addiction and those suffering from it. I believe that education is the key and ignorance is the biggest obstacle. We cannot successfully attack a crisis of this magnitude unless we understand the problem and set to work using our resources where they are most effective. Please join me as I take on some common misconceptions in “Misconceptions and Stigmas Part 2”.
“Addicts are All the Same, They Just Want to…”
This statement can end in a multitude of ways such as, get high, have fun, lay around all day, avoid reality, etc. I addressed the second half of this statement in Part 1 but there is also the ridiculous concept that all people of any group are the same. Confronted with this fallacy in their statement most would retreat to saying that they are not exactly the same but the concept remains. Addiction does cause the same changes in an individual’s brain regardless of the activity or drug of choice but people with substance use disorder are as varied in their thoughts and behavior as the rest of the population.
Most people think of “addicts” as the person that they see on the street corner asking for money, living under the overpass, sleeping on a park bench or any other of a number of negative stereotypes. It is true that some people struggling with addiction do behave this way. What is also true though, is that there are lawyers, doctors, skilled laborers, people of all walks of life that are suffering from addiction to alcohol, opioids, cocaine, crystal meth, or any other abusable substance. You probably interact with people suffering from substance use disorder daily but you don’t see it.
When our son died, his employer told us that of the 20+ people that they employ he is the last one that they would suspect was an addict. I know a civil engineer that was married to a lovely woman and they had two wonderful kids, yet he was addicted to crack cocaine. In both of these cases the drug ultimately won but they were hardworking, contributing members of society. Typically, individuals that are able to hide their addiction ultimately do one of the following: get help and find lasting recovery before they destroy their lives, get help and find recovery after they have destroyed their lives, or they die from overdose or the results of the abuses that they heaped on their bodies.
Why should this matter to you? So what if there are “functioning addicts”? This matters because as long as the negative stereotypes persist people will resist efforts to help those suffering from substance use disorder. People will look down on them and refuse to accept them. Individuals in recovery are fighting a tremendous battle that lies largely within their own injured brain, they do not need additional obstacles thrown in their way. AND they likely will keep their addiction hidden for fear of the stigmas and not seek help. Addiction that is not addressed typically ends in death. That should matter to you, they are people just like you and me that are suffering from a disease that they may have initiated but it quickly overwhelmed them (physically).“Addicts Don’t Think of Anything but Their Next Fix”
In discussing addiction and its impacts on the brain, I often speak as if this statement is true. I talk of how conditioning and neuroplasticity physically change the brain, making it believe that obtaining the addictive substance or behavior is necessary for survival. This appears to indicate that getting their next fix is all that matters but that is a gross oversimplification. The truth is that when the “need” is satisfied (when the person uses), the cravings, the drive to use is reduced. It is at this time that the person with substance use disorder may be crushed with thoughts of the impacts of their behavior on those that they love. There is overwhelming regret, shame, and remorse. The response to such feelings is typically the desire to hide from them and for those suffering from addiction, that means using again. The vicious cycle of use-shame-use is obvious and nearly impossible to break because of the physical changes to the brain that reinforce the addiction.
We often see in the media stories of parents found passed out in their car while their very young children are buckled in the back seat. The obvious conclusion is that these people do not love or care enough about their children. That conclusion is almost always wrong. They love their children deeply, but they are overwhelmed by their addiction and have acted upon the need to use.
A similar conclusion causes great pain to the children of addicts and alcoholics. They frequently feel that they are not good enough or important enough for their parent to stop their addiction and this causes low self-esteem and depression. The truth is that these are two very different drives in the brain. The love that they feel for their children is no less than the love that we all feel for our children but there is another area of their brain that is requiring them to obtain the substance that they “need” to survive. No one would think that their parents loved them less if they left them for a time to ensure that there was food. The problem lies in the fact that we all know, in fact those suffering from addiction also know on a logical level, that they do not need their drug of choice to survive. BUT the primitive part of their brain, that we do not have conscious access to, is driving them to get the drug that they “need”.
Addiction is Not a Disease. They Just Call it that so Insurance Will Cover Treatment
I read this statement in a letter to the editor and I was amazed. Within this blog, I have laid out all kinds of evidence and scientific investigations that would lead most people to conclude that addiction is a disease. I know that people resist the thought that addiction is a disease. Hell, so did I until I did my research. But to think that we only call it a disease to get insurance coverage underestimates the intelligence and lobbying power of insurance companies. The treatment of addiction costs millions if not billions of dollars. Don’t you think that if insurance companies could prove that addiction is wholly self-inflicted, they would refuse to cover treatment?
Please don’t think that I am making excuses. I believe that to succeed in recovery, an addict must accept what they have done. BUT
• Addicts do not choose to continue to use, they need to use.
• Willpower will not get an addict to stop because all of the willpower that they have to stop is also being used against them by their altered brain, to protect their addiction. Likewise, there is no threat that can be used to make an addict seek help.
• If you are not an addict, congratulations you got lucky. You don’t get to look down on addicts because you were born into a healthy environment and you won in genetic roulette.
• Addicts can succeed in managing their addiction but it requires help, support, understanding, and lots of time.
Do you have thoughts or experiences to share? Please comment, let’s work together and help each other to understand this problem.
“The secret of change is to focus all of your energy not on fighting the old, but on building the new.” – Socrates
All of us who have lost a loved one deal not only with grief but with the nagging question “what should I have done differently?”. The truth is that we will never know what may or may not have helped but that doesn’t stop those thoughts from intruding at the most inopportune times. I believe that some people are capable of learning to manage their addiction with support and structured help alone. But I also believe that there may be people for whom addiction is too powerful and they need therapeutic drugs to help them. Was our son one of those people? Would he still be alive today if we had convinced him to try medication-assisted treatment (MAT)? That is the major “what if” that nags at me. The last post discussed Narcan and I want to follow that up with a discussion of MAT, therapeutic drugs used to combat substance use disorders. So, please join me in this post, “Narcan and Friends Part 2”.
How does Medically-Assisted Treatment Work?
The short answer to how MAT works is that it depends on the therapeutic drug that is being used, but there is more to it than just that. I found this excellent summary on the Psychology Today blog:
MAT is most useful when combined with intensive one-on-one psychotherapy, group support, and complementary therapies. The way in which MAT affects the brain effectively gives the addict breathing room and time to address the underlying causes of their addiction. MAT allows the addict to focus on their recovery instead of being compelled to use by co-opted neurological processes. MAT is a tool to be used in reaching that goal of long-term abstinence from drugs and alcohol. However, if MAT is used on its own, without other forms of supportive therapy, it is unlikely that recovery will last.
Did you catch those two phrases, “gives the addict breathing room” and “instead of being compelled to use by co-opted neurological processes”? Not that I think you need an explanation, but we remember things when they are stated in language that we use. In other words, the person suffering from addiction has a brain that has been physically changed to believe that it needs the substance to survive and he/she needs breathing room from the thoughts, the cravings, the triggers, drug-dreams, etc. The other important concept in that summary is that MAT alone usually will not result in lasting recovery.
What are the Therapeutic Drugs used in MAT?
Methadone
Methadone is the therapeutic drug/MAT that people are most familiar with. We have seen in movies and heard in songs how a junkie goes to the methadone clinic every day to help them get off of heroin. That is not too far from accurate. In the early stages of methadone treatment, a person suffering from addiction to opioids must go to a facility to receive their daily dose of methadone. Methadone is a full opioid agonist, meaning that it functions by attaching to the opiate receptors in the brain and it causes a similar response. Therefore, methadone can be abused and that is why in early stages of recovery it is only dispensed one day at a time.
Methadone is a synthetic opioid that changes the way that your brain responds to pain. It gives your brain the same feelings that other opioids give but at a slower rate. It also blocks the high that you get from other opioids like codeine, heroin, hydrocodone, morphine, and oxycodone. In short, methadone tricks your brain into believing that it is getting what it thinks it needs and it holds off withdrawal, while not allowing you to get high. It gives you breathing room. Some people/groups oppose the use of methadone because they believe that you are “substituting one drug for another”. To a degree, this is true but if it allows someone struggling with addiction who could not have handled it otherwise to ease into recovery, maybe it is not a bad option.
Buprenorphine (Suboxone)
Suboxone is a new and improved methadone-type treatment. Suboxone is a partial opioid agonist, which means that it attaches to an opiate receptor and provides some opiate-like feelings, but it has other features that reduce the opioid-like response. Buprenorphine (Suboxone) functions similarly to methadone except buprenorphine has a ceiling effect, that is, it reaches a level at which increasing the dose does not increase the effect. This makes buprenorphine difficult to abuse and so it does not require daily distribution.
Suboxone also contains naloxone (Narcan) which is added to prevent abuse by injecting. Under proper use, the naloxone is not well absorbed so it has no effect, but if it is misused by injection, the naloxone dominates, and the user is immediately thrown into withdrawal. Obviously, not the desired result.
Naltrexone
Naltrexone, like Narcan, is a competitive antagonist for opiates, so it functions very differently from methadone and buprenorphine. This means that naltrexone pushes the opioid molecule off of the receptor and the naltrexone then occupies the receptor, keeping the opioid molecule from reattaching. Naltrexone does not provide the opiate response in the brain, rather it prevents the euphoria and sedative effects of opioids, so abusing opioids while on naltrexone has no effect. The person with substance use disorder is not tempted to use because it has no effect and if they relapse, the naltrexone prevents the feelings of euphoria. Naltrexone not only works for opioids but it has a similar effect for alcohol, it blocks the euphoric feelings and feeling of intoxication associated with alcohol abuse.
Vivitrol
Vivitrol is a long acting, injectable form of naltrexone. In order to combat the need to take a pill daily and the likelihood that someone battling addiction might fail to take the pill, Vivitrol was developed. Vivitrol is a monthly injection that cannot be started until the individual has refrained from using for at least a week. It is naltrexone, so it does the same thing, that is, block the euphoric and sedative effects of opioids and the euphoric and intoxicated feelings of alcohol.
Disulfiram
Disulfiram is used to treat chronic alcohol abuse and it cannot be used before detoxification is complete. Disulfiram works by causing very unpleasant side effects if an individual drinks alcohol while on disulfiram. It can cause nausea, headache, vomiting, and difficulty breathing shortly after consuming even a small amount of alcohol. And this can last for an hour or more. Remember your first hangover when you swore you would never drink again? Imagine that occurring as soon as you took your first drink, that would be quite effective at keeping you sober, if you continue to take it.
Acamprosate (Campral)
Acamprosate is used to treat chronic alcohol abuse, frequently in combination with naltrexone or disulfiram. Like other addictive substances, chronic alcohol abuse results in changes to the brain that that cause extreme responses when alcohol is no longer consumed (withdrawal). While the mechanism is not well understood, we know that acamprosate helps to stabilize the brain and reduce the impacts of withdrawal.
MAT is Not Perfect
You probably noticed that the drugs that I discussed above are used for opioid addiction and/or alcoholism. There are currently no FDA-approved medications to treat other types of addiction such as, methamphetamines, marijuana, or cocaine. Even for the substances that MAT is designed to address there are issues:
For the medication to be effective, it must be taken regularly. Individuals may forget to take their medicine or may intentionally not take it.
When we discussed suboxone treatment with our son, he pointed out that people who are not strongly invested in getting and staying sober will frequently turn to another (non-opioid) drug to get high when the cravings get too much for them to handle.
An integral component of MAT, noted above, is support such as 12-step programs, counselling and cognitive behavioral therapy. The drugs by themselves will not cure addiction because we have not yet found a drug that can undo the changes that the brain has gone through as a result of addiction.
My Personal Bottomline
Would my son still be here if we had gotten him into an MAT program? We will never know. The drug doesn’t stop your addiction, it just gives you breathing room, it is your desire and the support of others that gets you to lasting recovery. Is it wrong to replace a drug with a less dangerous drug? I think that the answer is no if that is the only way to keep that person alive until they can manage lasting recovery. You cannot succeed in recovery if you are dead.
Many people have very strong opinions regarding MAT and some even have experience with it. Please share your thoughts or experiences. We learn best when we learn from each other.
“Addicts Don’t Think of Anything but Their Next Fix”