“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
“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.
“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.
