Chemical Dependency: Cause and Effect

chemical dependency: cause and effect

When discussing addiction, or chemical dependency, not many people really understand the subject. Don’t feel bad, because many health professionals don’t understand chemical dependency. The most common idea I run across is that addiction is caused by underlying psychological problems. In other words, most people don’t understand chemical dependency as a primary disease. I’ll use CD to refer to chemical dependency or addiction, both terms are used – however, chemical dependency is the clinically preferred term. The term addiction has lost a lot of its meaning through popular use — I’m addicted to ice cream, I’m addicted to a person, I’m addicted to golf, and so forth.

CD refers to dependence on a chemical, a drug. Substance abuse is also used quite often when the person using the term is really referring to CD. Abuse, or misuse, of a drug is not the same as CD. A 22 year old college student might misuse alcohol to fit in or to feel comfortable in social situations, or to impress friends, but that doesn’t mean that CD exists, even if the young person gets in trouble and gets a DUI. Mostly this confusion over terms is based in lack of understanding of CD. Although lack of understanding is the main reason for confusion, there are other reasons people refuse to refer to CD as a chronic brain disease.

Way too many people resist acknowledging CD is a chronic brain disease because they believe it excuses the person from responsibility. In order to accept CD as a disease, they think they have to change their ideas about free will, choice, responsibility, accountability for actions, etc. We’ve all heard such stories as the young kid who killed someone while drinking and driving and was not imprisoned because he was brought up as a privileged kid and wasn’t taught responsibility. This type of situation mixes social, moral and legal issues with biological issues.

Determining why someone starts to drink, or if they should drink at all, does not tell us why the person develops a dependence on alcohol. A moralist might say the person should never have started drinking in the first place, that the act of drinking is a choice and the chooser is accountable for the outcome. True, true, but this doesn’t tell us why one person develops a physical dependence on alcohol while another who drinks doesn’t become dependent. The moralist might say that the person who drinks alcoholically simply didn’t control his/her drinking and thus became dependent. But what about the heavy drinker who never becomes physically dependent on alcohol? The moralist doesn’t have an answer. Science doesn’t have all the answers, but science has learned quite a lot about CD and drinking in general — the moralist can learn if he/she wants to truly understand chemical dependency. The moralist might still say that the person is responsible for his/her condition, and most everyone will agree — this is what recovery is about. Recovery from CD is about taking responsibility for this chronic brain disease and taking actions to remain abstinent. There’s common ground, but first let’s all accept the facts. We’ve learned in the addiction treatment field that blaming or shaming people for their condition, a condition they didn’t choose, is not helpful, but showing someone how to deal with the condition and how to change is helpful.

Alcoholics and Meditation

alcoholics and meditation

Peace, quiet and mindfulness

Writing about alcoholics and meditation might appear weird without context and an understanding of recovery from alcoholism. Also, having a little knowledge of Alcoholics Anonymous’s 12 Steps will help, especially Step 11:

Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

The world is much more secular in 2016 than in the 1930s when the Steps were written, but even then there was controversy over the use of “God”, prayer, “His will”, etc. The compromise was God as each individual understands, or perhaps doesn’t understand,  God/god. The “we” in the step meant the founders as each understood “God” at the time AA was started. There’s no official understanding of God or god. There are even Free Thinkers, Agnostics, Atheists AA meetings in many cities. Most AA meetings in larger cities don’t have a religious tone, but in the Bible Belt and Midwest you’ll find meetings that have a religious flavor. AA is wide enough and deep enough to accommodate the belief or lack of belief of any alcoholic. The point is the principles embedded in each Step, and for the purpose of this post, meditation is the point.

Many people think of meditation as a clearing of the mind, but the original meaning of the word had more to do with deep, serious mindfulness. In recovery from addiction, it helps to take time from each day to listen to thoughts/emotions, to consider life/purpose/spirituality/understanding more deeply. Sometimes it’s good just to clear the mind so that deeper thoughts and emotions can arise out of all the hubbub. Meditation is an individual thing — some people prefer more formalized methods, and some prefer to just let what happens happen. It’s up to the individual, but most people who try it say that it helps tremendously.

When the recovering alcoholic makes contact with a deeper part of the self, that deeper self usually doesn’t want to go toward destruction but rather toward healing and personal growth. This is an excerpt from alcoholrehab.com:

Using Mindfulness in Recovery from Addiction

When people are in the early months of recovery, they often experience a kind of mental fuzziness. They may struggle to think clearly as their mind adjusts to life without substance abuse. This is also a time when their emotions are erratic. Those who fail to cope with these challenges in early recovery are more likely to relapse. Mindfulness meditation can be a great tool at all stages of sobriety. It gives people more control over their emotions and increases mental clarity.

Mindfulness Meditation Defined

Mindfulness involves purposely paying attention to the present moment. It also involves being aware of thoughts, feelings, and emotions as they occur without being carried away by them. Mindfulness is a non-judgmental form of observation.

Apart from alcoholics and meditation, I think anyone can benefit from meditation — it’s a great break from all the noise, if nothing else.

Honesty in Addiction Recovery

Honesty in addiction recovery

Honesty

During their active addiction, before addiction recovery, addicts live in a world of pretension, half-truths, exaggerations, rationalizations, justifications, and flat out lies. These are mostly defense mechanisms to protect what the addicts thinks is holding it all together, the drug of their choice. From the outside it appears insane when an alcoholic’s dishonest about something that’s destroying him/her. When a heroin addict lies, cheats and steals to get a little more heroin, to the non-addict it seems to make no sense at all that a drug could be that important. Is the alcoholic or heroin addict having so much fun that they’ll violate all trust to get what they want? I doubt the addict is having any fun at all at this point. In the addicts’ mind they need the drug to keep going, to keep from losing their mind, to keep from suffering mentally and emotionally, to function.

In the later stages of alcoholism, withdrawal from alcohol can be fatal, and for the heroin addict withdrawal feels like dying. Addiction recovery seems impossible. Withdrawal can be so painful that it cancels out reason and judgement. The craving feels like a matter of survival, so, yes, the addict will lie to keep from getting in this condition. In early stages, though, the lies are merely a defense against the judgement of others. No one wants to see themselves, or have others see them, as someone who can’t handle alcohol or is a junkie or something like that. Out of pride most addicts in the early stages will make excuses for their excesses and periodically strange behavior. At this point the person still has some control over the drug, so they can straighten up for a while to prove they don’t have a problem.

The addict might be totally honest in business and in general, but when it comes to the addict’s drug of choice there’s growing dishonesty. In treatment and addiction recovery we stress rigorous honesty and try to break down the denial the addict has built to protect their drug of choice. It’s critical that the addict in recovery looks at the addiction with rigorous honesty. This takes a while. At first, it’s a simple decision to admit there’s a problem, then it’s a process of becoming more and more honest as treatment/recovery feels more comfortable, and as they witness others in the group become more honest. It’s not surprising when someone in early recovery still minimizes the problem — it’s not necessarily a sign that the person will relapse — it just takes time to become rigorously honest. As long as the person is still taking recovery type actions, there’s hope.

New Faces of Heroin Addiction

The new face of heroin addiction

Opium, Opiates, Opioids

The history of opium, opiates and opioids goes way back. Opium was used in prehistoric times according to research:

The earliest reference to opium growth and use is in 3,400 B.C. when the opium poppy was cultivated in lower Mesopotamia (Southwest Asia). The Sumerians referred to it as Hul Gil, the “joy plant.” The Sumerians soon passed it on to the Assyrians, who in turn passed it on to the Egyptians. As people learned of the power of opium, demand for it increased. Many countries began to grow and process opium to expand its availability and to decrease its cost. Its cultivation spread along the Silk Road, from the Mediterranean through Asia and finally to China where it was the catalyst for the Opium Wars of the mid-1800s.

In the late 19th century the methods to isolate morphine then heroin from opium were discovered along with the hypodermic needle, and this led to several periods of heroin epidemics. For the longest time in the US, heroin use has been associated with poor whites and minorities. Most Americans thought of heroin as something poor people did and something bad guys sold illegally for profit. There have been several government efforts to deal with heroin addiction, but for the most part society relegated that problem to inner city ghettoes.

Surely most people have heard lately about the opioid epidemic. To clarify the language:

An opiate is a substance derived from the poppy plant (which contains opium). Opiates are sometimes called “natural” since the active ingredient molecules are made by nature, not manufactured by chemical synthesis. Common opiates include morphine and codeine, both made directly from poppy plants.

An opioid is a substance (molecule) that is synthetic or partly synthetic, meaning the active ingredients (molecules) are manufactured via chemical synthesis. Opioids may act just like opiates in the human body, because of the similar molecules.

opiate – narcotic analgesic derived from a opium poppy (natural)

opioid – narcotic analgesic that is at least part synthetic, not found in nature

The terms are often used interchangeably. On the street, “heroin” may mean synthetic, natural, or semi-synthetic compounds. Manufactured opioids like Oxycontin are sometimes called “synthetic heroin”, also adding to the confusion. Genuine “heroin” as originally formulated is technically considered an opioid, since it is chemically manufactured, although molecules from the opium plant are used in the process. Some of heroin’s active ingredient molecules are not found in nature.

Currently many references are using opioid to refer to all opium-like substances (including opiates and opioids), and limiting the use of “opiates” to only natural opium poppy derived drugs like morphine.

As more and more people are prescribed opioids and become addicted, more and more people suffer from heroin addiction when they become desperate and can no longer get or afford legal prescriptions. The difference with this latest epidemic is that heroin and opioid addiction are affecting people from all walks of life. Young affluent white kids are overdosing and dying. Unfortunately, it takes reaching people with influence before action is taken. Maybe America will finally learn about addiction — and recovery.

Shortage of addiction professionals

addiction treatment professionals

addiction treatment

There’s a shortage of professionals with specialized training in addiction treatment. For decades the field of addiction treatment has seen this shortage developing as young people went to more lucrative fields, and there’s also a stigma still placed on addiction that turns people away from addiction treatment. Professionals who got into the field when insurance paid better than it has in the last decade or so are at retirement age. Now that insurance is again paying for addiction treatment there are not enough specialized professionals to meet the new demand.

Hopefully young people will choose to make a career in addiction treatment. I started in the field in 1983. It has been a rewarding journey. Old ideas about addicts being difficult to work with are not entirely true. Yes, it’s a demanding field, but if a person understands addiction, then it makes the challenges more understandable and less threatening. It certainly doesn’t get boring.

Most people are under the impression that recovery from addiction hardly ever happens, but recovery does happen quite often when a person can access quality treatment. Addiction treatment is not effective when the treatment is not well funded, or when the caregivers are not properly trained and when the treatment program is not based on best practices.

It still amazes me that insurance companies want to minimize resources spent on treating addiction when untreated addiction causes so many expensive medical conditions down the road. I think now that an opiate addiction epidemic is in the news, and opiate addiction is affecting people from all socio-economic levels, there will be more attention focused on quality treatment. I encourage young people who have an interest in caregiving to seriously consider addiction treatment as a career. It will one day be an important field of endeavor, because, as we see, the problem is not going away on its own. Untreated addiction causes way too many unnecessary deaths and drains way too many resources from our economy.

 

New form of Buprenorphine — implant

Addiction treatment

Opiate addiction

There’s new form of Buprenorphine coming out that should be approved soon by the FDA. Buprenorphine is a drug used for the treatment of opiate addiction. Suboxone is the best known market name for Buprenorphine, and Suboxone has been used since around 2002. There’s been a controversy surrounding Suboxone because it can be abused. Used correctly, Suboxone is a tablet or a film strip that has been a life saver for opiate addicts who before Suboxone didn’t respond very well to treatment. This new drug, Probuphine, is an implant that lasts up to six months — it’s touted as a solution to abuse and resale.

It’s great that new drugs are being developed and refined so that addicts have a better chance at recovery, and physicians have the comfort of knowing the drug  is used for its stated purpose, but there should be caution too as we go forward in the brave new world of medicine. So far, no drug has substituted for counseling when it comes to addiction. Addiction is far more than physical dependence to a drug. Addiction becomes a mental obsession that if left untreated will likely drive the addict back to their drug of choice.

Buprenorphine has been great to stop physical cravings for opiates, but unless an addict learns to cope with reality without a mood-altering drug, they’ll most likely continue using. There’s much to understand about addiction that will help healthcare professionals care for addicts in more effective ways. Any physician who prescribes Suboxone or some other form of Buprenorphine, or any other drug prescribed to treat addiction, without insisting the person also receive counseling, is doing a disservice to the patient. Physicians don’t have to maintain counselors on staff, but physician can refer the patient to addiction treatment professionals.

When an addict is simply given a drug and doesn’t receive any counseling, they usually have serious problems with relationships, employment, self-esteem, guilt and shame, and so forth, that can require months of counseling and years of recovery management. Addiction breaks a person down, and that person needs a period of rebuilding or they’ll likely return to their drug out of panic from mental pain and emotional confusion. Counseling helps a person understand what recovery entails. A good treatment plan gives the addict guidelines, a set of actions to rebuild what’s been torn down. No, there’s no drug that cures addiction — but there are drugs, like Suboxone, and perhaps Probuphine, which are good tools to make treatment and recovery more likely.

Freedom from Addiction

freedom from addiction

Recovery Management

It’s hard for the non-addict to imagine the loss of freedom that comes with addiction. Addiction is progressive and it advances in stages. In the early stages of addiction, it’s hard to recognize and accept. Many people go through life stages where they drink too much or party a little too hard, but they don’t lose their ability to leave it alone when they want to cut back. The non-addict might misuse alcohol or some other drug on occasion, but they can cut back when necessary. The addict, in the early stages of addiction, can cut back at times, but then will lose control at times, never knowing when they’ll intend to drink a few beers, say,  but wind up getting smashed. In the beginning, these episodes of control-loss are easily rationalized — I saw an old high school buddy — I had a bad day at work — I got caught up in the party atmosphere — so on an so forth. Alcoholism, especially in the early stages, has been called controlled/uncontrolled drinking. When you think about it, the non-addict hardly ever thinks in terms of “control”.  Just having to control drinking can be a sign of a problem.

When addiction advances and the periods of control-loss become more common and the consequences build up, the addict might become secretly worried that he/she is losing control. The rationalization and excuse making becomes harder and more elaborate. The addict might even admit that emotional problems exist from the past that could be the reason for the increase in drinking/drug using. This is where addiction becomes murky when searching for cause and effect. When the addict loses control on a regular basis and does things they never intended to do, it seems like a mental or emotional disorder. Traditional psychology has promoted this explanation of addiction, but medicine and science declared addiction a chronic brain disease long ago. This doesn’t mean that mental and emotional problems don’t coexist or are not caused by the chaos of addiction, but in order to gain liberty from addiction, the addict must first stop using the drug that’s causing the problems or preventing the person from dealing with problems. An alcoholic can deal with emotional problems but continue to drink alcoholically, because the alcoholic has developed a combination of physical dependence and mental obsession that drives them to drink regardless of their mental health.

Also, just quitting drinking or drugging doesn’t free the person from addiction. There is much more that needs to be done before an addict can claim freedom. The first step is admission of slavery to the drug, which is not hard to do in the later stages. When an addict wakes up in the middle of the night craving a fix from their drug of choice, and when the addict can no longer control the drug except for short periods of time, when the addict starts losing time in blackouts, not sure what they’ve done, then that person is no longer free, and it’s a miserable existence. Admission of slavery to the drug must be followed by action, asking for help. Most drug addicts can’t get off the drug by themselves, and even if they can, staying off is the trick.

Recovery Management is the key to long term recovery, and we’ve discussed Recovery Management in this blog many times. The feeling of freedom, once a person in truly in recovery, can seem miraculous — it’s a life changing transformation. In AA, a part of many meetings is the telling of a story of how it was, what happened and what it’s like today. These stories of recovery are powerful, and the newcomer finds hope in recovery stories. Most people only hear the negative consequences of addiction, but recovery is real and happens each day. Asking for help can set in motion a life long journey of sobriety and good living. Recovery happens — the addict can be free.

Addiction Treatment – Abstinence or Improvement?

substance abuse

Treating addiction

Improvement is also known as risk reduction. In addiction treatment, the question between abstinence and improvement doesn’t have to be resolved by absolutely choosing one or the other. Historically, those who advance risk reduction have clashed with those who advance abstinence. A lot depends on definitions and emphasis. Are we talking about clients who misuse drugs and aren’t addicted or is the subject addiction? Is medically assisted treatment under consideration?

I think this controversy relies too much on the expectations of the addiction professionals. In reality, there are clients who choose abstinence, and there are those who go through treatment and continue to drink alcohol or smoke pot or use some other drug. The problem with determining the validity of all this is the reliability of self reporting post treatment– however, such things as legal problems or job loses or divorce, etc., can be corroborated.

So, if a person who has experienced several DUIs, several job losses and a divorce due to drinking alcohol then goes into treatment and a few years after treatment is still drinking alcohol but has had no legal problems, no job losses and is now married reporting a healthy relationship, you can say that the person’s life has improved during this period of time post-treatment. The treatment professional can claim success if the measurement is improvement in the quality of life. If the measurement for success is abstinence, then the treatment professional might say that treatment didn’t work. This is all from the perspective of the professional’s expectations and measurements. The ex-treatment client might see it all from a different perspective. Perhaps the client was not an addict and went through treatment during a time of emotional stress and was simply misusing alcohol or some other drug. When addiction treatment professionals perform assessments, they should be sure that the signs and symptoms of addiction are prevalent, but assessments are not 100% valid. Abstinence is never a bad choice, but if someone chooses to drink or use some drug post-treatment, and if that person doesn’t experience the same problems as pre-treatment, then it is what it is. The most likely explanation is that the person was never an addict, just someone who misused drugs and was misdiagnosed. Another explanation is that when addicts return to drugs, they don’t always lose complete control right away — it can take awhile before the addiction causes major problems. If ex-client is taking a prescribed mood-altering medication to deal with co-existing problems such as depression or anxiety, then this is another situation that requires knowledge and careful decision making, but it’s not necessarily a failure of treatment just because the ex-client is not maintaining total abstinence.

Some treatment professionals who insist on abstinence, regard the use of Suboxone to treat opiate addiction as a failure of treatment and recovery. The evidence of successful long term recovery using Suboxone suggests that the abstinence model is too rigid for the evolving field of addiction treatment. For those of us who were in the treatment field in the 80s and before and who saw opiate addicts consistently leave treatment a few days after entering treatment, we see Suboxone as a life saver.

Treatment professionals should present the client with the facts about addiction and substance abuse. Once the client knows the risks of continuing drinking or using drugs, it’s the client’s decision. The danger of the improvement/risk reduction expectation, on the other hand, is that if the professional translates to the client that it’s reasonable to expect a return to alcohol or drugs can produce marked improvement, if the client takes proper actions to avoid severe consequences, this flies in the face of what’s known about addiction. On the other hand, the professional who insists that total abstinence is the only way does not respect the client’s free choice, and misses the fact some improvement in quality of life is possible without complete abstinence. It also misses the fact that some recovering addicts require mood altering medicine to maintain recovery and improve quality of life.

The best the professional can do is offer knowledge, understanding, compassion and expertise with honesty regarding addiction, based on what’s known about addiction, substance abuse, psychology, behavior, etc., then leave the client to the client’s free will to make his/her own choice. If the treatment team has provided knowledgeable, competent treatment and has educated the client on Recovery Management, then that’s success. There are different paths to recovery. Addiction and substance misuse are complicated — it takes a great deal of understanding to provide a nuanced approach that makes sense and helps the recovering addict make better choices.

 

Shaming Drug Addicts

Shaming drug addicts doesn't work

Understanding is more effective

There’s still a stigma placed on drug addiction — old ideas die hard. If anyone pays attention to what little news coverage drug addiction receives, they’ll know that people from all walks of life become addicted to drugs – preachers, police, judges, doctors, politicians, retired grandmothers, plumbers, lawyers, secretaries. Age doesn’t matter — young people become drug addicts, old people, middle aged people — nor does race matter, or religion or nationality, and so forth.

Looking down on drug addicts and shaming them into change is counterproductive and misguided. I hear it all the time, the way people talk about drug addicts, as if they’re an inferior, subhuman species. At other times the attitude toward drug addicts is more subtle, but the idea that drug addicts should be ashamed of their behavior is pervasive. In business circles when someone begins showing signs of alcoholism, the person is often shunned and viewed as weak willed. People gossip about the lady down the street who’s addicted to pain pills — she’s seen as a bad mother and wife.

One would think in 2016 that most people would understand addiction as a chronic brain disease, but that’s not the case with many in society who still place their own value judgments on addiction based on what they were taught growing up. Last night I was at an educational dinner regarding opiate addiction and medically assisted treatment. The speaker was a physician, and several in attendance were physicians. The doctors talked about their lack of training in medical school pertaining to addiction and addiction treatment. They all said the same thing, that addiction was an afterthought in medical school, yet hospitals are filled with patients who are there as a consequence of addiction. Sometimes, people in the helping profession are the worst shamers of all. They get burned out and develop disgust aimed at drug addicts who seek help. Addiction is complicated and difficult to deal with, but it’s very treatable if it’s done with kindness, understanding and competence.

It’s time to stop shaming people who are sick with addiction and start learning what addiction is and how it’s treated. You can take most anyone who feels superior to a drug addict and drill down into their lives to find something that you can shame them for, but rather than looking for ways to feel superior to others, many be we should look for understanding and ways to lend a helping hand.

Drug Courts: National Results

the treatment alternative

Treatment not Jail

Drug Courts have been around for a long time and the results have been very good. Most of us who’ve worked in the treatment field have known for a long time that jail has always exacerbated addiction, and that treatment of addiction is better for individuals and society. Drug Court as an alternation to jail is not a slam against the law and order position, it’s a practical position that has to do with the reality of addiction. In treatment, addicts aren’t escaping responsibility for their actions, they’re treated for a chronic brain disease for which they have to take responsibility. Addicts in Drug Court are held accountable – they’re expected to follow the rules and achieve the goals set for them by the treatment team.

In jail, the addict would be around other addicts and criminals and would not receive treatment for the condition that will likely keep the person in and out the court systems until something really bad happens. Below are facts about Drug Courts:

+ Drug Courts Reduce Crime

  • FACT: Nationwide, 75% of Drug Court graduates remain arrest-free at least two years after leaving the program.
  • FACT: Rigorous studies examining long-term outcomes of individual Drug Courts have found that reductions in crime last at least 3 years and can endure for over 14 years.
  • FACT: The most rigorous and conservative scientific “meta-analyses” have all concluded that Drug Courts significantly reduce crime as much as 45 percent more than other sentencing options.

+ Drug Courts Save Money

  • FACT: Nationwide, for every $1.00 invested in Drug Court, taxpayers save as much as $3.36 in avoided criminal justice costs alone.
  • FACT: When considering other cost offsets such as savings from reduced victimization and healthcare service utilization, studies have shown benefits range up to $27 for every $1 invested.
  • FACT: Drug Courts produce cost savings ranging from $3,000 to $13,000 per client. These cost savings reflect reduced prison costs, reduced revolving-door arrests and trials, and reduced victimization.
  • FACT: In 2007, for every Federal dollar invested in Drug Court, $9.00 was leveraged in state funding.

+ Drug Courts Ensure Compliance

  • FACT: Unless substance abusing/addicted offenders are regularly supervised by a judge and held accountable, 70% drop out of treatment prematurely.
  • FACT: Drug Courts provide more comprehensive and closer supervision than other community-based supervision programs.
  • FACT: Drug Courts are six times more likely to keep offenders in treatment long enough for them to get better.

+ Drug Courts Combat meth addiction

  • FACT: For methamphetamine-addicted people, Drug Courts increase treatment program graduation rates by nearly 80%.
  • FACT: When compared to eight other programs, Drug Courts quadrupled the length of abstinence from methamphetamine.
  • FACT: Drug Courts reduce methamphetamine use by more than 50% compared to outpatient treatment alone.

+ Drug Courts Restore Families

  • FACT: Parents in Family Drug Court are twice as likely to go to treatment and complete it.

  • FACT: Children of Family Drug Court participants spend significantly less time in out-of-home placements such as foster care.

  • FACT: Family re-unification rates are 50% higher for Family Drug Court participants.

There’s no question that Drug Courts provide long term solutions and that jail simply prolongs and complicates the problem of addiction.