Hurricane Withdrawal

Posted on August 29, 2011 by admin

This weekend, the East Coast was shocked and frightened by the approach of hurricane Irene. Though the hurricane didn’t do as much damage as the news media had forecast, people from North Carolina to Maine feared for their lives and property, and rushed to gather emergency supplies and find somewhere safe to wait as the storm approached.

The hurricane was highly unusual, but the fear and panic that came before it were things I had seen before. For someone suffering from addiction, every day can be like the day before a hurricane. They are constantly living in fear of withdrawal, to the point where every minor headache, cold, or stomach pain is seen as a sign that the storm is about to break, and the wretched withdrawal symptoms are about to hit them with the force of hurricane winds. People who haven’t experienced addiction tend to think of withdrawal as being similar to the flu; it’s uncomfortable, but after a while it goes away and you’re no worse for wear. They don’t realize that one of the symptoms of the disease of addiction is heightened sensitivity to the kind of pain and discomfort that withdrawal brings, to the point where it becomes completely crippling. I’ve had many patients who relapsed because they were unable to ‘wait out’ the withdrawal symptoms, which they say felt worse than a non-addicted person could imagine.

It’s understandable that addicted patients start to panic if they think they are about to experience withdrawal, and that will cause many of them to use. But it extends beyond the panic of a single moment. For addicted patients, withdrawal is always looming on the horizon, and they constantly have to take steps to ensure that they don’t suffer from it. As soon as they get one fix, they have to be looking for the next one. If they have to change cities, or take a trip on business, or deal with some big event like a wedding, they have to ensure that they’ll have an adequate supply of their substance if they don’t want withdrawal to overtake them. The frenzied planning and desperation many patients feel under the threat of withdrawal is similar to what East Coast residents experienced under the threat of hurricane Irene.

Those who say that addicts are ‘dirty’, that relapsing makes them ‘weak’, should consider that perspective before they make their judgements. It is possible for some people to wait out withdrawal symptoms, just as some people were better able to handle the fear and uncertainty produced by the weather predictions last week. But the desire to protect ourselves against perceived future threats is a deeply human trait, and no addiction treatment program can be complete without taking it into account. Physicians in addiction treatment must be aware of what the world looks like to their patients, and they must be willing and able to reassure their patients that the storm of withdrawal isn’t a problem. 12-step and detox programs attempt to just get their patients through the storm, patching up damage as it occurs and making no attempt to prevent further damage. Wouldn’t it be better to keep the storm from hitting at all?

You Don’t Have to Struggle

Posted on August 23, 2011 by admin

Instead of a blog post this week, I am pleased to announce that my book, The Addiction Conspiracy: Unlocking Brain Chemistry and Addiction So You Don’t Have to Struggle, has been converted into a e-book format and is now available for free on the Bel Air Center for Addictions website.

This book grew out of several slideshow presentations I developed to explain the mechanism of addiction in a way that everyone could understand. I urge everyone with an interest in the treatment of addiction to read it, and I hope that it will help clear some of the misunderstanding around this disease.

The book can be found under the “Addiction Conspiracy” tab on the sidebar.

Philosophy and Hedonic Tone

Posted on August 15, 2011 by admin

During the years I’ve spent in the field of addiction medicine, I’ve heard a lot of non-medical explanations for the symptoms and behaviors of people who suffer from addiction. One explanation that keeps recurring in different forms is the idea that all human beings are somehow born with a capacity for “something higher”. This is often described as “enlightenment” or a “higher plane of consciousness”; one Internet commenter recently described it to me as “sparkles and comfort”. The idea is that a normal, healthy human being is somehow lacking in some mysterious key to happiness, and it is this being destined for “more” that drives addicts to their substance of choice to try and find it.

We can also describe this idea using the more scientific concept of hedonic tone. The hedonic tone is a way of measuring the happiness or contentment a person feels or is capable of feeling. Each person has a unique base hedonic tone — that is, each person has a baseline level of happiness that they return to when their lives are free from great stress or achievement. Anhedonia is a condition in which someone’s hedonic tone is unusually low, so they are incapable of feeling pleasure.

People who argue for the “destined for more” model of addiction seem to be saying that we are all born with a certain hedonic tone — let’s say 50% — which is much lower than our maximum, and that this is something wrong with us. They see this unnaturally low hedonic tone as the real problem, while addiction is just a misguided attempt to self-medicate for the real problem. They therefore suggest that by fixing the real problem, you fix the addiction, which is only a symptom. The same commenter I mentioned earlier insisted that if patients could get their “sparkles and comfort” elsewhere, like from a spiritual or religious program, their addiction would no longer be a problem.

The fact is that while we do naturally have a hedonic tone that is less than our maximum, this is normal. By having a hedonic tone lower than the maximum, the brain leaves itself room to increase it in order to reward us for doing things that help us survive. If we were born with a maximum hedonic tone, we wouldn’t respond to any rewards, and we would have no motivation for even keeping ourselves alive.

We can physically see this in action when we study happiness and how the brain responds to it. The brain wants to stay at that ideal 50% hedonic sweet spot over the long run, so while it will reward you with endorphins that raise your hedonic tone, it will eventually return to baseline when they wear off. We see this in people who have achieved some goal that makes them happy, say by buying a new car they really wanted. At first, their hedonic tone is higher, but after some time the brain adjusts the baseline upwards, so that what was once 75% becomes 50% again. This is a way of preventing us from stagnating, and keeping us moving on to the next goal.

We see the same pattern when we look at chemical receptors in the brains of people who suffer from addiction. Normally receptors are active at a baseline level — again, say 50%. Drugs raise the saturation and the hedonic tone, mimicking the feeling of the brain’s reward; it feels good, so the addict continues to do it. The brain wants to be at 50%, so it will eventually adjust the receptor levels, producing more, until what used to stimulate 100% now only stimulates 50%, and to get to 100% requires a greater amount of drugs. This is called “tolerance”, and it’s a phenomenon that many addicts are intimately familiar with. If escalated too long, it can lead to severe brain malfunction, and eventual overdose from the ever-increasing amount of substance needed to reach that 100%.

We can see from this that the “destined for more” model is actually a very distorted way of interpreting real data. It’s true that doing drugs raises the hedonic tone towards the maximum, and that this is the reason addicts first seek it out. Where the “destined for more” model goes wrong is in thinking that humans are supposed to be at 100%, that we are meant to be there, and that being at our natural state of 50% means we are somehow “broken”. It puts a mystical and philosophical distortion over a very real biochemical phenomenon.

Addiction has been around for a very long time, and like any scientifically classifiable disease, it often follows predictable patterns. People with ulterior motives or a lack of medical training have come up with all sorts of theories that claim to explain the nature of addiction, but ultimately fail to hold up under the evidence. It is imperative that all research and treatment of addiction be based on sound science, instead of mysticism, if we are ever to make progress against this disease.

‘Medical’ Marijuana

Posted on August 8, 2011 by admin

In September of 2010, ASAM released a statement expressing what many people considered to be a surprising opinion about the legalization of medical marijuana. The document, The Role of the Physician in “Medical” Marijuana, came down largely against the legalization of ‘medical’ marijuana that have been enacted by several states. This seems surprising, since many professionals have expressed the opinion that, while it is mildly addictive, marijuana is safer to use than other common, legal recreational drugs like alcohol and nicotine. In fact, it’s not the legalization of marijuana itself that ASAM and other professionals are objecting to; it’s merely the haphazard way in which the ‘medical marijuana’ system is constructed.

According to this article from Time magazine, only about 10% of those who use marijuana become addicted, as compared to 25% of heroin users and 15% of alcohol users. The overwhelming majority of marijuana use is recreational, and occurs in people who are not (or are not primarily) addicted to it. To this population, marijuana is still illegal, but is also desirable, and they will try to obtain it through the ‘medical’ system where such a system is in place. This leads to the main point of the ASAM paper; though marijuana is supposed to be dispensed in a medical capacity, it isn’t regulated like an ordinary medicine. It hasn’t been tested thoroughly by the FDA; there is a lack of real dosing guidelines, especially for smoked marijuana, where the amount administered is less easy to control; and the potency, usually measured by THC content, can vary widely, making proper dosing even more difficult. There are no specific illnesses which marijuana has been proven to effectively treat. In short, the ‘medical marijuana’ system is not very medically sound.

It seems that the ‘medical’ system is designed largely to exclude the ‘potheads’, those who are addicted to marijuana or only use it recreationally, from obtaining it. As I’ve written previously, patients who are addicted or have a history of addiction act very differently from other patients, and by making a prescription necessary to obtain this drug, the system gives these patients a strong incentive to lie to their physicians, who may not be prepared for this behavior. Physicians untrained in the field of addiction are now having to deal with people who might be suffering from addiction, instead of whichever disease marijuana is meant to cure. This will lead largely to misdiagnoses and over-prescribing of the drug.

This has also shifted some of the focus of the marijuana legalization debate to physicians, who are in no position to deal with it. Since there are no real protocols or procedures for the administration of marijuana in a medical capacity, physicians are being forced to make decisions about its use based on little or no scientific information. They have been made unwilling gatekeepers, which brings with it a great deal of responsibility and liability.

I am not opposed to the federal legalization of marijuana for recreational use; as I mentioned earlier, marijuana is no more dangerous than alcohol or nicotine. With proper regulation, and age-limit laws like those in place for alcohol, I see no particular reason why it shouldn’t be legal. If we’re going to make it legal, though, widespread regulation is absolutely essential. The ‘medical marijuana’ system is largely uncontrolled, ineffective, and full of loopholes which are ripe for abuse.

Buyer Beware

Posted on August 2, 2011 by admin

I recently heard the story of a woman in California who was lied to by a Scientology-based addiction treatment facility, Narconon, and is now suing them to try and regain some of her lost money.

I went to investigate the website of the facility in question, the Narconon facility in Vista Bay, CA. The website is impressive and appears very professional, and uses many of the buzzwords common to nonscientific treatment programs, including vague promises of “lifelong recovery”, warnings against medication, and an unspecific list of treatments including “vitamins, exercise, and… our sauna”. They claim several times that their method is “proven”, but nowhere on the site do they offer any scientific journals, papers, or research studies that support this claim, and a few of the statements about addiction supposedly made by M.D.s on the Narconon staff are dubious at best. One of many opposing sites, Narconon Exposed, makes an attempt to catalog the problems with Narconon, especially those relating to the organization’s supposed ties to Scientology.

The suffering of those who have been misled by Narconon’s advertising is cause for outrage, but Narconon is also merely a symptom of larger problems in the addiction-care system. I’ve written previously on this blog about the lack of standardization in addiction care, and the tragic consequences it can have for underinformed addicts and their families. The sad fact is that Narconon is licensed by the state of California to adminster addiction treatment, a fact which is flaunted at great length on the website, which includes scans of many impressive-looking official documents. It would be very, very easy for someone who wasn’t aware of the many problems to be taken in by Narconon’s marketing, and sign themselves up for treatment that is not only ineffective, but potentially harmful.

The licensing of Narconon has been blamed on the understaffing and low budget of the California government offices responsible for vetting and approving treatment facilities, and it is likely that as our nation faces growing cuts to public services in the face of the recent budget crisis, such oversights will only grow more common. It is more vital now than ever before for people suffering from any illness to inform themselves on all their treatment options, and carefully investigate any program or facility before they pay for what may be fraudulent care. Snake oil salesmen thrive in times of uncertainty, and decades of misinformation have made people suffering from addiction prime targets.

Narconon’s program is unusually harmful, even cruel, but there are many, many more programs out there that claim to treat addiction with regimens that are stunningly ineffective. I’ve written a great deal about various 12-step programs on this blog, and I am sad to see that Narconon displays many of the same traits that 12-step programs use to market themselves; a warning against all medications, an emphasis on permanent recovery and “cure”, and affiliation with a religion or “spiritual” approach. It just happens that Narconon is affiliated with the Scientologist religious model instead of the vaguely Judeo-Christian one that most 12-step programs are based on.

Snake oil salesmen of this type have been around as long as humanity, and the only way to weed them out is to combat their misinformation with proven medicine, sound science, and rigorous oversight. It has happened in other fields of medicine, and it will undoubtedly happen in the field of addiction, though it may take several years. I am confident that, if we continue to move ahead with research and treatment using medicine to treat the disease of addiction, that the patients who are being taken in by these scams now will be among the last to be fooled.