Monthly Archives: September 2011

Addictive Personalities

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We used to think of addiction as a moral sin — something that happened to people who were weak, or sinful, or broken in some way. Over time, this view grew into the perception of addiction as a moral failing, or some type of personal deficit that made some people become addicts and others not. The first few haphazard attempts to medically describe the disease of addiction still held onto this viewpoint, that addiction was caused by an inborn character weakness; eventually this gave rise to the idea of an “addictive personality”, a vague series of personality traits thought to cause addiction.

The concept of an “addictive personality” as a cause of addiction has been discredited for years, ever since physicians have begun to think of addiction as a physical disease and not an inbred moral issue. It became clear that certain chemicals had the potential to addict anyone, regardless of personality, and before long most serious medical  discussions had abandoned the concept of an addictive personality altogether.

Now, as we struggle with the concept of addiction as disease of the brain, those who work with addicts still have to deal with the many “bad” behaviors that those with addiction display. We have also started to realize that to some extent many people with addiction display many of the same characteristics — poor judgement, poor evaluation of risk/benefit analysis, impulsevenss, easy boredom, craving for excitement, difficulty learning new
behaviors, lying, and others.  These clusters of behaviors seem to be common to many suffering with addiction; in other words, they appear to form a pattern of behavioral symptoms that are linked to the physical disease.

Do these behaviors arise because of the addiction and the neural damage it can cause, which would make them a set of acquired cognitive deficits secondary to the development of addiction?  Or are they a set of dormant, inborn characteristics that exist in our patients that are pre-disposed to developing addictions (which we know have a genetic component)?  We don’t know the answers to these questions, and they will be very difficult to study, partly due to the complexity and misunderstood nature of addiction, and partly because it develops at a very early period of life when a person’s full personality is not yet formed. If, at some point, it can be proven that these behavioral traits come before addiction and contribute to its development, then perhaps there is a definition for an addictive personality disorder after all.

The discussion of a possible “addictive personality disorder” is not about developing a new way to label addicts, or trying to go back to the concept of addiction being some type of inbred defect. If there were a cluster of personality traits that we could recognize as being suggestive of the development of an addictive disorder, then perhaps it would lead to early
recognition of a “pre-addiction” condition that might be amenable to early recognition, intervention, and prevention. Even if we can prove that an “addictive personality” exists, it should still not be seen as a defect or a moral failing; like other potential personality disorders, it is due to factors beyond a person’s control and merits treatment, not punishment.

The brain is such a complex system that there are certainly undiscovered connections between chemicals and behavior still waiting to be uncovered. I am looking forward to physicians and patients moving forward together to advance treatment and prevention of this disease.

The Physician’s Position

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Working in the field of addiction has the tendency to put M.D.s and other health care professionals in a very unusual and often disorienting position; we are expected to give in to the instructions and demands of ‘counselors’ and other self-proclaimed addiction experts who are not professionally  or medically trained. This is often very frustrating to us when we attempt to make our voices heard. We are used to being respected for our education, the number of years that we have put into training, our professionalism, the standards we try to uphold, and our expertise regarding issues of human health and disease. Yet, in this particular field, we are often viewed by others as knowing less than the patients we treat. And it’s all because most doctors and highly-trained professionals don’t have a personal history of addiction.

I have experienced this strange anti-non-addict prejudice many times in my online discussions with representatives of 12-step programs. (In one memorable argument, I was ridiculed for having letters after my name — as though the ‘M.D.’ was a pair of mystic runes that prevented me from seeing the truth.) Trained doctors are relative newcomers in addiction-related fields. Our profession has not, historically, been the one leading the treatment of this disease. In fact, many blame us for ignoring addiction, not understanding it, offering false hopes, enabling it, or in fact being a major cause of it through our prescription pads. And while it’s true that mismanagement by uninformed doctors has been a contributing cause of addiction — particularly addiction to prescription painkillers — that is reason for more doctors to come into the field and get the education to understand this disease and its causes. Efforts to keep physicians out of addiction certainly won’t help us understand and deal with addiction as a disease.

I’ve seen it said often that “nobody understands but another addict”. This attitude does not exist anywhere else in medicine, and I am not sure where it comes from. While it can certainly be helpful and emotionally supportive to speak to someone who’s shared the same problems you have, there is a limit to this idea. Cancer patients don’t refuse to be treated by doctors who have not themselves had cancer. A patient with chronic headaches won’t storm out of a doctor’s office because the doctor doesn’t have chronic headaches and “wouldn’t understand”. Physicians are trained to be able to offer help, understanding, and compassion to patients in many different situations. In fact, a physician who has specialized in treating a particular disease may “understand” better than the patient what the disease is doing to their body, and how to fix it. Most people who have a problem are anxious to explain their problems to others, to make them understand what it is like from their viewpoint, and to seek their understanding and help. Only in this field does there seem to be this rejection of assistance from those who have not had addiction problems.

I believe that the tide is changing, and that physicians do have both a stake in this disease and some very valuable ideas to offer, which is why I write this blog. There are certainly going to be some bumps in the road, and physicians will have to prove that they are compassionate and competent in treating addiction, but there is only so much proof that can be offered. I am afraid that no amount of successful care from trained professionals will convince some of those who cling to ineffective treatment methods and are not interested in learning anything new.

Medication Metaphors

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I have many patients who have been stable on Suboxone for a long time, sometimes for years, who come to me and ask to taper off their dose in the hope that they can get off the medication altogether. I have used blood pressured medication and insulin as examples to explain why Suboxone is a maintenance medication that needs to be taken continuously, but these patients never seem convinced. They feel that they are not ‘succeeding’ or are not ‘sober’ while they are taking the medication, even if they are living full, healthy, happy lives. I’ve talked a lot on this blog about why I believe people come to feel this way, and why I disagree with their reasoning. I haven’t spent as much time talking about the reason why I try to dissuade my patients from trying to taper off. The reason is very simple: it doesn’t work.

With some medicines, tapering off is a valid strategy. Antibiotics work like catapults or bombs; they are a way to kill a large number of invading enemy organisms very quickly. Once most of the invaders are dead, the problem is over, and more antibiotics won’t do any good. There’s no point in firing weapons at an empty field with no enemy soldiers on it. After following the prescribed course, the patient can stop taking the antibiotics and return to their normal lives, feeling perfectly healthy. Other medicines, like non-narcotic painkillers, are given only for a short time because the human body can heal itself without their help. Something you would need to take painkillers for — say, a cut from a surgical procedure, or a broken bone –  will repair itself whether or not you take medication; the painkillers are only to help you feel more comfortable along the way. Once the body’s healing process is finished, there’s no need for you to feel more comfortable, so the painkillers can (and should) be stopped with no ill effects.

Buprenorphine works very differently from either of these examples. Addiction isn’t caused by any invading organism, so taking one massive dose and then stopping the medication won’t do any good. Many people seem to think that buprenorphine will work like other painkillers, and that the brain will repair itself while they take it, but for the vast majority of people this simply isn’t the case. The damage caused by addiction affects a very delicate part of the brain, which won’t heal on its own the way a broken bone will. Our current understanding of the disease of addiction is that  the damage caused by addiction is permanent, so the symptoms will also be permanent, unless they are treated by a maintenance medication like buprenorphine. 12-step and counseling programs sometimes tell their clients that the brain can repair itself after a certain amount of time and counseling, but there is absolutely no solid science to back up such a claim. As soon as a patient stops taking buprenorphine, the underlying damage asserts itself again and the symptoms return, which very often leads to relapse.

A good way to think about this is to imagine the damage caused by addiction as a leaking crack in a dam, and imagine that the dam is holding back a reservoir from flooding the town where you live. It’s fairly easy, and VERY important, to put a patch over the crack to keep it closed; if you don’t, then the water pressure will make it wider, and it will be harder and more difficult to seal up later. As long as the patch holds, life can go on as normal in the town, but the patch isn’t fixing the underlying crack or causing it to “heal” itself magically. All the patch is doing is keeping the damage from getting worse, and keeping the people in the town from suffering the consequences of a break. If the patch is ever removed, the water will immediately start leaking through again, pushing the crack wider and causing a flood.

Using this image, we can think of buprenorphine as a patch over the damaged parts of the brain, holding back the flood of symptoms, cravings, and damaging behaviors that addiction will cause if left untreated. It doesn’t fix any of the underlying damage. It only keeps it from getting worse and keeps it from negatively affecting a patient’s life. In my experience, patients who taper off their medicine because they feel that they aren’t fully ‘clean’ will suffer a relapse in almost all cases.

Providing patients with the complete truth is very important when they have questions or concerns. I always tell my patients that while it is possible for a very few people to taper off Suboxone successfully, for most people it is harmful and counter-productive, and I rarely recommend it. Understanding how buprenorphine works and what it does and does not do is essential to a comprehensive and effective treatment program, and I would hope that all prescribers of buprenorphine take the education of their patients and their loved ones very seriously.

Anecdotes and Data

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Of all the people offering addiction treatment, those who are not trained professionals tend to be laypeople who have struggled with addiction problems in their own past. They may describe themselves as “ex-addicts” or still in recovery, but they offer a common reassurance: that they have experienced all the troubles that addiction brings, and they understand what their clients are going through. Often, they market their particular
treatment program as something that worked for them personally, which they
want to share with others.

The desire to share something that helped you, so that it can also help others in your situation, is a good and noble impulse. But it often happens that the results of that impulse do more harm than good. Brain chemistry and behavior are complex, finicky things, so much so that even our oldest and best-tested methods of treatment often have wide margins of error. In this field, moreso than any other, what works for one person may do no good, or even harm, to someone else. In this field more than any other, we need large
studies and statistics to collect data on huge amounts of people and categorize it so that we can filter out individual eccentricities and find strategies that will help almost everyone.

Anecdotes, personal stories, and testimonials can sometimes be helpful, but they are not medical data. They are often incomplete, exaggerated, or inaccurate, disregarding the people who have strong financial motives to outright lie. People suffering from addiction are often desperate, frightened, and may be functioning at less than their full mental capacity, which makes them perfect prey for unscrupulous con-men selling a program
that they claimed worked for them. Even programs run by honest people who truly were helped by them are often grossly unsuited to help others. Stories and anecdotes tend to be more compelling than statistics, because it is easy to relate to someone telling their story, and the emotional impact of a person standing in front of you telling you about their life is very hard to ignore. But for those same reasons, anecdotes are incredibly unreliable as
the basis for seeking medical treatment. Many people distrust statistics, thinking that they might be fabricated or biased, but the fact is that medical statistics from credible sources (such as the CDC or ASAM) go through a much more rigorous fact-checking process than the founding myth of any nonmedical treatment program ever will. It is the stories of such
programs that are more likely to mislead their clients or put them in harm’s way.

This is only one more way in which we need to bring the field of addiction up to the same scientific standard as other fields, such as dentistry and cardiology. Very few people would, say, switch to an all-banana diet because they heard a story from a neighbor’s friend who said it had cured his cavities. Yet people routinely pay tens of thousands of dollars for the promise of a nebulous “spiritual transformation”, or for a bizarre program
of vitamins, horses, sauna treatments, and other provisions that have nothing to do with addiction, all because they have been fed bad information through “patient testimonials” and other stories.

Healthcare and medicine are based on truth; on what, in reality, actually can be proven to help people. I have seen many peoples’ lives improve after they come through my program, but I won’t ask that people come to my office just because I say that. I prescribe opioid maintenance treatment because its use has been continuously and irrefutably supported by the scientific study of brain chemistry and how it can be altered to improve the lives of people suffering from this disease.