Local Crisis

Posted on February 20, 2012 by admin

My local community is currently undergoing a massive addiction crisis.

A large pain management clinic was recently shut down because the physician overseeing it lost his license. It was suspended last week on an emergency basis because an investigation revealed that many of the patients there were being over-treated, undoubtedly because of an addiction they had developed to the narcotic pain medications. The physician himself is under investigation for dispensing excessive quantities of controlled substances out of his office, and he was felt by the investigating body to be a danger to the community. With his center closed,there are four or five hundred poorly-managed chronic pain patients in this community who have suddenly lost access to their source of drugs. Some of these people surely have chronic pain issues that need to be addressed, while many probably have primary addiction problems, but either way, all are physically dependent on massive doses of methadone, Percocets, and Oxycontins. Without these medications, or any managing therapy to replace them, these four or five hundred people will be horribly sick, in great pain, and possibly driven to unacceptable behavior (theft, etc.) in order to find new sources of the drug they feel they need.

Physicians in the area are not excited about taking on new patients with poorly maintained or spotty medical records and poorly managed, poorly documented pain issues, especially since all these patients need immediate refills of their massive amounts of narcotics. The addiction doctors in the area, the few of them that there are, are not really qualified to evaluate these patients for the true status of their pain condition, and so have no real way to separate the primary pain patients from the primarily addicted patients. Most addiction-based physicians are at or near their 100 patient Suboxone limit in any case, and do not routinely prescribe other narcotics.

We also can’t forget about the ERs, where physicians are also wondering how they will handle this massive crisis. ER doctors will ultimately become the last resort for many of these patients who cannot get their prescriptions filled in a more controlled manner. The ER will be flooded with people with a multitude of pain complaints and withdrawal symptoms, trying desperately to get their narcotics filled. I cannot begin to imagine how much time and money will be wasted doing unnecessary testing for complaints of abdominal pain, back pain, and headaches — not to mention the delay in attending to others who will be competing for ER time with many of these patients.

This is not the fault of these patients — it is primarily the fault of the physician who so badly mismanaged their care, and his staff who were clearly not trained to recognize or deal with the addiction problems that so often attend pain management. (I very much doubt that he knew that he might want to be on the lookout for addiction problems.) Due to his recklessness and carelessness, the medical systems of this community are very shortly going to be overloaded with patients who desperately need to be managed and are extremely difficult to correctly diagnose.

A harm reduction model would suggest that somebody just needs to open up an office and provide all these people with the narcotics they want to keep them from flooding and incapacitating the rest of the system. That is essentially the role that the suspended pain management center was playing, and while it was logistically effective, no plan like that will ever be sustainable. Not to mention, of course, that it is a gross violation of the goals and ethics of medicine.

I don’t know how this situation will resolve. I will do my best to take on excess patients when I can be sure that their problems are primarily addiction-related, and I’m going to make an effort to educate my fellow medical practitioners about this issue. If nothing else, I hope this can serve as a warning of what can happen even when we do the right thing by closing down a poorly-run pain management center. Maybe soon we will be able to move forward to find a more sustainable solution.

Casualties in the War on Drugs

Posted on February 10, 2012 by admin

Demi Moore was reported as having had “convulsions” after smoking an undetermined substance (probably “Spice”) late last week. Spice and K2 are both generic names used to refer to a wide range of synthetic cannabinoids, designer drugs intended to mimic the effect of marijuana on the brain. Many varieties of spice boast that they are made of “legal herbs”, which is always almost untrue — and even when the substances involved are legal, they are not intended for smoking, and tend to have severe adverse effects. A physician quoted in the linked article above states that spice usage can often lead to “prolonged seizure and seizure-like activity”, and that the lack of quality control makes purchasing these compounds a potentially lethal form of gambling with the amounts of chemicals involved.

Yet one of the most stunning things about this story is how little attention it’s getting. If Demi Moore had collapsed from a new flu strain, the public health resources of the entire country would be focused on dealing with the issue in a major way; people would be lined up to buy their hand sanitizer and get their flu shot. Because her collapse was addiction-related, and we see addiction as being “not a public health problem” or just a natural price of stardom, it is essentially ignored — despite the fact that the same condition is epidemic in almost every community in the nation. Where are the people lined up to buy lock boxes for their prescription pills? Where is the public education campaign asking people to do this? Where are the resources of the CDC aggressively pursuing an answer? Where are the parents boycotting those stores that sell stuff like this to our kids? Where is leadership from the addiction treatment community to get any of this done? There is a bill currently in Congress to outlaw Spice, K2, and other compounds, but the designer drug industry will only continue to flourish, pushing more and more dangerous compounds that have been carefully engineered to evade the strictest legal rules, regardless of what effects that engineering has on the health of those who use it. Without widespread public education and public health resources available to everyone, substance-seeking and addictive behavior will just move on to more and more lethal experiments.

What we are experiencing now in the “War on Drugs” bears many similarities to what the country experienced during Prohibition. Outlawing alcohol did little to decrease drinking; instead, people moved on to bootleg methanol, which caused seizures, blindness, and death. What we are seeing in the proliferation of spice compounds is the same pushback against ineffective and harmful legislation. Marijuana is safer, less addictive, and less likely to cause violence than alcohol; it has been grouped in with other, much more dangerous drugs like cocaine, and been outlawed along with them. For those who claim it is a “gateway drug”, I would like to note that the marijuana substitutes being produced now are, technically, legal – those who want to smoke marijuana are very interested in staying within the bounds of the law. No one bothers with “legal” synthetics of heroin or cocaine, because those drugs cause a potent addiction that makes the drug a priority over all legal or moral concerns. Marijuana does not do the same.

If we believe that all mind-altering substances should be forbidden and illegal, then it makes no sense at all to have alcohol freely available and encouraged throughout our society. If we agree that some mind-altering substances can be taken recreationally, when well-controlled and in safe circumstances, then legalizing marijuana becomes a sound health and economic choice.

I do not personally endorse anyone taking mind-altering substances, or breaking the law. But I think it’s foolish that we seem willing to sacrifice countless people to harmful synthetic drugs rather than legalize a substance that wouldn’t even be the most damaging or addictive substance a 21-year-old could purchase anywhere in the country. Demi Moore is a highly visible personality, but for every celebrity whose drug use makes the news, there are millions of others who are being harmed out of the public eye. That’s an epidemic, and it’s time we worked towards stopping it.

Fear and Education

Posted on February 1, 2012 by admin

It’s clear that more adults, including physicians, need further education about the causes and consequences of addiction, but it may be even more important to educate our children before they make decisions that can end up tearing apart their entire lives. Drug education in schools is mandatory and ongoing, but it’s clearly inadequate, for much the same reasons that health and sex education standards are inadequate.

The approach most schools take to drug education is a unilateral, completely straightforward “Just say no!” campaign. They struggle to paint all use of any substance, even one sip of alcohol or one cigarette, as a horrifying and potentially lethal act of self-destruction. While it’s true that beginning to drink or smoke at a young age can have horrible long-term effects on health, painting the situation with such a broad brush just sets the education program up for failure, because it creates an illusion that can’t be maintained. Kids — especially pre-teens and teenagers, who are the target of most drug education — are immature, but they aren’t stupid. They will see adults having a drink, or smoking, in their everyday lives. They may see their friends trying a beer or a cigarette, and when that adult or that friend doesn’t immediately crash a car, vomit, or suffer some other horrible comeuppance, the kid who has been through that style of drug education will conclude that they have been lied to. They will also realize, possibly just by going home in the afternoons, that not all people who are addicted to substances are bad, dirty people. By refusing to deal with any of the nuance or complication of addiction, much of drug education sets itself up as a lie — a lie that will be easily disproven. And the worst thing is that, once a kid has realized that official education sources may exaggerate or lie, that kid may never trust an official source of education again. Any future attempts to correct the bad drug education will fall on deaf ears.

If we are going to have any hope of reaching kids, we must show them the basic respect they deserve, and tell them the truth. They have to understand that a large number of people want to get high, or feel an altered state of consciousness, and that there are safe ways to do it — drinking in moderation with friends (without driving afterwards), for example. Kids need to know that some things, like marijuana, are almost infinitely safer than others — like the “legal” marijuana analogues that use things like toxic bath salts and tar, and can cause seizures.

The drug education standards prevalent today are not strictly “education”, in my opinion. Education is a process designed to give people true and useful information with which they can make decisions and keep themselves safe. The statistics and medical consequences discussed in drug education programs are certainly true, but they are not presented in the context of giving useful information; they are presented in the context of propaganda and scare tactics. While I understand the deep concern and fear for the safety of children that is behind this style of teaching, I also feel certain that it does not work, nor will it ever work, the way it was intended. Giving students information you swear is true, which will be contradicted by their real-world experience, will only set them up for lifetime distrust of education. It may also lead to them throwing out the legitimate warnings along with the trumped-up fear tactics, and put them in a worse position than before.

Drug education, like health and sex education and all other important topics, must be discussed with children in a way that is serious and straightforward, but it must also take into account the complexities that that child will face as they attempt to make their way in a nuanced adult world. “Just say no” has some valuable aspects to it as a campaign, and I would certainly rather that no one under legal age used any substances at all, but a lack of proper education will only lead to more addicted people living more self-destructive lives.

Unforeseen Consequences

Posted on January 24, 2012 by admin

One of the first things I saw when I got online this morning was this article from the Comcast.com news page:

http://xfinity.comcast.net/articles/news-general/20120123/US.Meth.Severe.Burns/

It’s a report on how burn centers in some states are being forced to close due to a spike in patients who were burned making methamphetamine in their homes. Since meth-related injuries are among the most difficult and expensive to treat, and patients who sustain this kind of injury usually don’t have insurance, the cost is being absorbed by the hospitals and burn units, which is leading to the shutdown. The reason for the recent spike in meth-related burn cases is the rise of a new meth-making process which involves combining the volatile ingredients in a two-liter soda bottle, which is then shaken near the face. In contrast to fires in a meth “lab”, which people can often escape, a meltdown in the soda bottle process invariably causes debilitating burns to the face, chest, and hands, and often results in blindness.

There are several reasons why this new, more dangerous technique is taking hold in states where meth is a severe problem — the new method is more cost-effective, requires smaller amounts of controlled substances, and produces a smaller quantity of meth, for personal use rather than sale. But wouldn’t the vastly increased risk make it a less attractive option?

The fact is that one of the many symptoms of addiction is a decreased ability to appreciate risk, especially where the addictive substance is involved. The strength of an addictive craving will convince a patient to take greater risks to their health and safety in order to fulfill it, but it doesn’t end there — after prolonged use, addicted patients show a habitual desensitization to, and comprehension of, risks to themselves or others. If the risks of soda-bottle meth (called “shake-and-bake” by the linked article) were associated with any other product, they would act as a discouraging factor; but because we are dealing with a specifically vulnerable population, it cannot be assumed that the greater risk will act as a deterrent.

Knowing that, and desiring to keep their burn centers open and able to serve all patients, it seems like the only course for affected states and hospitals is to try and prevent these people from sustaining these injuries in the first place. One of the reasons given for the rise of shake-and-bake meth was “greater attempts to crack down” on traditional, larger meth labs. As an experiment, I googled “how to make methamphetamine” and found thousands of recipes and explanations. Clearly, enforcement after the fact is not working, and will probably never really work; with no way to limit the spread of information on how to make meth, and a segment of the population who are less sensitive to risk and incredibly desperate to attain their drug of choice, it is clear that all attempts to “crack down” will only drive addicts to more dangerous (and possibly lethal) methods.

I have no doubt that extensive programs to prevent meth addiction are already in place in these states where it is an epidemic, but these burn center closures are sending a clear message that whatever programs currently exist are inadequate. Programs designed to alleviate financial stress and the living standard of residents might be an improvement, since substance abuse is often tied to socioeconomic stress. And while any such program would undoubtedly be extremely expensive, it would surely fall far short of the “hundreds of millions” of taxpayer dollars currently being used to absorb the cost of treating uninsured burn victims.

This is just a symptom of a wider problem that I encounter every day — namely, the disgraceful lack of attention that is given to addiction as a wide-reaching problem on the national stage. People in positions of power, as well as most people who have never been affected by this disease, appear to think that drug addiction is “under control”, or is a problem that will never have any consequences for them. The fact is that, besides being a huge drain of human life and economic resources, addiction has shattering and unpredictable affects on all people in this country. Now, as we are seeing, victims of fires in some states will have less access to adequate care. The fact is that addiction is in no way a small or insignificant problem, and any attempt to decrease it must have just as widespread and long-lasting benefits.

Interpretations of AA

Posted on January 19, 2012 by admin

I spend a lot of time on this blog discussing 12-step programs. But what exactly constitutes a “12-step program”? The term itself is rather vague.

I tend to use this as an umbrella term to describe the group-based, discussion-heavy, and non-medicated treatment style that claims to be the spiritual successor of AA. This approach has been expanded to treat narcotic addiction, nicotine addiction, and any number of other conditions. It has also been adopted very widely, and while it’s common for treatment providers to stay close to AA’s original 12 steps, they also tend to tweak and change and “put their own spin” on the program as much as they can. What this has led to is a huge variety of treatment approaches that, to an outsider with a critical eye, all appear to share a few core principles that they have taken from the founding tenets of AA. Usually this includes belief in a Higher Power; the righting of wrongs done to others in the past; establishing a social network with other ex-addicts; and a strong moral emphasis on being “clean” rather than “dirty”; and a refusal or demonization of medication.

I write about 12-step programs mostly from my own experience, because as a doctor advocating medication maintenance for addiction, I encounter a great deal of hostility and resistance from the staff of these programs. I also witness firsthand the effects that this style of treatment has on my patients, who refuse to stay healthy on maintenance because they believe they are still “dirty”. Most programs that fight against medication maintenance do so using a kind of authoritative hair-splitting; they claim that, since buprenorphine affects the opiate receptors, it takes away a patient’s right to be called “clean” or “in recovery”. I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization. You can read Bill W.’s opinion on who should be allowed to be a member of AA here.

Alcoholics Anonymous was founded in 1935 by Bill W. and Dr. Bob as a way to help alcoholics find strength and comfort in community. As part of my education in the field of addiction, I’ve read a large amount of AA literature, including the “Big Book”, considered the central text of the organization. I have reached the conclusion that the original spirit of AA was an unflinchingly inclusive one, and that the founders would not have approved of keeping an addict out of “recovery” based on what other medication they were taking, or what other measures they might be taking to control their alcoholism. Addiction is a disease, and taking regular medication for it should be no more problematic than taking regular blood pressure medication. It certainly shouldn’t be used as an excuse to keep stable and thriving patients out of the nebulous category of “in recovery”.

Yet a great deal of resistance to medication maintenance comes from a widely-held belief that medication somehow violates the principles of AA, and the 12-step programs that have descended from AA. I would argue that this belief is factually wrong, but the factual correctness of a statement like that doesn’t even matter, because every interpretation of the “principles” of AA is equally valid. AA (used here as the flagship example of the 12-step type of program) is a nebulous, widespread organization without a central authority capable of making policy decisions. It is based on a certain amount of written material, all of which is open to interpretation, and there is no one with the authority to call any interpretation right or wrong. It actually resembles many religions in this way.

I would argue that the belief that medication goes against the spirit of AA is widely-held, not because the texts support such an interpretation, but because it has become a sort of canon that has been mixed into the original philosophies of AA and passed on due to tradition and financial advantage. Thankfully, since all interpretations are equally valid, I will tell all my future patients that this ugly and discriminatory policy does not come from a place of authority and should have no power to prevent them from seeking the most effective treatment they can.

Inside the Anger

Posted on January 11, 2012 by admin

Last week, I wrote about how 12-step programs that hire exclusively from the small pool of “12-step successes” may be misleading their patients — and how patients are taken in by their own tendency to trust in anecdotes more than statistics and data. This week I want to write about a very similar trend among those who defend 12-step treatment programs against the advance of other, more scientific methods of treatment.

I spend a great deal of time on various forums online, debating the merits of different forms of addiction treatment with professionals and laypeople alike. I see it as a vital and valuable way to stay informed and relevant to the conversations going on in the community I am trying to serve. One thing I’ve noticed over the course of these discussions is that people who tend to support 12-step programs tend to be much more emotionally invested in their arguments, and often react to disagreement as though it were a personal attack.

I don’t think this has anything to do with these people in particular; I’ve gotten enraged, nearly hysterical responses from people who work at these programs, people who don’t, even people who relapsed after undergoing a 12-step treatment. I think a feeling of deep emotional attachment to the ideals of 12-step programs are a symptom of the way these programs are run. I mentioned last week that anecdotes, especially when they are highly emotionally charged and are coming from people in positions of authority, may well be the most powerful persuasive force that can act on a human mind. 12-step programs engineer situations that harness this force in their favor. They present sick, frightened, desperate patients with calm and reassuring counselors (remember, all drawn from a small percentage of addicts), and have those authority figures relate stories of how their lives were ruined and 12-step programs saved them.

The effect this has is very difficult to overstate. It is, as I said, very persuasive — but it’s persuasive on an emotional basis rather than an intellectual one. Emotional certainty can be very useful and necessary in our lives, but it can also cloud our judgement and make us miserable when we are confronted with facts that disprove the foundations of our emotional knowledge.

This is what I believe is going on today in the ongoing war between 12-step supporters and medical professionals who advocate maintenance therapy for addiction. 12-step programs have become almost a kind of religion; they introduce their patients to an entire moral worldview, one based on willpower and a “Higher Power”, complete with narratives of sin and redemption. They introduce this system in very stressful and vulnerable situations, and encourage their patients to rebuild their lives on this foundation. There would be nothing wrong with this, if the foundation itself wasn’t fundamentally, factually flawed. It turns out that addiction is not solely a moral failing, and often cannot be overcome by willpower alone, the same way that willpower can’t overcome diabetes. But statistics and science that try to make that point are rejected and even attacked, because they threaten the deep emotional foundation on which 12-step patients have constructed their world. Because it’s an emotional threat, the reaction is emotional as well; I, as a physician, don’t have a particular emotional attachment to any one mode of treatment, and I’m willing to debate them all on intellectual grounds. That’s why I’m often caught off-guard by the intensity of the anger that I find when talking to those who have been through this 12-step persuasive process.

I want to say again that I don’t think these people are “stupid”, or weak, or that they have some kind of innate problem. I believe they have been taken advantage of by a system that, wittingly or not, has been fine-tuned over decades to make its patients believe that no other method or provider can be trusted.

It is my hope that, through education and continual refinement of the science behind addiction treatment, we can replace this manipulative system with one based in factual reality, which will hopefully help more patients to live healthier lives.

12-Step Statistics

Posted on January 2, 2012 by admin

It’s common for addiction treatment centers and 28-day rehabs to advertise that their staff is made up only of ex-addicts. They treat it as a selling point that patients won’t talk to anyone who hasn’t found success fighting addiction — if not at that particular center, then almost certainly through similar methods of abstinence, willpower, roleplaying, and lectures.

There’s a valuable element of encouragement for patients to see and talk to role models who have overcome the problems they’re facing. It is completely natural and commendable for people who have struggled with addiction to want to help others who are currently struggling. But by hiring only one subset of people, these treatment programs end up spreading a deeply misleading and harmful idea of addiction, which can delay or even stop their patients who are on their own “roads to recovery”.

First of all, hiring only those who have “succeeded” on 12-step programs is playing a statistics game. Out of all comers — anyone who considers themselves an addict or alcoholic and attends at least one 12-step meeting — between 90 and 95% find the program doesn’t work, and leave. Success rates given by 12-step treatment centers are often framed with the understanding that these 90% of people don’t count — the program has an “80% success rate”, which means “successes” are 80% of those who were in the 10% who stayed. While this might be a good argument that the 12-step treatment works well for a certain kind of people who find the program helpful, it is not a compelling reason to say the treatment will work for all addicts. When you further narrow the field by choosing an arbitrary definition of “success” — three years clean, or five, or ten — the end result is that the program works for a very, very small percentage of the total addicted population. 12-step centers then go on to hire exclusively from this very small pool. What this means is that, although the whole point is to show patients that they, too, can become “successful” like the staff has, the reality is that it is very unlikely any particular patient will be part of the same tiny percentage of the population that all of the staff are drawn from. (It is also worth noting that when I say “very small”, I don’t mean that the total number of successes is small. It might be several million; that doesn’t matter. All that matters is that, for every success, there are many millions more addicts who 12-step programs would call a failure.)

So the “inspiring” message that patients can become like the staff is likely very misleading. What can make it harmful, though, is a fact of human psychology; human beings tend to find anecdotes more convincing than data. Especially to patients in a treatment center, who are often sick and frightened, a personal story of redemption told by an authority figure (a counselor or administrator) is much more powerful than a presentation on statistics of the kind I’ve discussed.

This is a very well-known fact of how human brains work, and there’s no getting around it. It’s the reason people buy lottery tickets, or refuse to fly on airplanes, or do any number of things that don’t make much sense from a statistical point of view. It can sometimes be very helpful to our survival, but it can also do us a great deal of harm. I personally have had patients leave my practice because I have statistics, data, FDA reports and medical science behind me, but I can’t offer a personal anecdote of having been at “rock bottom”. This emphasis on personal stories means that, not only are patients in 12-step treatment centers being told stories that are unlikely to apply to them, they are being taught to trust those stories more than any hard data they might see in the future. For the vast majority of people who won’t turn out to succeed in 12-step programs, the anecdotes they heard from ex-addict staff may prevent them from seeking other methods of treatment that might work better for them. It sends them back into ineffective 12-step programs again and again, utterly convinced that they can overcome all odds, projections,and medical facts, just because they heard that some other person once did (or thought they did).

While it may seem heartless to say that people shouldn’t try to beat the odds, the fact is that the odds are there for a reason. Moreover, acknowledging the facts and acting accordingly will almost always lead to a healthier and happier life for the larger number of patients.

We at the Bel Air Center for Addictions hope that all of you have a healthy and happy New Year.

Pain and Addiction

Posted on December 27, 2011 by admin

This week, an excellent article on the American Pain Foundation (APF) was brought to my attention. In it, the APF’s stance that “the risk of [opioid] addiction is overblown” is examined in light of the fact that the APF receives a great deal of its funding from companies that produce addictive painkillers. I highly recommend you click that link; the article is thorough and well-researched, and provides a valuable perspective on the kind of misinformation that can harm patients when medical issues become overly profit-driven. The companies producing and promoting the use of addictive painkillers clearly have financial motives to conceal their potentially harmful effects, and they also have clear motives for funding institutions such as the APF, which can lend credibility to research that might otherwise appear “scant or disputed”. Whether or not the people working at APF believe what they say about the “low risk” of opiate addiction — and despite the real good that APF may have done in the realm of patient advocacy — maintaining that prescription of opiates should be uncontrolled is severely irresponsible.

Will Rowe, the chief executive of the APF, is quoted in the linked article as saying that “The problem isn’t opioids… It’s poorly trained doctors who prescribe them too easily or in excess.” That is certainly true. No drug in and of itself is “good” or “bad”; all treatments are appropriate in some situations while being inappropriate in others. But Rowe and others similarly associated with the foundation also express fears that regulation of physicians will “scare them away” from prescribing opiates, and induce “opiophobia” that will harm patients.

Even if the fear of “opiophobia” is legitimate, I have a hard time believing that encouraging doctors to be more conservative in prescribing highly addictive drugs will cause more harm than it will prevent. What pain management doctors don’t seem to realize is that addiction is a distinct disease, and that some symptoms of what they think is “chronic pain” are, in fact, symptoms of addiction. Some patients absolutely do have chronic pain that requires long-term opiate treatment, but I would argue that many more patients have “chronic pain” which is actually chronic withdrawal. I have had more patients than I can count who, after a few days on buprenorphine, tell me that the underlying cause of their opiate use (back pain, joint pain, or other common pain conditions) has disappeared. In these patients, the initial problem that caused them to seek treatment for pain probably cleared up long ago, and that the pain they had been self-medicating was in fact withdrawal.

Patients who are addicted without knowing it, and who self-medicate for withdrawal, are among those most harmed by the APF’s insistence that opioids have “low risk” and must be protected from regulation. These substances are absolutely, unequivocally addictive, and downplaying that risk is an appalling betrayal of trust on the part of the APF and all similar institutions. Whether patients are willing to take that risk is a matter to be decided with their physicians, but that decision cannot be made well if both physicians and patients are assured that there is no risk.

I’ve written before about how more regulation on the prescription of pain pills could very easily decrease addiction (and its associated costs), choke off the supply of narcotics being sold illegally, and improve pain management by not compounding pain with further addiction-related problems. The APF’s stance against such regulation seems to me to be blatantly self-serving, which undercuts their claim to be focused entirely on patient welfare.

The Gold Standard

Posted on December 7, 2011 by admin

On this blog I tend to talk about opiate addiction more than any other kind, mostly because opiate-addicted patients are the ones I most often see and treat. Of course, we can still learn from other kinds of addiction — in fact, if we really want to look at a powerful model for the disease of addiction, we need to look back at the gold standard: smoking.

There is very little actual advantage to smoking a cigarette, not in the way that there is for other drugs. It does not give you a lasting or euphoric high; it is not a great way to party or relax after hard week at work; it does not have nearly the psychoactive effect of any other typically abused drug. It can be a social activity, but more and more restaurants, hotels, and even public parks and bars have been banning smoking in recent years; smoking is becoming less and less feasible as a means of social connection, like alcohol is. The nicotine itself, apart from its addictive effects, provides a minimal amount of relaxation or stimulation (depending on how it is smoked) that literally lasts only for seconds.

So why do people smoke, and why do they continue to smoke after it becomes costly, inconvenient, and even life-threatening? The answer, of course, is because of nicotine’s addictive effect on the brain’s reward system. People become so addicted to this short-lived effect that they find it necessary to reproduce it hundreds of times per day. A one-pack-per-day smoker is smoking 20 cigarettes each day, perhaps taking between 10 to 15 puffs per cigarette. That equals 200 to 300 hits per day. The effect on the brain of a single hit of nicotine lasts about 4 seconds. 250 hits per day gives 1000 seconds, or slightly less than 17 minutes of nicotine-stimulated brain activity per day. If someone smokes their one pack a day over a typical 16 hours of being awake, each day they are providing nicotine to the brain for only 2% of their waking hours.

Now think about the cost that society and individuals pay for this addiction in years of life lost due to cancers, chronic lung disease, premature heart disease, etc. On average, smokers die 13 to 14 years earlier than nonsmokers. (You can check out some of the tobacco statistics here.)

Smokers are exactly like anyone addicted to any other drug. They aren’t weak, and they aren’t bad people. To non-addicts, it looks like they are constantly, continuously making an irrational choice, but that’s not the case. Their brains have simply become so dependent on those little bursts of nicotine that it is incapable of putting any long-term health or financial consequences before getting the next hit. The very fact that it’s not so obviously harmful, and that it generally takes years to start showing negative health consequences, allows smoking to escape a great deal of the stigma of other addictive drugs. While it’s true that no addict should be stigmatized for their illness, that also doesn’t mean that smoking should get a pass, or be considered ‘not a problem’, when it can be just as powerful a controlling force in an addict’s life as a stronger opiate.

Cigarette smoking is less extravagantly destructive than heroin or methamphetamine, but it follows the same pattern of all other addiction. These are all different forms of a single disease. Our current scientific advances in the treatment of addiction notwithstanding, the best way of dealing with addictions is still with education and prevention, so that they never start in the first place.

Thanksgiving Thoughts

Posted on November 25, 2011 by admin

The blog is updating a little late this week because of the holiday. I hope that you all had wonderful Thanksgivings, and that you got the opportunity to spend time with your families and think about the things in life you’re thankful for. Though eating and shopping have become large traditional parts of this weekend, it’s always worthwhile to stop and reflect on what we are grateful for in our lives.

It’s always difficult to feel thankful when you’re suffering from a long-term illness, and the disease of addiction has a uniquely destructive effect on the lives of those it afflicts. The behavioral and psychological aspects of the disease often lead to broken families, as theft, lies, and betrayal take their toll on relationships with parents, spouses, and children. The financial drain of drugs and treatment can prevent addiction patients from being able to provide a large Thanksgiving feast. It’s a long, hard road to emerge from this disease, and it’s difficult at any point to feel particularly thankful for the troubles it brings.

But there are still reasons to be grateful. We now live in one of the few decades in history where an effective treatment for addiction is generally available. That treatment is not a cure, and it is not as widely available as I would like, but there is more hope of a normal life for addicted patients than there has ever been before. With more understanding of and education about this disease, the family members of addicted patients can learn to help their suffering loved ones and make treatment easier. And it is my sincere hope that understanding and treatment will only continue to improve.

Thanksgiving is now over, but I think it is worthwhile to remember what we have to be thankful for every day of the year. I am thankful for the ability to help my patients, and I will continue to reflect on that opportunity on Monday. Until then, I wish you all happy holidays.