Archive for the ‘Addiction Explained’ Category

“Any problem which can be solved with money is not really a problem.” Anonymous

No amount of money and no amount of “medicine” will heal an addiction. The fundamental healing which occurs in the setting of addiction comes about as the result of a spiritual awakening. For some reason, as yet unknown by science, a spiritual awakening displaces the compulsion to drink or use drugs. Science, with all its power and knowledge, may assist the process but it cannot supplant it. This simple fact has been known for the past 74 years and the process for achieving the spiritual awakening was codified in the first 164 pages of the Big Book of Alcoholics Anonymous some 70 years ago in 1939. Not one word of the first 164 pages of that book has changed since it was written. It is classic knowledge and it contains a “spiritual technology” which can enable anyone, regardless of their beliefs—or the lack thereof, to achieve a fundamental psychic change which will ensure sobriety so long as that person maintains a fit spiritual condition.

Unfortunately for some, “spirituality” is inextricably bound to “religion” and many of the people who enter recovery have been traumatized by their early “religious” training. In effect, they have been “de-churched” and the mere mention of spiritual matters evokes strong feelings of resistance, or even revulsion. “God” or a “Higher Power” is an anathema to these people and it is something that they reject out of hand. In the course of growing up, our first contact with a “higher power” is often in the guise of our parents. Most addicts and alcoholics come from families in which the disease was active and emotional, physical, or even sexual traumas have occurred. Given this possible history of family trauma, it would make sense that these people would reject a “higher power” concept. Even when this type of trauma has not occurred, the afflicted may reject the idea of a higher power based upon their intellectual constructs or their life experience to date.

Alternatively, some people have a strong faith in the God of their religion, but this faith does not keep them sober. What this amounts to is “faith without works.” The spiritual technology set forth in the 12 steps of Alcoholics Anonymous is hard work. Getting sober is hard work. Staying sober also requires ongoing work, however, it is much easier to stay sober than to get sober. Getting sober is like pushing a broken-down car on a flat road—it takes a lot of energy to get the car moving, but once its moving it takes less energy to keep it rolling. In any event, the key ingredient to sobriety involves a spiritual awakening which occurs as a result of “working the steps.”

The “science” involved in addiction medicine has to do with the use of various tools in order to facilitate a spiritual awakening. These tools include: an introduction to 12 step concepts and philosophy, individual and small group psychotherapy, and the use of medications to manage cravings and concurrent psychiatric disorders (aka. Dual Diagnosis). Science does not have a “magic bullet” for the disease of addiction. There is no drug, vitamin, or technical procedure which can ensure sobriety. However, treatment of concurrent psychiatric disorders has been shown to improve the duration and quality of sobriety in affected patients.

The purpose of this website is to offer encouragement, information, and general knowledge on the topic of addiction and alcoholism. The author believes that “healing and sobriety are possible for anyone” provided that the individual is willing to do some simple (but not easy) work.

A recent article in the Mayo Clinic Proceedings highlighted the severity of opiate addiction due to prescription drug abuse. According to the article in the July 2009 edition: “nonmedical use of prescription opioids has increased exponentially since the early 1990s. Not surprisingly, the expanded use of prescription opioids for all reasons, legitimate and illicit, has correlated with the steady increase in opioid related deaths nationwide.” The article noted that “methadone related adverse events increased 1800% between 1997 and 2004; fatalities increased 390% from 1999 to 2004(the most recent national data available), and methadone was the drug with the greatest increase in fatalities; methadone also is the sixth most frequently suspected drug in death and serious nonfatal outcomes. . . Half of methadone deaths are pain patients who are being mismanaged by physicians who lack sufficient knowledge or skills to use methadone in the treatment of pain.” The number of deaths due to prescription opioids in 2001 was 3,994 and this more than doubled in 2005 to 8,541.

What accounts for this drastic increase in deaths due to prescription opiates? In the opinion of this author, the current epidemic of prescription opiate addiction and deaths have come about as a result of the “pain movement”. In the late 80s and early 90s, numerous studies within the medical literature indicated that physicians were under-treating pain in the setting of advanced cancer and other terminal conditions. The “pain movement” originated as a valid response to the dilemma of poor pain control in the setting of malignancy and other potentially terminal conditions. Unfortunately, unbridled enthusiasm on the part of “pain doctors” soon led to the use of narcotics for the management of chronic forms of nonmalignant pain. While the use of narcotics in some of these conditions is certainly justified, the difficulty which arose had to do with the dissemination of this information to overburdened primary care doctors who would now be expected to become pain experts and to manage their patients with the same skill and oversight which was being promulgated by academicians.

Another factor which contributed to the problem had to do with the patient population being managed by the academicians. The patients managed by the academicians were highly selected and thoroughly screened for a pre-existing history of substance abuse or other risk factors likely to predispose them to the adverse outcomes associated with narcotic addiction. Obviously, this is not the population that a primary care doctor would be seeing. Also, the amount of time dedicated to the evaluation of these patients within the academic setting was likely much greater than the amount of time spent by the harried primary care doctor (or even the community-based “pain doctor”). Given this set of circumstances it is no wonder that we have an epidemic of opiate addiction related to the overuse of narcotics.

Of course, some unscrupulous physicians have also seen the profit potential which exists for servicing addictions and, at this writing, a bill is currently pending in the Texas Legislature to outlaw so-called “pill mills” — – these are clinics which are infamous for their reputation of prescribing narcotics at /the drop of a hat.

 During the course of my career as a general internist, I have come to believe that 80% of illnesses are lifestyle induced and 20% are the result of bad genes, bad luck, or a bad infection. My job is to ask myself whether or not the patient sitting in front of me is an “80 percenter” or a “20 percenter”. If the patient is a 20 percenter, then the diagnostic workup will be more involved than the workup of someone with a common illness. It is my belief that 80% of those individuals with common illnesses are suffering from an addiction. I define an addiction as a pathological relationship to a mood altering substance, behavior, emotion, or relationship that results in life damaging consequences. Using this very broad definition of addiction, I can define my obese, type 2 diabetics as food addicts. These diabetic patients use food to mood-alter an uncomfortable emotional state. Indeed, food is the cheapest drug available in American society. The end result of food addiction is early death due to heart attack, heart failure, or end-stage kidney disease requiring dialysis. However, if I were to label my diabetic patients as “food addicts” they would look at me as if I were crazy. These patients do not view themselves as addicts simply because “no one ever got arrested for driving while fat.”

In other words, in order to be considered an addict a person must have violated some social norm or legal standard. Typically, addicts and alcoholics are viewed as weak willed or morally bankrupt individuals who have lost the power of choice when it comes to the use of drugs or alcohol. This mistaken notion is a byproduct of American culture. We live in the society of John Wayne; where everyone is rough, tough, and individualistic and pulls themselves up by their bootstraps. If you are an addict or an alcoholic, you have a weakness of character, an inability to deal with life, or a case of chronic “wimphood”. Given this set of circumstances, it is no wonder that denial runs rampant in the setting of these diseases. Who in their right mind, would ever admit to being an addict or an alcoholic given the social stigma that surrounds the disease. This unfortunate set of circumstances results in untold suffering in millions of people. Unfortunately, these persistent myths shame the afflicted and prevent them from getting the treatment that they need.

The truth of the matter, however, is that addiction and alcoholism are brain diseases. The brain, for the purpose of this discussion, can be divided into three major areas: the pons and medulla or “reptilian brain”; the mesolimbic system also known as the “emotional brain” or the “rat brain”; and the cortical brain or the “big brain”. The reptilian brain tells your heart how often to beat and how often you should breathe. In other words, it coordinates automatic functions within your body. The mesolimbic system, or rat brain, sits above the primitive reptilian brain– and this is where the disease of addiction resides. The cortical brain represents what we think of as characteristic of an individual human being. It is the repository for higher thinking, personality, willpower, and the capacity to judge, plan, moralize, or philosophize. The hierarchical organization of the brain is such that the reptilian brain will trump the emotional brain which will trump the cortical brain.

What then, is the purpose of the emotional brain? From the evolutionary standpoint, the emotional brain exists for a very good reason; there are certain activities in life which are essential to survival, these include: food, sex, exercise, and drinking water when you’re thirsty. When you perform these acts, so-called pleasure chemicals are released in the emotional brain which tells you at an irrational, nonverbal, emotional level to: “keep doing this– it’s essential to your survival”. Drugs of abuse (such as alcohol, heroin, cocaine, methamphetamine, etc.) directly and reliably stimulate the production of these pleasure chemicals within the emotional brain. Each time the addict or alcoholic takes a “hit” or a “drink” they are directly stimulating the release of chemicals which tell them “keep doing this– it’s essential to your survival”. Notice that the term is “essential”, not optional. In effect, the addict’s brain is hijacked by their drug of “no choice”. Once they begin to use their drug of “no choice” they trip the switch on a self reinforcing circuit which perpetuates a deadly obsession and compulsion.

All of this occurs in a very primitive area of the brain. The deeper within the brain that the lesion exists, the more difficult it is to eradicate. The prevailing or stereotypical view of this disease suggests that the disease is due to a lack of willpower. Of course, this is not true. Willpower is a function of the cortical brain which sits above the emotional brain. Willpower is ineffective in changing lower brain functions. The following example is instructive with respect to the limitations of willpower; when my youngest son was eight years old he went out on Halloween night for trick-or-treat. The next day he had a bag filled with candy. He was overindulging in the candy and I took the bag away from him, at which point he threatened to hold his breath until he died unless I gave him the candy. Of course, I said go ahead and try. By sheer force of will he attempted to hold his breath until he would die — – needless to say, this didn’t work. It didn’t work because his lower brain, i.e. the reptilian brain, overrode his desire to hold his breath. In the case of the alcoholic or drug addict, their attempts at controlling their disease through willpower are doomed to failure because they are trying to override a lower brain function by depending upon a higher brain function.

So does this mean that the addict is doomed? No, of course not. It means that he has a disease which can be arrested, but not cured. How then, is the disease arrested? First of all, the degree and severity of the disease must be assessed with respect to the need for inpatient detoxification or concurrent medical or psychiatric care.  Once the patient is stabilized, the real work of recovery begins.  To date, the most effective means of arresting the disease of addiction or alcoholism comes about as a result of a spiritual awakening. For some reason, as yet unknown by modern medical science, a spiritual awakening has the capacity to displace the compulsion to use drugs or drink. Of course, I am a medical doctor — – I don’t dispense spiritual awakenings. The most reliable means for attaining a spiritual awakening in the setting of alcoholism or addiction comes about as a result of working the 12 steps. The 12 steps is a spiritual technology which has the capacity to free the individual from the deadly obsession and compulsion with which he is afflicted.

The problem with the 12 steps is that many people confuse it with religion. 12 step programs focus on spirituality, not religion. In effect, spirituality represents the progressive death of self-centeredness combined with the growing awareness that the purpose of life transcends the mere gratification of instinctual drives. A key component of spirituality is the discovery of, and dependence upon, a power greater than oneself. However, the definition of that higher power is left up to each individual. The road to recovery is broad and inclusive; it is also simple, but not easy. The purpose of my practice is to use my skills as a medical doctor to facilitate the growth and eventual recovery of my patients. It is my belief that anyone can recover if they are willing to follow a few simple suggestions and to work at their own healing.

The purpose of this essay is to acquaint the reader with the “elephant in the living room”, i.e., the disease of addiction. Addiction, or its secondary manifestations, represents the most common cause of suffering and death in this country today. This idea, however, is a new one and is not widely embraced by the medical community as a whole or by our current society. The failure to identify this mechanism of disease as a primary cause of death and disability relates to how the disease is perceived at the societal level. Most often, people think of addiction as a destructive habit related to the excess use of drugs or alcohol which results in the violation of social norms or legal standards. The negative societal stereotypes associated with addiction ascribe its cause to: a weakness of character; a moral failing; or an inability to deal with life. Given this set of circumstances, the application of the label “addict” is associated with considerable stigma. To some degree, the presence of denial is understandable given the negative social stigma.

The key to understanding addiction as a primary pathophysiologic mechanism lies in its definition and its relationship to the physiology of brain function. Webster’s Unabridged Dictionary (2001) defines addiction as: “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” This is a very good definition and a good starting point. From the standpoint of a disease model, this author defines addiction as: “a pathologic relationship to a mood-altering substance, behavior, emotion, or relationship that results in life damaging consequences.” Using this very broad definition, this author can define his obese, type 2 diabetics as food addicts. These patients use food to mood-alter uncomfortable emotional states. However, the recognition of the primacy of addiction as a cause of obesity is not reflected in the medical literature. Typically, medical reviews of obesity ascribe its cause to: a sedentary lifestyle, genetics, rare endocrine diseases, or a simple excess of caloric intake related to caloric expenditure.

Interestingly, however, the current pharmacologic research in obesity revolves around brain function and the neurotransmitters associated with the endocannibanoid system. Yes, cannibanoids, i.e. receptors in the brain that are stimulated by marijuana. According to the Journal of the American Dietetic Association (2008;108:823-831): “Weight gain, particularly abdominal fat mass gain, along with consumpiton of a high-fat, high calorie diet are postulated to overstimulate the endocannabinoid system, initiating dysregulation contributing to the pathophysiology of body weight regulation.” This statement implies that central nervous system regulation of body weight is a key factor in obesity. But how does the central nervous system regulation of weight relate to the disease of addiction?

From a biological perspective, the disease of addiction is a central nervous system disease. The brain, for the purposes of this discussion, can be divided into three separate areas. The “reptilian brain” consists of the pons and the medulla, this is a very primitive area of the brain which regulates automatic functions such as how often your heart beats and how often you breathe. Above the reptilian brain, is the “emotional brain”, this is the area of the brain which is involved in the disease of addiction. Above the emotional brain and is the cortical brain. The cortical brain is what we think of as representative of the attributes of a human being. The cortical brain is the repository of the ability to plan, to think, to analyze, to philosophize, to moralize, and to exert one’s “willpower”. A general law of brain function, is that lower areas of the brain have the capacity to trump higher areas of the brain.

The disease of addiction resides within the emotional brain. From an evolutionary standpoint, the emotional brain exists for a very good reason; the emotional brain contains the pleasure center and stimulation of the pleasure center reinforces a human being to perform acts which are characterized as “essential” to survival. There are certain activities in life which are essential to survival; those activities are: food, sex, exercise, and drinking water when you’re thirsty. All of these natural activities result in the stimulation of the pleasure center, which conveys to the human being (at an irrational, emotional, nonverbal level) that the current activity is “essential” to survival. It turns out that drugs of abuse directly and reliably stimulate these pleasure centers resulting in the feeling that the continued intake of drugs or alcohol is “essential” to survival. In effect, drugs of abuse, of which food may be considered one, hijack the emotional brain and override the impulses of willpower exerted by the cortical brain. This is the essence of addiction at the neurochemical level.

Currently, our country is in the midst of an epidemic of obesity. The medical consequences of obesity are numerous, dangerous, and life limiting. However, this is not the only manifestation of addiction which results in increased suffering and death within the population. Cigarette smoking, a manifestation of addiction to nicotine, is the cause of the number one cancer in American society, i.e., lung cancer. Alcohol, a more traditionally recognized substance of abuse, results in significant morbidity and mortality as noted in the following: 15% of men and 10% of women meet the criteria for alcohol dependence; 25% of medical-surgical inpatients have serious alcohol problems; 10-46% of ER visits are prompted by alcohol; and 17% of ER patients are harmful drinkers. Alcohol is a factor in: 60-70% of homicides; 40% of suicides; 40-50% of fatal motor vehicle accidents; 60% of fatal burns; 40% of fatal falls; and 50% of trauma cases. In addition to all of this, 15-30% of demented nursing home patients have dementia secondary to alcoholism. This devastating litany of statistics demonstrates the primacy of addiction as a pathophysiologic mechanism of disease in modern America.

Given all of the aforementioned objective data, why would someone “choose” to continue their abuse or dependence on food, alcohol, or drugs? The answer is that they don’t “choose”. They are trapped within a deadly obsession and compulsion, which left untreated, will reliably progress to insanity, incarceration, or death. Those who live with the alcoholic or addict can see that their lives are falling apart, the addict, however, doesn’t see this because his emotional brain is telling him that the continued use of his “drug of no choice” is essential to his survival. At this point, the addict’s cortical brain is largely engaged in rationalizing and justifying his continued use. The approach to the patient at this point will be addressed in a separate article. If you are an addict, or the family member of an addict, do not lose heart. There is hope and help for recovery. The purpose of this author’s practice is to facilitate that recovery.