More Musings on Addiction

By Dr David Laing Dawson

As some have suggested, I didn’t say addictions were brain diseases, I wrote that the trend to think of them as brain diseases has not helped and is coincident with a dramatic increase in people addicted. I also said little about “cause” other than those causes for which we can do something: prescription practices, maintenance of addiction in a least harm approach for long standing addictions, parents and family more involved with teens. I did mention some illnesses that lead to self medication and I should have included trauma (PTSD) in that list. These are all illnesses that can be treated without opioids if we have available and accessible services.

The other purpose of this particular blog was to get past all the BS we tell ourselves, and find a little truth.

I have never seen an addict wake up one morning and decide “today is the day I go clean because overall that is probably a better life choice”. On the other hand, just as I say tomorrow I will start my exercise program, addicts frequently say tomorrow is the day I quit using. When they actually do stop ‘tomorrow’ it is because of a realization that: I will be dead in a couple of weeks otherwise, I will lose my license to practice medicine, I will be fired, my wife and children will leave me, I will not be allowed to live at home unless I stop. They quit when they have to. I am not disparaging addicts saying this. It is true of most habitual human behaviour.

I am getting tired of “childhood trauma” being blamed for everything. First of all if that were true, all of these everythings should be drastically reduced by now in most western countries, for the prenatal and postnatal lives of children are dramatically safer than they were just a couple of generations ago. Yet teen suicide is up, addictions are up, and rates of serious mental illness persist unchanged but for changes in diagnostic criteria. Besides, we can’t go back and remove childhood adverse events, we can only continue to improve the various ways we prevent such trauma.

The other two human characteristics I am trying to address in this blog are: 1. We are often satisfied with the appearance of doing something to help. Hence “national strategies” that are written, publicized, and shelved, television awareness programs, more money devoted to programs that don’t work. 2. We take the easy route of “more of the same” even if there is no evidence the same has made any difference to date. More counselors, more officers, more money spent.

I remember all too well sitting in on a case conference reviewing a patient who had been in “psychotherapy” with at least three counselors over 10 years, and was once again in hospital. At the end of the discussion the treatment recommendation was “psychotherapy”.

“But, but…..”. I said.

******

Historically rates of addiction and the particular demographic addicted have varied exactly with availability and promotion of the addictive substance. That is, to whom the substance was being promoted by pharmaceutical companies, other business interests (legal and illegal), and peers. At one point 3.5 percent of the Egyptian population were addicted to heroin, at the time promoted and sold as a cheap cure-all. In the late 1800’s in North America the people most likely to be addicted to morphine and heroin were older women of some means.  From the Peruvians chewing coca leaves only during religious ceremonies to the present, the history of cocaine use follows just this pattern: cultural and peer acceptance (Peruvian religious ceremony, subduing a population of workers, cure-all for malaise, heightened sexual abilities (Freud), Coca Cola, the entertainment industry, jazz performers, jet setters and businessmen, University students, and then teenagers) plus promotion by business interests, from the farmers to the producers, shippers, the cartels to the low level dealers.

Marvin mentioned American soldiers in Vietnam previously. Research at the time showed up to 20% were addicted to Heroin. But more importantly, those kept in Vietnam to dry out and become abstinent showed only 5% relapse after being sent home.

Those sent home while addicted and who were then treated in the U.S. (in treatment centers in the US) had a relapse rate of 95%.

All of this information speaks to several points:

1. Though some of us may be more vulnerable to addictions, any of us can become addicted.

2. The possibility or probability of becoming addicted depends a great deal on availability and promotion of the substance and the social acceptability of using it. (in Vietnam within companies of soldiers in 1970, women of means in the late 1800’s, 56% of teens using cocaine say they were introduced to it by peers as a cool thing to do.)

3. Coerced, socially enforced or necessary abstinence plus a new social environment when abstinent, has worked very well.

I would add another fact. Smoking cigarettes, being addicted to smoking, has dramatically decreased over the past 40 years in Canada. Two things are responsible: cigarettes are a little less accessible, but more importantly it has become NOT socially acceptable to smoke. In the background we became more and more aware of all the health hazards of smoking, but this is background. Simply presenting this information to teens in the 1950’s increased their smoking. Only when it became not a cool thing to smoke did smoking decrease.

One of the most difficult aspects of keeping a teenager abstinent from opioids, amphetamines, ‘shrooms once he or she is “dried out” is finding new friends. That is, finding a social environment, becoming part of a social environment, where doing drugs is NOT cool.

And these facts underline a fourth point.

4. De-stigmatizing drug use and addictions is more likely to increase drug use and addictions than to decrease it. At least with adults. All bets are off with teens. They are contrary creatures. Though I must admit, from what I have seen, even young adults who are addicted seem to derive some satisfaction from being “outlaws”. The long list of colorful nicknames for each drug tells the story of the ambivalent relationship addicts have with their drug of choice. This is just the list of phrases created for the act of using heroin:

  • Chasing the Dragon
  • Daytime (being high)
  • Evening (coming off the high)
  • Dip and Dab
  • Do Up
  • Firing the Ack Ack Gun
  • Give Wings
  • Jolly Pop
  • Paper Boy
  • Channel Swimmer

We are about to embark on a social experiment in Canada. Will the legalization of marijuana decrease or increase the number of teenage Canadians who go to school stoned?

******

We are the only species needing a set of Ten Commandments. Moses didn’t finish with the humans, send them away and say, “Okay, all you other species, gather round. I have some rules for you too.”

Most of them, I suspect, especially the seagulls, would have had issues with the ‘thou shall not covet’ clause.

There is a reason we put stop signs at cross roads and don’t leave it to individual motorists to choose to stop.

Methadone is a replacement addiction, albeit one that can be monitored, controlled, with a goal of careful weaning. But the urine test at the methadone clinic is not a standard medical test. It is a lie detector.

The veterans who became addicted in Viet Nam and came home addicted and received “treatment” in America were introduced to a drug culture here, and within that culture 95 percent relapsed. The ones treated (forced abstinence) in Viet Nam came home to the suburbs and small towns where drug use was not part of the culture. 95 percent stayed clean.

When I say addicts lie, that they only stop using when they have to, that if they don’t change friends and social groups they will relapse, I am not making a moral judgment, I am just trying to observe human behaviour without blinders. Only if we do that can we develop good programs to assist those addicted and prevent more people from developing addictions.

For alcohol, prohibition is known to not have worked. In fact, it did reduce alcoholism and it did reduce the rates of cirrhosis of the liver and all other medical consequences of drinking. But it did, as we know, support organized crime, start an inner city war between cops and rival gangs, create an industry of illegal alcohol production and smuggling, and provide the fodder for numerous novels, movies and TV programs.

Our compromise in Canada has been provincially controlled sales, thus providing each province and the Feds with billions in taxes, some of which are earmarked to publicize the dangers of drinking, and to treat or deal with some of the consequences of drinking in excess. In a sense the addiction has shifted to the state, now dependent on the revenues from alcohol sales.

Throughout recorded history we humans have sought elixirs, roots, potions, quaffs and smoke that might alleviate our tiredness, our aches and pains, our anxiety, our weariness, our sadness. Most of them used in excess become addictions. Most of them used in excess cause disability and disease. And now, thanks to modern chemistry, some of them kill with simple overdosing. (60,000 Americans last year)

The excess use of these substances does not satisfy the concept of disease, any more than smoking cigarettes is a disease. And thinking of this behaviour as a disease is not helpful.

On the other hand, we live in a time when multiple civilized, industrialized, educated, organized societies have tried different approaches to common social problems. This is a laboratory from which we can learn (not the USA, for they learn from nobody, but at least Canada). What are the rates of marijuana use among teens in Holland? Does the legalization (with interesting controls) of marijuana reduce use of more dangerous drugs? Is it true that the “legalization” of all drugs, plus mobile clinics to deliver these drugs to addicts, reduced the rate of addiction in Portugal?

Undoubtedly the administration of Naloxone in a timely fashion saves lives, but will having it readily available reduce the overall death rate from overdose?

Has combining addiction detoxification and treatment of the mentally ill within one facility helped either population or has it simply led to more injuries, more need for security in these institutions, along with a hardening of attitudes?

 

 

 

 

 

 

 

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Addictions and Mental Illness: We Need To Stick Together

Guest blog by Angie Hamilton

A response to Marvin Ross and Dr. David Laing Dawson

Thank-you Marvin Ross for this opportunity to respond to your article Addictions and Mental Illness Do Not Belong Together and Part Two of that article by Dr. David Laing Dawson.

PART 1

In your article you state that addictions are quite separate from mental illness but that, for some inexplicable reason, addiction has been lumped in with mental illness.

However, the reality is that they occur together more often than not. How is it possible to separate addiction and other mental health conditions? Dr. Kim Corace, a psychiatrist at The Royal in Ottawa, recently presented a paper at the Issues of Substance Conference by the Canadian Centre on Substance Use and Addiction (CCSA) entitled “Opioid Use Disorder in Youth: Mental Health Comorbidities and Treatment Outcomes”. It showed that 100% of the youth with opioid use disorder also had depression, 70% had anxiety and many had other co-occurring mental health conditions. In my experience attending support groups for parents of addicted youth for over three years, all of the teenagers had co-occurring mental health conditions (although statistics usually range from 70% to 90%).

Numerous studies point to the overlap between addiction and other mental health conditions and we are not, as yet, able to determine causation. Did self-medication of the other conditions lead to addiction or did addiction cause the other conditions or did something else lead to both?

Your article also states that lumping addiction in with mental illness does a disservice to the mentally ill because addiction, at some point, involved a choice whereas there is no choice involved for schizophrenia, bipolar or depression. It is true that, at some point, addiction involved a choice to use an addictive substance. With respect to alcohol, it is a decision that has been made by 80% of Canadians. When you add in prescribed medications that can lead to addiction it is a decision that maybe all Canadians have made. There are many patients who have become dependent on, or addicted to, painkillers taken as prescribed by their doctors. Rather than vilify people for making a choice that most of us make, it would make more sense to ask “Why do some people who use an addictive substance become addicted and others do not?”

Addiction is a pediatric illness. Early initiation is a major risk factor. Seventy to ninety percent of addiction develops during adolescence. The decision to use or overuse a substance that leads to addiction is usually being made by a teenager. The adolescent brain, in layman’s terms, has been described as all gas and no brakes. Because the pre-frontal cortex (home of executive function) is not fully developed we have all kinds of laws designed to protect minors because we acknowledge that their ability to understand the consequences of their behaviour is not developed.

Other risk factors include genetics (which accounts for 40-60% of the risk), co-occurring mental health conditions, personality traits (risk-taking, impulsivity, anxiety and hopelessness) and environmental factors especially adverse childhood experiences (trauma). Adolescents do not choose their genetic predispositions, personality traits, environments (with the exception of peer groups) or to be traumatized. And they don’t choose to become addicted. It happens without them knowing. By the time they figure it out, it’s too late.

As to where the experts stand with respect to addiction being a choice or a disease, The National Institute on Drug Abuse (NIDA), a U.S. federal government drug use and addiction research institute, defines addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. While most experts and professionals do not dispute the disease model of addiction, it is not without controversy.

You quote Dr. Sally Satel in your article. In her article Addiction and the Brain Disease Fallacy she states:

First, we do not address the question of whether addiction is a “disease.” With the potential exception of certain organic brain syndromes, the field of psychiatry recognizes “disorders” or syndromes, rather than diseases because the etiologies of mental illness are not yet well understood. So, addiction fits the notion of disorder insofar as persistent craving and/or continued, excessive use leads to dysfunctional behavior. We are more concerned with the very different issue of whether addiction is best construed as a brain disease or brain disorder.”

It is clear that while she takes issue as to whether addiction is a disease or not, she still views it as a disorder. If we are focused on treatment and recovery, does that distinction really matter?

PART 2

The gist of Dr. Dawson’s article is that people with addiction choose to use and choose to continue to use. Accordingly, they are to blame for their addiction. They are immoral and should be criminalized for any crimes they commit because of their addiction, unlike people with other mental health conditions who are engaged in criminal activities (those deemed not criminally responsible). But many have developed an addiction while trying to self-medicate other mental health conditions.

Disease or not, all experts would agree that addiction creates changes in the brain that result in compulsive drug seeking in spite of adverse consequences. At its core, addiction is about self-harm. It is a slow death (or quick in the case of overdose). At the severe end, people struggling with addiction do not make decisions in their own best interest with respect to all aspects of their lives and they lose everything that matters to them – jobs, family and friends. They lose control over their lives which become chaos. And so yes, they consume substances that could kill them.

It is estimated that eighty percent of overdoses are accidental and twenty percent are deliberate. Which side of that equation is more horrific? Dr. Dawson wants to blame them for their self harming behaviours. I believe Dr. Dawson would say that those without addiction who are depressed and take their lives are not to blame and are innocent victims of their depression. Their decision is not their own, as they are struggling with a serious mental illness or disorder that impairs their ability to make decisions in their own best interest. To which I would say yes, just like addiction.

Prior to 1972 it was illegal in Canada to attempt to kill yourself. We look at that law now and think how irrational it is. Criminal law is meant to punish people who harm other people, not to prevent people from harming themselves. It is time we realized the same for people struggling with addiction.

It appears Dr. Dawson thinks persons with addiction don’t deserve treatment because their harms are self-inflicted (their choice). So we should not treat the obese? Those who smoke? Those who do not wear their seat belts or bike helmets?

Finally, Dr. Dawson does not believe that treatment exists for addiction. He states “I put treatment for addiction here in quotation marks because there is no treatment as such.” Like most primary care physicians and psychiatrists, he does not know that there are very effective evidence-based treatments for addiction, like medication assisted treatment (MAT), cognitive and other behavioural therapies and motivational interviewing.

To quote one of Canada’s most pre-eminent addiction medicine specialists, Dr. Meldon Kahan, Women’s College Hospital, Toronto:

The scandal is that there are evidence-based treatments for substance use disorder which are effective that are not being used. META:PHI presentation, May 24, 2017.

WHY WE NEED TO STICK TOGETHER

Most addictions start during adolescence and the vast majority of adolescents struggling with addiction have other mental health conditions. It is widely accepted that treating these conditions concurrently is most effective. We do not yet know which causes which, or if something else causes both.

Instead of fighting amongst ourselves, we need to stick together to eliminate the discrimination in health care funding and treatment against those with addiction and/or other mental health conditions.

Stigma in the U.S. health care system contributes to disparities in funding for research and treatment of mental disorders in comparison with physical disorders and to the negative attitudes, beliefs, and behaviors of health care professionals toward people with mental and substance use disorders. Structural stigma is manifested in the health care system in the low quality of care for people with mental and substance use disorders and the limited access to behavioral health treatment and other services (Institute of Medicine, 2006; Schulze, 2007; Schulze and Angermeyer, 2003…”(at p.45-46) Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change published by the National Academies Press.

In Canada we spend just over 7% of our public health budget on mental illness and addiction but the burden of these diseases in Canada in 2013 was between 10% and 11% (Global Burden of Diseases, Injuries, and Risk Factors Study, 2013). By comparison, countries like New Zealand and the UK spend 10%-11% of their public health budget on mental illness and addiction. In 2012, the Mental Health Commission of Canada in Changing Directions, Changing Lives, The Mental Health Strategy for Canada, called for Canada to increase the amount it spends on mental illness and addiction from 7% to 9% over 10 years. This recommendation pre-dates the federal government’s commitment to legalize cannabis, which will generate income for the federal and provincial governments, and the current opioid overdose epidemic which is killing thousands of Canadians annually, many of them our youth and young adults with addiction and mental health conditions.

This sad state of affairs is the result of decades of discrimination in how society, including physicians, continue to view addiction as the moral failing that it is not, instead of the illness that it is. And so it is that doctors have overprescribed opioids, their patients have become dependent or addicted, and yet they do not know how to prescribe suboxone or methadone to treat opioid use disorder. They are also unaware of, and do not know how to prescribe, the medications available for treating alcohol use disorder (Campral and Naltrexone). Addiction medicine is not taught in medical school yet it affects one in seven. No wonder we are in the midst of an opioid overdose epidemic. In the words of another pre-eminent addiction medicine specialist, Dr. Evan Wood, British Columbia Centre on Substance Use (BCCSU):

Oftentimes, I hear people say that the addictions system is broken … Actually, the system isn’t broken, we need to build a functioning addictions system.” CBC Interview, Sept. 16, 2016.

Angie Hamilton is the Executive Director of Families for Addiction Recovery and has lived experience as the parent of a child with substance use disorder.

The Rise of the Far Right

By Dr David Laing Dawson

In the 1988 presidential debates Mike Dukakis was asked whether he would support the death penalty should his wife, Kitty, be raped and murdered. A long time opponent of the death penalty, Dukakis responded to the startling question from CNN’s Bernard Shaw, “No, I don’t, Bernard, and I think you know that I’ve opposed the death penalty during all of my life.”

It struck me at the time that Dukakis missed a moment in which he could be human, present himself as fully human, and at the same time as worthy of being a president.

He could have answered, “Of course. If a man raped and murdered my wife I would want to disembowel him; I would want to kill him in a manner that caused him maximum pain and suffering. Which is exactly why we have laws, and courts, and due process. Which is exactly why it cannot be my choice as victim or survivor to decide in the heat of the moment what should happen to the accused or convicted. Which is exactly why, to remain a civilized people, we must decide on appropriate penalties that will keep us civilized, that will not harden or poison our souls, that will not undermine our social contract. If the state does not value life, why should its people?”

And herein lies a human dilemma. We are biologically not far removed from chimpanzees and great apes. Our instincts, our immediate emotional responses, have been honed for years as jungle tribes. We guard our own watering hole. We are reluctant to share. We distrust the other. We are greedy. We are vengeful. We are easily brought to rage.

But, at least since the second world war, with many attempts before then, we have managed to overlay our primate instincts with a social contract that includes the rule of law. We have elected many leaders who could see beyond their primate selves and form alliances, be inclusive, share watering holes. We have created international forums, unions, agreements. At least in much of Europe and North America.

But those primitive instincts remain, the ones that led to the Holocaust, the massacres in Bosnia, the plight of the Rohingya, the destruction of Syria, the building of walls. They lie not far beneath the surface of each human. It is our collective that can overcome them, and that collective must have leaders and lawmakers who can see beyond their immediate fears and desires. Leaders and lawmakers who appeal to our better selves.

We always have had would-be leaders who could reach in and stoke our fears, fire up our distrust and hatred, get us ready to pick up torches and weapons, defend our watering holes from thirsty strangers, set upon those unlike ourselves in our villages. But, for the most part we have rejected them and chosen instead the Merkels and the Obamas. Trade has flourished. Europe has seen a long period of peace, cooperation, and open borders. Overall the people of this planet live longer and healthier lives than ever before.

I am writing this because a cousin asked me to write about the current struggles in Austria, where a far right fascist party has gained enough support to become part of a coalition government. This is happening seventy-two years after the death of Adolf Hitler, 90 years after the early Nazi’s received only 779 votes in a general election in Austria (1927), and 79 years since Nazi Germany annexed Austria.

I know little of the intricacies of Austrian life and politics. But this resurgence of the far right neo-fascist movement is occurring nearly everywhere in the west. Its leaders are appealing to our primate instincts, our rat brains. And this time, just as in the years between 1927 and 1938, they are finding more and more people responding to their simple message.

They stoke our fears and our grievances. Some of these are real. Most are manufactured or displaced. They point the finger at the other, the cause of our trouble. We respond and chant “Lock her up.” “Build a wall.” “Divorce Europe.” “Stop Immigration.”

We should have learned, especially Austrians, where this can lead. But apparently we didn’t.

Neo-fascism, jingoism, isolation, the breaking of alliances, the undermining of cooperation and the weakening of our international institutions will not fix our problems. And from recent history we know exactly where this trend can lead.

Our instant access of unfiltered world wide information, some truth, some fake, has us grossly exaggerating our risk. We find ourselves afraid of events that have a miniscule chance of occurring. We fear a terrorist attack more than we fear riding a motorcycle, when clearly death by motorcycle is far more likely than death by terrorist. Donald Trump can make us fear illegal immigrants when that, statistically, should be the least of our worries.

We do have real problems, problems big enough to spell the end of a habitable earth.

Paradoxically, these real problems can only be addressed by the unified, cooperative, inclusive, citizenry of one planet. These real problems cannot be addressed by walled off, exclusive, defensive separate states, each populated by a homogenous group of humans who feel they are the chosen.

We are really all at risk because of an interrelated set of developments:

  • Over population
  • Extremely uneven wealth distribution
  • Man-made global warming.
  • And a large subset of problems that flows from these three.

We can change this, turn it around, make progress, but only if we can function as the citizenry of one world, only if we have strong international institutions, only if we recognize that we will survive together or perish alone.

Addictions

By Dr David Laing Dawson

We are a flawed species.

Many years ago, with the divorce rate rapidly increasing, an industry of couples therapy and marital counseling developed. I noticed they were growing (divorce rate and couples therapy) at about the same pace, though the idea of couples therapy was, at least to some extent, to prevent separation and divorce. At the time I did some research and found that the average length of any marriage had not changed in 100 years. But now, instead of death (war and accidents for the male, childbirth for the female) maintaining the average around 7 or 8 years, it was divorce. The trend continued; couples therapy grew. Clearly all the money spent on couples therapy, statistically speaking, did not change this trend.

Over the past twenty years we have dramatically increased our awareness, public education, and tools for assessing the potential for suicide. This has paralleled two other statistical trends: a 14% increase year over year of people being taken to hospital emergency wards for “assessment of suicide ideation”, and a small increase in actual suicides within some age groups, and no change whatever in others. So again, while we have dramatically burdened our resources, from school counselors, to emergency room doctors and nurses, to mental health workers and psychiatrists, we have NOT been successful reducing the numbers of actual completed suicide.

I mention this before talking about addictions. The popularity and availability of some addictive drugs change over time, so the use of some goes down while the use of others goes up. Some surveys show alcohol use among teens has gone down, while use of other drugs has increased. But overall, especially in our adult population, there has been a steady increase in the number of people addicted within our population. Most addictions do start in teen years. But overall the numbers have lately increased year over year.

And this increase has coincided exactly with the trend of combining our addiction and mental health services, and our growing attitude towards addictions being brain diseases over which the addict has no control. I would not suggest this is cause and effect, but this certainly is statistical evidence that combining these services has not stemmed the trend of addictions. It has certainly not reduced the numbers of people (and their families) suffering from addictions, and dying from addictions.

Of course the “war on drugs” did not work either, and cost billions of dollars and much suffering.

So what is the answer?

We should probably start with some truths.

  • Telling teens to “Say NO to Drugs.” is ineffective at best.
  • The relapse rate after most “drug treatment programs” is extremely high. The officially quoted figure is 40 to 60% relapse overall, but with drugs like heroin the relapse rate is really over 90%.
  • Once someone is addicted we do not have specific treatments. All we have are forced or coerced abstinence, programs of persuasion, and substitute controlled addictions (methadone, buprenorphine).
  • When addicts quit using it is usually because they have to. (medical or financial reasons, forced abstinence). Not “want to” but “have to.”
  • Brain recovery does not happen after too many years of use of heroin and opioids or amphetamines. That is, after many years of heroin use, the brain’s ability to produce its own endorphins is seriously damaged.
  • As with two similar situations described above, the increase of addiction counselors runs parallel to the increase in addicts. There is no evidence it makes an actual difference. More counselors has not lead to less addiction.
  • A large number of addicts start in their teens, while still living at home.
  • Some addictions begin with self-medicating afflictions for which we have non-addictive treatment available. (depression, ADHD, anxiety, early psychosis)
  • Professional and non-professional chemistry labs have managed to create condensed forms of synthetic opioids that are extremely potent and dangerous.
  • When the supply of the drug of choice for an addict dries up, he will seek an alternative.
  • Someone addicted to one substance is easily addicted to another.
  • The pharmaceutical companies and doctors are responsible for a large number of current opioid addictions.
  • Many deaths occur after a period of forced abstinence and loss of tolerance followed by relapse. (post jail or rehab program)
  • Many deaths are now occurring because the suppliers are contaminating their heroin, cocaine, and morphine products with fentanyl and carfentanyl.
  • The search for, need for, substances that numb and/or artificially give pleasure, is as old as human self-awareness.
  • The propensity to addiction is at least partially genetic.
  • The personality traits that leave one vulnerable to addiction are: need for instant gratification, no tolerance for boredom, low tolerance for suffering of any kind, no tolerance for delayed gratification, no patience, tendency to externalize cause and not take responsibility for own actions, impulsiveness, and, as a teen, risk-taking and a sense of invulnerability.
  • Addicts lie and steal to survive. They cost society a great deal, directly and indirectly.
  • The all out “war on drugs” did not work, and cost billions.
  • Incarcerating users is a futile and costly venture.
  • Marijuana may or may not be a “gateway” drug, but as everybody who ever told himself, “Tonight I’m just going to have one drink.” knows, one drink is a gateway to two drinks. And at a party the intoxicated or high teenager is much more likely to answer, “Sure.” when offered a capsule from someone’s pocket.
  • On the other hand marijuana use, casual or heavy use, has never (US statistics) been listed as the direct cause of death.
  • Drugs are not free. Money is always involved.
  • A teenager is not an adult.
  • Most teenagers are dependent on parents for food and housing (money).
  • Criminalizing use does not help anyone.
  • But absolving of responsibility does not help either.
  • The groups of people with highest rates of addiction are the unemployed, first nations, the mentally ill, single or divorced, poor.
  •  Death by overdose can be divided into three groups: 1. Those who have lost tolerance through a period of forced abstinence and then relapse and use the same dose as before. 2. Those who mistakenly use a much stronger substance (cocaine or heroin laced with fentanyl). 3. Those who are desperate, suicidal, careless (in the literal sense of the word).

As with suicide, generic programs aimed at everybody do no good. But the above “truths” about addictions could lead us to some rational targeted interventions.

These could include:

1. For addictions that have persisted for several years (perhaps research can tell us the number of years) free maintenance programs need to be established. The cost of doing this can be compared to the cost of addicts committing crimes to get money, health care costs,  buying from dealers and thus supporting a criminal network. With the true recovery rate from many years of heroin or amphetamine use being close to zero, addiction maintenance programs would be far more humane and less costly than repeated attempts at abstinence. Such programs should include controlled use of the original drug, or controlled substitute.

2. For more recent addictions, coerced detoxification and relapse prevention programs could continue. The degree of coercion that can be applied depends on the court when crimes are committed, but otherwise depends on family, friends and employers.

3. The practices of Doctors and Pharmaceutical Companies (for opioids) should be reviewed and changed. (with the caveat that the replacement maintenance programs should be put in place at the same time)

4. A greater effort to assess young would-be addicts for otherwise treatable disorders could be made. (e.g. There is solid evidence that untreated ADHD or anxiety leads to self medication and addiction). A side effect of perceiving addictions as brain diseases for which one is not accountable, coupled with the allure of walking on the wild side for teenagers, is that seeking psychiatric help for anxiety, ADHD, and depression, especially for boys, may be more stigmatizing than buying Percocets from older boys.

5. Targeting teenagers and early 20’s: Counselors, psychiatrists, family doctors should always involve the parents. It is the parents who can provide the coercion and the safety. It is the parents and sibs who suffer, and who must find the right balance of help and tough love. Only parents can control the money.

6. Accepting the high relapse rate after incarceration or “treatment” programs, addicts should be bluntly warned and educated: “You will probably relapse. The dose you could tolerate before will now kill you. When you relapse start with a very small dose. Do not re-up before one hour has passed.”

7. Legalizing marijuana may reduce the numbers of potential addicts turning to more dangerous, but easier to conceal, drugs.

8. If pain medications are used for acute pain, surgery etc., clinics and hospitals should plan, at the outset, a monitored withdrawal program.

9.

10.

 

More on Weinstein and Friends

By Dr David Laing Dawson

Say it ain’t so, Al, Jeff,  Kevin…..

What is happening?

We turn 16, 17, or so, and the mating game begins. The sexual competition. This plays out within many different cultural rules, regulations and customs. It can be an open market, so to speak, in some modern cultures and driven by family status and economics in others. But it is a competition fought with all the weapons and symbols of female and male desirability. For most primates this involves tests of strength and the flaunting of secondary sexual characteristics and pheromones. We humans have added a great many more symbols of availability and readiness, from lipstick to sports cars. (so many symbols, in fact, that decoding them can be complicated).

But the game is on, and perhaps it lasts from the teens to late 20’s, often now followed by a second inning between 30 and 50.

Some years ago someone observed wedding receptions to watch this mating game unfold with several generations present. The most interesting observation was that each party had at least one older uncle who danced randomly and crazily into the small hours, without self-consciousness, with enjoyable abandon. The writer’s conclusion was that this uncle was a man who knew he was no longer in the competition. He could drop all pretense, all posing. He could simply have a good time without worrying about which fair maiden might be watching and judging him.

Which brings me to my point. All these men being accused of sexual impropriety are older (and often no longer attractive) males surrounded by beautiful younger women (and men) who are not interested in them. They, the older men, are out of the game, sidelined, retired. The women are no longer sending them signals of availability. In other ways these men are admired and desired, but not sexually, not by younger women. The younger women are looking elsewhere.

This is not to excuse their behaviour. Their actions display anger and resentment about being left off the dance card, perhaps more anger, resentment and entitlement than desire. Time to grow up, gentlemen. We are not forever young.

Trying to Understand The Harvey Weinsteins of this World

By Dr David Laing Dawson

Harvey Weinstein. We can call his behaviour evil, reprehensible, outrageous, nasty, illegal, criminal, or sick, but is there a way to understand it? Such behaviour does require a degree of sociopathy, the absence of empathy, of guilt or remorse. It does require a degree of self-importance, of narcissism. It does not bother him much that he hurts people.

But the cloying, nasty, crude, pleading, begging, and disgusting aspects of his behaviour, combined with the physical reality of the man speak to a different impulse. The same with most of the others who have been recently exposed, with the exception of George H. W. Bush, whose fixation on a single play of words that provides him the excuse for a fanny squeeze suggests a little frontal lobe dementia is at work.

But the others, what of the others? What strikes me is that they are physically repulsive men living in a world that values youth and beauty.

To some extent we all live in that world. Beautiful young, and beautiful not-so-young women are paraded before us on our screens, on our billboards, at the office, on the campus, in our newspapers and magazines. Every man notices. Every man enjoys this visual treat. Every man is attracted to this spectacle. And if drag queens are anything to go by, the attraction is not limited to the heterosexual male. Even gay men are fascinated by the adornment, the display, the theatricality, the vigour, the exhibitionism – youth and beauty.

If the Harvey Weinsteins of this world took advantage of their positions to court, seduce, and then maintain as mistresses a couple of beautiful young women, it would be understandable as the fulfillment of a natural biological yearning experienced by an Alpha Male. Common around the world, with humans and other primates.

But that is not what they do. They display their own disgusting selves, their bodies, and then force these young women to degrade themselves, to experience the disgust they must feel for themselves.

So Harvey looks in the mirror and finds himself physically repulsive, unhealthy, weighted with an excess of mortal flesh. His successes in film making do not remove this repulsion, this self-disgust. Especially when he is reminded every day that some others, most notably young female actors, glow with health and beauty, and command the eyes of everyone else in the room.

He will make them suffer too, and suffer with the same sense of self-disgust he feels. And then make them flee from him as they must, but now reduced and no longer threatening.

………………..

There is a cartoon circulating now with a father explaining to his son that, regarding sexual abuse, “We hold our movie stars to a higher standard than our presidents.”

But is there a real link here? I mean between the presidency of Donald Trump and so many women now blowing the whistle on abusive male behaviour?

It is not surprising that Donald Trump has provoked a backlash of Democrats being elected. Maybe a little surprising that one of those Democrats is a transsexual. But has the election of Donald Trump and his band of privileged rich white males caused a reactionary wave of female empowerment? Maybe.

That would be a treat. Perhaps Trumpism will ultimately produce, by reaction, a universal health care system, some environmental protection, some concern about global warming, a more equitable distribution of wealth, some actual gun control, less racism rather than more, a rational, thoughtful and more realistic assessment of America’s place and role within an interdependent world.

It is the silver lining to this mess. His two steps backward may cause a mighty leap forward.

But I am surprised and troubled by just how many rich privileged males have been behaving as if they were 16 year old brain damaged boys living in a group home.

Addictions and Mental Illness – Continued

By Dr David Laing Dawson

Folk wisdom tells us that with alcoholism and addiction, at several points in the spectrum of these afflictions, there lies choice. Free will is at play. The law generally agrees. Drunkenness is not grounds for “not responsible due to mental illness.” Even science and rehab experience agree. All treatment and rehabilitation programs for addiction and alcoholism are founded on a principle of choice and free will.

No doubt alcoholics and addicts develop a sort of tunnel vision. The big picture is lost to them. The effect they are having on others is lost to them. The ability to plan beyond the next few hours is lost to them. Reality for the addict becomes a set of shadings and lies he tells himself and others.

Scholars and philosophers can debate the myth, reality or limitations of free will, but the concept is in itself a foundation of community, of organized society. To function communally we must assume that individuals generally have free will and are responsible for their actions. We are careful and strict when we allow exceptions to this rule, as we must be. Science and compassion inform these decisions.

Our courts debate these decisions every day. The age at which one can be tried in court as an adult rather than a child has been changing and varies from state to state. At what level of mental development should we assume a mentally handicapped person is fully responsible for his crime? Harvey Weinstein will claim he is a sex addict and couldn’t help himself; the prosecutor will point out he is a serial predator who chose to debase women over and over because he could get away with it.

Within our long history we have only recently absolved people of personal, moral responsibility for falling ill with recognizable physical diseases. Though not totally, for we still expect them to assume some responsibility for working to get better, take their medicines, and do the things that prevent illness in the first place. e.g stop smoking, get vaccinations, use condoms.

It is only more recently, within two hundred years, that we began to include severe mental illnesses in the body of afflictions for which people should not be held morally responsible. Nobody chooses at any point in their lives to become schizophrenic, bipolar, depressed, have regular panic attacks. These are illnesses. Nobody chooses for these illnesses to continue.

Folk wisdom regarding who with mental illness should be absolved of moral and personal responsibility (and therefore not punished if a crime is committed) remains fluid. The question is often decided, in the public’s mind, by our visceral reaction to the crime itself.

But at least without horrendous crimes occurring, folk wisdom generally, today, accepts that severe mental illnesses are indeed illnesses and no personal decision making is involved.

But this is always a tenuous belief.

Which is why it was such a setback for the public’s attitude toward mental illness when our institutions for addictions and for psychiatric illnesses were merged, and many of the philosophies for “treating” addictions slipped over to mental illness. I could argue that this merger has set us back a hundred years and allowed us to believe (or by inaction accept) that many with mental illness choose to live on the street or cycle in and out of our jails. (I put treatment for addictions here in quotation marks because there is no treatment as such. All programs for addictions are forms of organized browbeating to quit, and then to stay abstinent. Whereas we actually have effective medical treatments for severe mental illness.)

I might even argue (with the exception of it providing more resources for addictions) this merging of the services was also a disfavor for society, addicts, and alcoholics. For when we absolve people of responsibility for their behaviour, we give it wings.

Hence the astounding human behaviour we see today in all our communities in which a person is offered in a back alley or a house party a substance that promises to alleviate any suffering (emotional or physical) for a few hours, maybe cause the experience of a little euphoria, but which has a 30% chance of being lethal – and still that substance is greedily taken and snorted or injected.

Conflating mental illness and addictions has caused a paradoxical shift. It has allowed us to absolve addicts of personal responsibility for their addictions and, at least tacitly, blame the mentally ill for their illnesses.

Though I am in favour of suing, for billions of dollars, the pharmaceutical company that lied about and promoted oxycontin/oxycocet/oxycodone  and then pouring that money into “treatment” and prevention of drug addiction.

Addictions and Mental Illness Do Not Belong Together

By Marvin Ross

For some inexplicable reason addictions is lumped in with mental illness or, to be politically correct, mental health. Combining the two is, in my opinion, like putting orthopaedic surgery together with chiropractic. Addictions are quite separate from mental illness and combining them does a disservice to the mentally ill.

I do no want to demean the seriousness of addictions but there is a fundamental difference. Addictions at some point involve choice. You made a decision to go into a bar and start drinking or to snort coke, take opioids or inject heroin. No one has a choice to become schizophrenic, bipolar, depressed or any other serious mental illness. There is no choice involved whatsoever.

Before you jump all over me, take a look at a court case before the Massachusetts supreme court called Commonwealth v. Eldred . Ms Eldred admitted to stealing in order to support her drug habit and was sentenced to probation with the term that she not use drugs and submit to regular drug testing. Ms Eldred tested positive for drugs in one of her tests and her probation was revoked and she was put in jail pending the availability of a treatment bed.

She appealed using the argument that the sentence of abstinence was cruel and unusual punishment as she has no choice but to take drugs as she is an addict. Addiction psychiatrist, Dr Sally Satel, co-wrote a brief with others arguing against the grounds for this appeal. Those grounds are that addicts are involuntary drug users who cannot be held responsible for their drug use. If that is upheld then it would “affect the future of successful treatment programs that are based on the verified principle that addicts can and often do say no to drugs” and “it would hobble successful judicial interventions that help addicts stay out of jail by making probation and parole contingent on testing clean for drugs”.

Dr Satel argues that this position runs counter to accepted science in her blog Addiction, she says, is not a chronic and relapsing brain disease. Addicts can and do learn to say no to drugs and recover in large numbers without intervention. Three epidemiological studies done in the US found that “among those who ever met the criteria for addiction to controlled substances, 76% to 83% were at the time of the surveys ex-addicts. They no longer used drugs at levels that met the criteria for substance dependence.”

Dr Satel also points out that the argument that is often used is that the drugs or alcohol change the structure of the brain so that the addiction continues and cannot be controlled. However, as she points out, all actions, including reading an article, change the brain and thus brain changes are not a valid marker for loss of self control.

One analogy that comes to my mind is smoking. It is generally recognized that nicotine is a very strong addicting substance and it is not easy to quit. My generation smoked a great deal as it was socially acceptable and allowed just about everywhere. One brand even advertised that 4 out of 5 doctors smoked whatever. Then, we were given more and more evidence of how harmful it was and it became socially unacceptable. The vast majority of us were able to quit and I don’t recall anyone ever arguing that we suffered from an illness and that we had a brain disease. Once we determined to stop, we did using a variety of methods. What was key in each and every case was a true desire to do so.

During the Vietnam War, it was discovered that 40% of US servicemen had used heroin and that nearly 20% were addicted. Government officials were stunned and worried and Richard Nixon set up a new office called The Special Action Office of Drug Abuse Prevention. Its goal was to prevent and rehabilitate as well as to track troops returning from Vietnam. What they found shocked them. Nearly 95% of the addicted servicemen gave up heroin voluntarily upon return to the US.

They stopped, it was hypothesized because they found themselves in a totally different environment from that of a hostile war zone. In contrast are drug users who go into rehab who relapse at a rate of about 90% once they return to their regular environment. That is an environment and life situation that caused them to become addicted in the first place.

The solution to addiction is not to treat it like it is a brain disease where the addict has no control but to try to change the life circumstances of those who do become addicted.

As Dr Satel said, addiction is not a conventional brain disease like Alzheimer’s. “Addiction is self-destructive drug use, and those who are destroying their lives with drugs deserve our help and sympathy, but they are not helpless victims” like those with serious mental illnesses.

Trick or Trump

By Dr David Laing Dawson

I had in my office yesterday an 11 year old who was in a bit of trouble at school. His defense was “Kevin did worse than me and he didn’t get in trouble.”

I laughed and then explained to the parents that I had just read a Donald Trump tweet along the same lines, “What about Crooked Hillary and the Dems.”

The parents smiled warily, but the boy took offense. He did not like being compared to Donald Trump. I tried to explain that deflecting the blame, or trying to do that from an immature sense of playground fairness, was quite appropriate at his age. He was still unhappy that I had compared him to Donald Trump.

Then I saw a 12 year boy, a little fire-plug of a kid who happens to have a mop of blonde hair, a square face, and a passable rendition of a Donald Trump pout. I asked if he was going to go out Halloween as Donald Trump. No way he told me. There are too many Donald Trumps. He was dressing as a robber. Besides, Donald Trump is stupid.

So, at least, I concluded, the fear that Donald Trump might be a role model for our children, at least our Canadian children, is unfounded.

Trump And/Or God?

By Dr David Laing Dawson

In Richard Russo’s novel, “Nobody’s Fool”, Rub Squeers, sometime friend of Sully (played by Paul Newman in the movie), often says with a stutter, sometimes to Sully, sometimes to himself, “You know what I w-wish -t?”

His wish is usually for a small improvement in his circumstances, never realized. Yet, he is optimistic and quite endearing.

The moment science reported that those among us with a modicum of optimism live longer, recover faster from illness, and tolerate chronic illness better than pessimists, a poster went up in the hallway of a mental health center I visit, proclaiming HOPE in bold letters. It has since come down.

I thought of these things while watching a bunch of religious (or faith community) leaders praise Donald Trump and the power of prayer in the oval office. One went as far as to announce that we all know prayer works. They each thanked Donald within the same paragraph they thanked God, knowing, I’m sure, who really had the power to dispense favour at this moment.

Of all the players in these three separate stories I think I prefer the simple honesty of Rub Squeers. He wishes, and momentarily it gives him hope and small pleasure, but he has few expectations as he trundles on getting by.

And prayer itself. I have always had a problem with prayer. Okay, it can support hope; it can strengthen community, but this juxtaposition of the stroking of Trump’s ego and the appeals to God certainly drew a clear parallel. For prayer itself implies that before God might notice my suffering, I must praise him. Not just praise him, but prostrate myself before him, beg him to intervene. So that image of God, that particular concept of God, involves an ego even bigger than Donald Trump’s. God the narcissist.

And as long as they have prayer I suppose they can continue to pave over the wetlands, ignore the disrepair of the damns, dykes, levees and drainage systems, cut taxes, remove environmental regulation, promote unfettered growth, and ignore climate change.