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.

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3 thoughts on “Addictions

  1. Interesting comments, but this is odd: “forced or coerced abstinence” — many people with substance use disorders *choose* to abstain from recreational drugs and we really need to move the conversation on this.

    Your article is much too pessimistic about people with substance use disorders. People can and do recover from substance use disorders – and those on opiate replacement therapy are successfully abstaining from recreational substance use.

    Those on ORT medications are undergoing medical treatment for addiction NOT using substances, good treatment programs welcome people undergoing ORT and support them in their continued rebuilding of a new life.

    We really should not let the old-fashioned, non-evidence based programs own abstinence.
    Taking medically prescribed treatments for diagnosed conditions is medical care not substance use!

    Like

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