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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5 thoughts on “More Musings on Addiction

  1. I find the sentence “We are often satisfied with the appearance of doing something to help” intriguing. Why do we continue to approach the situation in the same way and expect improvement? “More of the same” even if there is no evidence the same has made any difference.

    Just throw money at it and it will get better. Does not the saying go that the definition of insanity is to do the same thing over and over and expect different results?
    I am thinking specifically of the mentality of our local LHIN. Despite the fact that we have Patient First Legislation, this organization chooses to ignore the voices of patients and families and continues to send a good part of its “mental health” funding to designated service providers who continue to insist on providing “voluntary” service and deny service to those who have anosognosia and no insight that they are ill. Why would they need service if they are not ill? Rather than spending energy in trying to engage these people, the standard response is that they are bound to respect an individual’s right to choose. No-one would choose to suffer a death on the streets.

    Despite the fact that service providers have been encouraged to look at new modalities, the standard service for the seriously mentally ill is either the cumbersome, very expensive, disruptive Assertive Community Treatment Team, or weekly or bi-weekly case management and irregular visits to a psychiatrist’s office. The quality of care from the psychiatrist depends on how good the psychiatrist is. And how to we find that out?

    The only way a seriously mentally ill person can get the care that they desperately need is to kill someone and get into the forensic system if they are lucky to get a NCR designation. We really need to bring back long term care for seriously mentally ill people. If you want to learn more about this look at Dr. Stephen Seager’s documentary “Road Map”.

    Those that don’t kill someone are supported by their families until their families shatter. Then the person becomes homeless (and a candidate for the Housing first program in Canada) or dies from neglect on the street, or gets shot by the cops, or ends up in jail where they can be brutalized by long periods in solitary confinement.

    So back to the question Why “More of the same even if there is no evidence the same has made any difference?” I think it is time to cut through the BS and start addressing the problem realistically. We need long term care that reflects the complexity of serious mental illness and accessible supportive housing for people upon discharge.

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    1. I agree. I noticed earlier on in my advocacy for the seriously mentally ill, that the ones that appeared to do better in the long run were those who were given appropriate hospitalization at the beginning of their obvious illness. With proper inpatient care, education at the appropriate time about their diagnosis, and then proper follow up by professionals often were able to function at the level that their treated illness would permit. But alas nonsense is talked and more and more ill people slip through the cracks. This is basically because a dearth of beds and a Mental Health act that fails to meet needs. BC seems to be heading in the same way via a pushed for M.H Act that would be as bad as that of Ontario’s.

      As I walk around the new palacial edifice of a psych hospital ( a palace of Versaille without the mirrors) in my area . The ceilings in the foyer reach the sky the corridors are wide long and Kafkaresque among other things . But the few and a quarter of those beds are forensic beds. But where are the other patients ? ON THE STREET or in jail, or their families are struggling to keep them safe. One despairs. As Dawson says why do they do the same rubbish over and over again.

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  2. The most glossed over addiction must be gambling, it is hard to find anything of value written on gambling, but it is too easy to find incentives to gambling all over the internet .

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  3. David, I have changed my mind somewhat on the issue of addictions. So I will answer to your points. 1). I am entirely convinced that there is an immense spectrum of brain differences that are decisive as to the probability of someone becoming addicted. For some it is highly improbable, even if they experience availability, peer pressure, and so forth. For some others, even without being enabled, they will become addicts of one sort or another.

    That fact reminds us that current conditions of social evolution, in much of the world, are likely selecting for addictive brain types, rather than against, in a number of ways. There is a need to do more genetic research in that regard, but not only to find the genomes and variants that are related to brain characteristics that tie in with addictions. It is also necessary to study how sociological factors are becoming genetically selective. That means how those who are more addictive, as to their brains, are being given a higher probability of reproducing than those who are not. I predict some surprising results that show that addictive types of brains are far more likely to reproduce. All of that has a lot to do with social function, and the nature of modern work. One could write books about that. Current technological evolution is becoming a major factor. In many areas addicts actually do better at work and life than non addicts is part of how that plays out. Even if not the only reason.

    2). Availability of substances is a factor, but unless some Draconian tyrant appears who puts an end to organized and transnational crime, by implementing unlikely extremes, availability will never be much of a problem for anyone who seeks it. The big battle between criminal provision and legal enforcement is, in many ways, more a battle of licit versus illicit provenance, and that means prescription versus non prescribed. The illicit industry battling against the licit industry for billions of dollars is the crux of that issue. It is more about who makes the money than it is about considerations of “harm”.

    3). Those who are inclined to become addicts, due to their brains being as they are, will almost invariably find others who are of the same type, somewhere. Though there is a percentage that tends to remain isolated and alone with their addiction, simply because the addiction is given more value than social connection is given value. Society tends to foster the latter tendency, to a remarkable extent, even in addition to the “culture of self” that has become so prevalent. There are a plethora of complex social mechanisms conspiring nowadays to shift values, and addiction tends to win in that complex of social factors where the predisposition exists. If anything society, even that portion that is not substance addiction inclined or practicing, is remarkably coercive, enabling and fostering of addiction. There are many reasons for that, and some of those are very unlikely to change anytime in the near future, if ever. In some regards it goes all the way to the question of how social controls are practiced and implemented, and there you have to look at how governments actually work to enable, and even foster, addictions, despite coming out superficially as opposed. All of that tends to shift one’s thinking and approach to the issue.

    4). Addicts have an endless number of rationalizations, even mythologies and superstitious beliefs, of many different sorts, that they buy into, as though it is a religious faith. In some ways it is exactly that, as to the paradigm involved. We have seen that most clearly in how Cannabis culture evolved, but we saw that so clearly only because of current developments as to social media. It was far less transparent before. If you strip the details and analyze the paradigm you find that the paradigm is largely applicable to any type of addiction. There is a belief system, and a lot of faith, involved. Faith that is typically very difficult to shatter. Likely because it has become so “core” to many an addict’s worldview and functioning. It also provides social cohesion between the like minded. So not only do they share similar brains, but they share similar behaviors, determined by similar values. They become a society unto themselves, insular from their opponents. All of that serves their own destigmatizing. They do not really require someone else to do that for them. At the same time they tell the commonly accepted lies to their therapists, to doctors, to outsiders of any sort. They most often tell them what those people are believed to want to hear. That is something most people, other than some who are severely mentally ill, learn to do. They learn to play the game, and that includes the insiders, outsiders, game. Thus destigmatizing actually is acceptance of what already happens to a very large extent within addicted society and its creation of its own cultures.

    How does all of that relate to my own changed views on the subject ? I suggest inform them of what science has found to be the risks. Have them sign a form. Issue them a registration. Let them use whatever they want, as long as they do no violence to anyone else, and to not break other laws. The penalty for crime where drug use is found to be involved would be at the more severe end of the spectrum of punishment. Forbid them from engaging in any occupations and activities where it has been found that drug use compromises public safety appreciably enough to justify those being “listed occupations” and activities requiring one or another type of licensing. Their choice to choose addiction, and its legal limitations. The rationale for that ? Society does not really need them. Letting them do what they do, does not really matter anymore. There are too many people, seeking to do what people do, otherwise, and getting rid of some is no real problem. We have robots now, waiting to take on some of the highly addiction oriented routine jobs. We don’t need addicts doing them. We have artificial intelligence and expert systems that can do many of the mentally confining, routine, tasks of traditional “brain work”. Addicts used to be good for some of that too. Rehabilitation and treatment really are very costly compared to addiction, and they have a very poor record in terms of recidivism. Most addicts fall of their wagon and end up back again and again. I have met some, and hey themselves, privately laugh at the endless cycle that they find themselves in, and accept as such. Falling off the wagon is part of their culture as addicts. That too is bein destigmatized. Of course that creates another huge and growing industry. That economic factor is perhaps more significant than actual measurable results. So I tend to say give them their choice of lifestyle, and let them go. No point holding them prisoner and claiming that the self serving industry of diagnosis and treatment is actually serving addicts. It largely isn’t doing that at all. It is serving itself as to its own incomes. For society that is the most expensive option, rather than legalizing drug use and letting people destroy themselves if they choose to.

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