Category Archives: Addictions and Illness

Coming in January: Mind You The Realities of Mental Illness A Compilation of Articles from the Blog Mind You

We have decided to publish a book on the best of our mental illness blogs over the past 4 and a bit years. The book will be available in print and e-book formats everywhere in early 2019.

Below is the introduction:

We began this blog in October 2014 in order to provide commentary on the state of mental illness and its treatment for the lay public. What we provide is a viewpoint from that of a psychiatrist with many years of experience (David Laing Dawson) and a family member of someone who does have schizophrenia (Marvin Ross). Aside from his personal experience (or lived experience as it is commonly referred to), he is also a medical writer, advocate and publisher of books that take a unique look at mental illness.

To date, we have had close to 75,000 views and have been read in 151 different countries since 2014.

We also write on other topics but these are the ones on mental illness covering topics like recovery, treatments, suicide, addictions, and alternative treatments (or pseudo science).

When we began, we had this to say of our purpose:

 Welcome to the launch of Mind You. While we intend to post on mental illness,mental health and life, we decided on the name Mind You to reflect that not everything is black and white. There are ideas and opinions but then mind you, on the other hand, one can say…….

And that is what we would like to reflect. Ideas about mental illness,health and life that can be debated and discussed so that we can come to a higher understanding of the issues. And, we have separated out mental illness from mental health because, despite their often interchangeability, they are distinct.

The National Alliance on Mental Illness defines mental illness as a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a  diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder.

On the other hand, the World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. That is quite different from mental illness.

Unfortunately there is a tendency to confuse these and organizations like the Mental Health Commission of Canada have a tendency to talk about mental health issues and problems which are not the same as mental illnesses.

 Both Dr David Laing Dawson and I (Marvin Ross) will be posting on a regular basis on a variety of topics.

The posts we have selected for this volume are the most widely read over the past 4 years.

Mind You, ISBN 978-1-927637-31-9, 193 pages distributed by Ingram

 

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A Theory of Addiction

By Dr David Laing Dawson

My new theory about addictions, at least about the explosive increase in serious opioid addictions in the last few years:

I am well aware of the culpability of Purdue Pharma promoting Oxycodone, Oxycontin as “non-addictive”, coupled with an “academic” push to have doctors pay more attention to chronic pain, and then some sloppy prescription practices after acute injuries. And I am well aware that some addictions begin as self-medicating, usually self-medicating a mood or anxiety disorder.

I understand how hooked they are. How, once addicted, consciousness is reduced to getting that fix. Empathy is lost along with any ability to think beyond the fix and the avoidance of withdrawal. By that point there are brain changes and it is a disease.

And pockets of addiction can be found alongside unemployment, poverty and despair.

But this is 2018. Not 1932. There really is no shortage of easily acquired food, and despite the cries for more affordable housing for families, there really is no shortage of basic shelter for single men.

So why now are so many men sleeping on benches and on the hustle for drugs around the Sally Ann in my neighbourhood? And why is the otherwise fit looking man with his German Shepard dog willing to stand for hours in a cold drizzle at a busy intersection collecting coins from every tenth car that stops? And why on earth does anyone ever inject a substance into his vein that has a ?10, ?20 percent chance of killing him?

I have also had many clinical experiences of addicts, vague, unhappy, scattered in thought, pathetic in actions, but laser focused and energetic when it comes down to the moment of trying to persuade me to write a prescription. Tenacious, persistent, with far more stamina than I.

And here are two more seemingly unrelated bits of information: When we go on holiday our sense of well being peaks on day 8. It is downhill after that. Time to go back to work, we say, by day 12. And some zoos have learned that making the carnivorous animals hunt for their food, rather than just giving it to them, makes them happier and healthier. And the retired couple, free now of children, mortgage and job, free to roam in an RV. What do they always do? They get a dog, or two dogs to fuss over, look after.

We humans were not made for leisure. Our DNA tells us we need to hustle. We need to hunt for food, check the barricades, repair the roof, fashion the spear, dig the trenches, work for ten hours in the mine, or kitchen. We are programmed to be busy. And our busy-ness rewards us with food, safety, or some small achievement. (I am quite amazed how delighted I am when I manage to complete a New York Times Crossword puzzle and then cast it aside to look for a new one.)

Challenge, occupation, risk, reward, repeat. (note that this is the same sequence video games provide)

Our focus has been on the reward, the drug, swallowed, snorted or injected. We can make that safer with safe injection sites. We can eliminate the need for the hustle if we provide the drug. But what of the challenge, the occupation, the risk and the repeat? What of the need for the hustle?

My new theory is that these last few decades have removed the natural life challenges and occupations for more and more men, and that drug addiction provides just that. That is, it provides not just the reward (the drug) but also the challenge and occupation, the risk and repeat.

As do video games for the young man in his parents’ basement.

We can “treat” addiction, try to eliminate drugs, or provide the drugs legally, but how do we replace challenge, occupation, risk, reward, repeat as the robots take over all the work?

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?

 

 

 

 

 

 

 

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.

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.

 

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.

Opioid Epidemic and Childhood Trauma – NO!

By Dr David Laing Dawson

Social worker, Alexander Polgar, writing in the Hamilton Spectator suggests that the current opioid epidemic and death by overdose can be traced to “adverse childhood events”. This of course is patent nonsense. Some children do suffer terrible things that affect them their entire lives. But, from a statistical view point, the children growing up in the last 30 years (in Canada) will have experienced the fewest adverse events than any generation in history before them. (prenatal care, safe childbirth, child protection laws, diminishing physical punishment, plentiful food, no measles, mumps, smallpox, polio, pertussis, fewer sibling deaths, available medical care, safe toys, safe playgrounds, safe pools, safe beaches and lakes, accommodation in schools, organized play, sports, new safety rules for everything, child labour laws…). Sure, the parents may be more likely to divorce, but they are much less likely to die.

In the late 40’s and early 50’s my classes of 35 or so always had one kid with scars from a boiling water accident or a fire, another not coming back to school after a summer of polio, one on a cane or crutches or with a withered arm, another pockmarked from some communicable disease or other, and another two or three undernourished, lice ridden and dirty. Not to mention the shaming and physical punishment some teachers used to control behaviour. And in those decades many children grew up without fathers who had been lost to them in the war.

While one might be able to trace a specific addict’s misery to childhood trauma, to blame the current epidemic on an epidemic of childhood trauma is nonsense.

I could make a case for the problem being the opposite.

Clinically I have many discussions about “motivation”, as in “my child is not motivated.” or the teenager saying “I’m just not motivated” with respect to going to school, getting a part time job, joining anything. With some I joke that I don’t have a pill for motivation. With many of course I look for the anxiety or depression or circumstances underlying the apparent lack of motivation, now redefined as avoidance. With others I engage in a longer discourse about the nature of “motivation”.

Now, it is pretty clear to me that the prime motivator for humans and human children throughout history has been necessity. Without necessity we fall back on, I suppose, pleasing our parents, keeping up with our social group, plain old curiosity, immediate sensory gratification, the pleasure of an adrenaline rush, and perhaps, occasionally, finding an inner flame of ambition or artistic seeking or even altruism.

The other day I had a quite interesting conversation with a very bright, self educated, articulate 15 year old. Not in school, and as he said himself, not motivated to do anything. He rationalized that any “motivation” was pointless because life itself was pointless. He could talk about existentialism, absurdity, about the expanding universe, even the nature of consciousness.

So with him I engaged in a rather intellectual discussion about the nature of “motivation”. Of course from a social perspective, a “lack of motivation” equates to “not being willing to do what someone else thinks you should do.” But when we talked of the prime motivator for most humans being necessity (to avoid being cold, starving, hurting, wet and banished) he agreed, and pointed out that he faced no such necessity. Nor did most of his peers. They dressed as they liked from a selection of clothes in their closets; they always had a roof and a bed in a heated home; food in the refrigerator; much more than a penny in their pockets; and no one who could “make them go to school, or work”.

He was “motivated” to seek a few days a week of instant pleasure from weed, MDMA, mushrooms or acid, the chemical compositions and history of which he knew at least as well as I.

Now I may also get the opportunity to treat this young man’s depression, once he has done his own research on SSRI medication, but, thinking of this generation as a whole, I can go back to my main point. Which is that we have removed necessity as a motivator for many of our children and teenagers and young adults.

They are not experiencing more adverse events but fewer, and they are always ensured of their basic needs being met without any effort on their part, and, with the safety and esteem building tone of today’s parenting and pedagogical methods, coupled with the proliferation of things and activities that offer instant gratification (Good boy, wonderful picture, nobody fails, every child is special, dress as you want, here is an Iphone and a laptop, video games, information by clicking a mouse, substances that eliminate anxiety and stimulate the pleasure centers of the brain), the necessity of an extended period of work and discomfort to achieve something seems almost anachronistic.

I have said at times to some of the teen boys refusing to go to school, “But that’s where the girls are.” only to realize that, no, today, naked women reside 24/7 on the laptop in his bedroom. So even the vaguely formed wish and longing hope of sexual gratification after a lot of struggle, social embarrassment, attending school, joining the drama club, staring at, avoiding, talking to, asking on a date…. has been replaced by no-effort instant gratification without having to shower, brush your teeth and get dressed.

Blaming a 21st century problem on a 19th century scourge is not helpful.

It is very hard to understand and assess the vectors and forces that affect one’s own time, but the causes of teenagers doing stupid and dangerous things, and the causes of adults injecting themselves with something that offers equal odds of a pleasurable few hours or death, probably lie elsewhere.

Psychosis impairs brain function beyond the apparent symptoms. Depression impairs brain function, the scanning, filtering, perceiving functions. Depression eliminates perspective. Similarly, once addicted, the addiction impairs brain function. It seems to eliminate any sense of time and perspective, any way of thinking about long and short term priorities; it clearly impairs the brain’s ability to assess risk; it impairs the brain’s ability to consider short term pain for long term gain. It wipes out empathy. Once addicted the human brain becomes as if a shark’s brain with a solitary single purpose.

So we must treat addiction itself as an illness, offer detoxification and rehabilitation services and reduction-of-harm care. And this includes safe injection sites, and maintenance programs.

Secondary prevention of relapse should be another focus, and we know of several groups we could target for this: recently discharged from hospital, psychiatric hospital, drug treatment centers, jail, or prison.

Primary prevention is much more complicated. But there are some factors that could be addressed:

  1. Physician over-prescription of Opioids, both in dosage and length of time.
  2. Illegal availability of these drugs from a variety of sources, including the internet.
  3. Self medicating for something better treated by professionals in other ways: anxiety, depression, PTSD
  4. The simple fact that this is a very profitable business for many in the chain of supply.

Which means:

1.Education, guidelines, controls for physicians, pharmacists.

2. Taking a look at ways to stem the flow of drugs across borders (other than another “war” on drugs).

3. More readily available mental health treatment, sensible pain management.

4. And perhaps consider removing the profit motive by legalizing and providing opioids for addicts in a controlled fashion. Is this approach working in Portugal?

And then teenagers, early twenties. Though they have newly acquired logical thought processes and information at their fingertips, they do not have perspective, experience, and fully developed frontal lobes. They take risks uninhibited by the knowledge of a 10 or 20  or even 40%  probability of a disastrous outcome. They often respond to warnings in a paradoxical fashion. They still need parents, and parents who are willing to intervene in a strategic fashion and not give up.

 

 

 

Psychotropic Medication, Addiction, Withdrawal, Discontinuation, Relapse

By Dr David Laing Dawson

I can offer some thoughts on this from many years of observation.

Addiction is addiction. Defined as the development of tolerance (requiring more and more of the drug for the same effect) and physiological withdrawal symptoms upon stopping the drug.

Benzodiazepine drugs are addictive. The “pam” drugs. They are safest prescribed for short periods or for intermittent use. But most of us struggle with this because they offer instant relief and there are few alternatives. (this deserves a longer discussion at another time)

SSRI and NSRI antidepressant medications are not (by definition) addictive. We do not develop tolerance and require higher and higher doses. But when they are stopped abruptly patients often suffer “discontinuation” symptoms. Perhaps this is a euphemism for withdrawal symptoms but usually they are not severe, and some people come off SSRI medication without any such symptoms at all.

Usually these symptoms are unlike a true relapse and are short lived. They are described many ways by people using such words and phrases as “not like myself, foggy headed, pinging, buzzing or electric shocks in my head”.

Some of the SSRI and NSRI medications have worse discontinuation symptoms than others. Perhaps Paxil and Effexor XR are the worst offenders. But again, some patients go on and off these medications without any ill effects. Strategies to ameliorate withdrawal effects include very very slow weaning and switching to an SSRI with a longer half-life.

And it is usually not difficult to distinguish these withdrawal symptoms from a relapse of the original illness being treated with these drugs. The withdrawal symptoms are almost immediate, depending on the half-life of the medication; they are odd feelings rather than the slow return of the depression or anxiety disorder they were treating.

A true relapse of the illness may occur months or even years after discontinuation. And usually the discontinuation symptoms last a few days to a couple of weeks. When these illnesses relapse (depression, anxiety, OCD) the symptoms are usually identical to those of the first episode. This fact is one of the reasons it is reasonable to call Depression, Anxiety, and OCD illnesses.

Anxiety disorders and depressions can be chronic persistent disorders or relapsing and remitting disorders. They can be seasonal or more closely associated with events and transitions in life.

Usually these medications work. And the more severe the illness the more dramatically effective they can be.

Do these drugs actually cause a later vulnerability to depression? I think the short answer is “no”. Impossible to prove of course but I have not seen it. But I have seen much relief from suffering and dramatic improvement in function.

With all that, the SSRI’s are undoubtedly over prescribed for less serious mood problems, unhappiness, and disappointment.

Of course if non-pharmacological means of alleviating mood problems do so for you on their own, then by all means use these instead: exercise, meditation, yoga, SADS lamp, counseling and therapies of any kind, better diet and sleep, better balance in life……

But I must admit that in 40 plus years of prescribing life-balance, exercise, meditation and yoga, my patient compliance rate is running roughly 5 percent. It is very hard to initiate any of these activities if you are house bound with anxiety or morbidly depressed.

Rehab and Drug Overdoses

By Dr David Laing Dawson

News item: Newly released inmates face higher risk of overdose death.

“The weeks immediately after release are a precarious time for former inmates. Job and housing prospects are usually bleak and drug tolerances are generally at a low point because of the relative scarcity of drugs in prison.”

This information is being used to support wider availability of the drug Naloxone, an antidote for opioid overdoses.

I am not opposed to the wider availability of Naloxone, but several things struck me about this report.

The first was the rather ambiguous statement about the “relative scarcity of drugs in prison.”

And the second was, “drug tolerances are generally at a low point.”

Yes.

And even with good jobs and excellent housing, every year a half dozen or so rock stars, musicians, actors, and other celebs die from overdoses of opioids. And always not long after a stint in rehab or otherwise imposed abstinence.

So while we need to do many things to help people with addictions, and help them survive and recover from those addictions, there is one very inexpensive and realistic thing we could do.

And that is tell, instruct, educate addicts when they are in jail, or in rehab programs that

  1. They are likely to relapse and
  2. When they relapse they will have lost their high tolerance to opioids, and the dose that previously gave them relief will now kill them. When they relapse they need to start with low doses, as if from the beginning of their use.

Maybe rehab programs already do this. I doubt it though, for it entails admitting probable failure.

If Philip Seymour Hoffman and Prince did not know this, how can we expect the average guy coming out of jail to know this?

This should be emblazoned on the walls of jails and rehab centers:

If you relapse, return to the same dealer, use the same dosage as before, it will now kill you.