Category Archives: Addictions and Illness

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.

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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.

The Word ‘Issue’ Has Become an Issue.

stone of madness

By Dr David Laing Dawson

There it was again. The local paper reporting on homelessness, reporting on the results of a survey of over 400 homeless people in our city. All very nicely written and laid out. The number of homeless people who have been the victims of violence; the number who struggle with addictions. And the over 80% who suffer from “mental health issues.”

Dictionary definitions of the word ‘issue’ include:

“An important topic or problem for debate or discussion” – the operative portion of that definition being “for debate or discussion.”

Now I understand that how we describe or name something may shift and change over time, often for good reason, often not. We no longer use the word ‘retarded’ to describe someone who has less than average intellectual capacity. It is a word that accrued a lot of baggage through the years, and became a schoolyard epithet, implying, at least in the vernacular of teenagers, something like “willful stupidity”, or “in bad taste.”

But euphemisms often creep into our vocabulary to hide the truth, or to reduce the sting of truth. Sometimes the euphemisms are simply more polite (‘disability’ may become ‘special needs’); sometimes they are obfuscations with only a limited reference to the original activity, problem, or thing (‘illness’ becomes ‘issue’), and sometimes they are softer vague words chosen to hide the reality of the action or intention of our governments, bureaucrats, and military, and sometimes they are even, a la George Orwell, antonyms of the word that would actually reveal the truth.

I don’t know how the word ‘issue’ became the mot du jour, sometimes even added as a totally unnecessary noun. As in ‘he has addiction issues’ instead of ‘he is addicted’. I suspect it is related to the actual meaning of ‘issue’, (a topic open to debate), and by calling mental illness an issue we are placating the deniers of mental illness and we are reducing it to an abstraction, a topic for discussion and debate, rather than a reality in our midst, and often the actual cause of homelessness.

Even if, reasonably, we want to reserve the words ‘disease, illness, and disorder’ for only severe forms of this reality, this plight, we still have other words to chose from that do not imply a debatable abstract: ‘problem, difficulty, trouble, worry’. We might even say “mental health concerns, including mental illness”.

But let’s stop with the “issue” when we are naming or describing a painful reality.

The Disease and Medical Models as they Pertain to Illness and Addictions

David Laing DawsonBy Dr David Laing Dawson

The “disease model”, the modern concept of disease, developed alongside enlightenment and the science revolution through the 19th century. One of its components is the absolution from moral responsibility. This means, for example, that one is not held morally responsible for developing the affliction of lung cancer, notwithstanding the fact that twenty years of smoking may be an etiological factor. Similarly we do not hold people morally responsible for developing the disease schizophrenia. It is an affliction unwished for, unwanted, and it has nothing to do with the moral character of the sufferer. And once the disease begins, it is not within the power of the sufferer to stop the disease.

The “medical model” is short-hand for a definable relationship between a doctor and a patient. The responsibilities and privileges of each participant in this relationship are both traditional and defined in codes of ethics. One aspect of this relationship is responsibility. The patient’s responsibility is to do his or her best to get well and follow the prescriptions and proscriptions of the doctor. The doctor’s responsibility is to do his or her utmost to treat the patient’s illness and alleviate suffering. This model, this way of understanding the relationship between healer and sufferer, is age old, and predates science.

Can we apply these two models to addictions, the same way we can and should apply them to cancer and schizophrenia?

There is little argument about the second, the medical model. In its assignment of primary responsibility to the physician (as described above), the medical model always fails when it comes to addictions. When the doctor assumes the same level of responsibility for his or her patient’s alcoholism or heroin addiction as he or she does with pneumonia, cancer, and schizophrenia, trouble ensues. Usually, in fact, we physicians find ourselves contributing to a poly substance addiction. In fact, one can safely say that a major component of any addiction is the sufferer’s failure to assume personal responsibility for his own behavior. An understanding of this is built into the tenets of AA, and most addiction treatment programs. It is, ultimately, unlike with schizophrenia and cancer, the sufferer’s responsibility to stop reaching for that bottle or pipe.

Addicts suffer and we need to help and develop programs for them. But a full frontal medical model does no good.

What about the disease model? A cancer or schizophrenia sufferer cannot stop his illness by simply doing something or simply not doing something. An addict or alcoholic can, though to do so he or she may need extraordinary courage and a willingness to tolerate a lengthy period of physical and mental pain. We should help him find this courage and we should ameliorate his suffering and we should always consider reduction of harm (e.g. safe injection sites). But we cannot and should not assume responsibility for the actual act of his drinking, smoking, swallowing, or injecting.

Inebriation, intoxication, alcoholism, and addiction, do not qualify, under our law, our science or our folk wisdom, for “not criminally responsible due to mental illness.”