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?