The Anatomy of Addiction (13 page)

It's when benzos are taken recreationally for their sedative effect that they cross the line into substance abuse.

Here's the shocker: They're as popular for their illicit use as they are for their legitimate use. Nearly 15 percent of Americans aged twenty-one to thirty-four have taken tranquilizers without a prescription or recreationally according to 2012 data from the Substance Abuse and Mental Health Services Administration.

There's even a sinister side to their abuse. Benzodiazepines are the so-called date rape drug, which can impair normal brain functions to the point that a person cannot resist, or even want to resist, sexual aggression.

Withdrawal from benzos is similar to that for alcohol, with seizures and delirium being the most serious side effects. Symptoms can last between one and two weeks. Because benzos are legal, a detox program can use the drug itself to slowly wean the patient from it. Alternately, a different benzo drug from the same class can be used for detoxification.

Detoxification Venues

Where detoxification takes place depends on the severity of the patient's addiction and overall health condition. Physicians' offices, mental health treatment facilities, urgent care centers, hospitals, ER departments, and even patients' homes can be appropriate once a proper assessment has been made of the nature of the detox required and, most important, if medical assistance is needed.

On the other hand, the worst detox scenario is having an addict sent to a so-called rehab clinic without medically trained
personnel or one that outright rejects evidence-based medicine for addiction treatment; these facilities are often called “12-step recovery programs” or a variation on that theme. In other words, they are making a profit on the philosophical teachings of AA, which was always meant to be free, and offering no medical safeguards in the potentially dangerous detox process.

Patients most at risk are those with a history of severe withdrawals or multiple withdrawals. It's bordering on the criminal and is certainly unethical to place one of these patients in a nonmedical setting for detoxification.

As If They Were Never Treated

If there's one message to take away from this chapter, it's this: Medications offer help in suppressing withdrawal symptoms during detoxification; however, detoxification is not in itself a full treatment program. For addicts to believe their treatment program ends at evacuating the addictive substances from their body is nothing more than wishful thinking. Rather, it is only the beginning of the treatment process.

Patients who go through withdrawal—including medically assisted withdrawal—but who do not receive any further treatment, mimic drug abuse patterns similar to those who were never treated. It's as if they were never detoxed at all.

A
ddiction is not a disease you can treat with a shot and be done with it. It's not the flu. It's a chronic disease, which, by definition, means there's no cure. Again, think heart diseases, asthma, and diabetes as reference points. Once the disease is stabilized, it must be treated over a lifetime.

As with any chronic disease, a degree of patient relapse is to be expected. The disease flares up, and you have to start the treatment again. Relapse is part of what having a chronic disease means—whether its hypertension or drug addiction. In fact, the relapse rate for addiction is typical of chronic diseases, slightly more than diabetes but less than hypertension and asthma.

A relapse is not an occasion to scold, punish, or otherwise stigmatize the person. It's not a moral failure but a symptom. Modern-day diagnostics indicate that most brains eventually
return to relatively normal when the drug use stops. However, the neurological and psychological after-effects of drug use persist, and they make a relapse a significant possibility for months, years, even decades after initial treatment.

A single act can instantly reignite addiction pathways, causing the former addict to renew drug-seeking behavior. In effect, the addict's brain remembers that the substance—alcohol, cocaine, meth, Vicodin, bath salts, you name it—relieves stress, no matter how much time has passed.

The key to successful sobriety is regular, quarterly wellness checkups with a medical professional trained in addiction medicine, who can monitor brain chemistry, particularly neurotransmitter levels. Therapy and counseling can also assist in maintaining a lifestyle that avoids people and places that provide potential relapse triggers.

The Changing Face of the Addict

Knowing who suffers from the disease of addiction is essential for marshaling limited resources, both on a personal and societal level, and tailoring programs that best fit the most common profiles. A patient's demographic profile also can affect treatment. Women, for example, react differently from men to the same dosage of many drugs. Older patients absorb drugs differently from the population at large (age affects changes in body composition; the elderly typically have an increase in adipose tissue, decrease in lean body mass, decrease in total body water and lower metabolisms than the adult population at large).

Yet, the popular concept of who is an addict in America in the twenty-first century is woefully out of balance with reality.

The term
addict
still conjures up ideas of heroin junkies shooting up in a burned-out tenement in the Bronx. In reality, the drug addict today is likely to be a grandmother living in the suburbs who's hooked on prescription pills.

There's a whole new population of addicts unthinkable a generation ago, the so-called accidental addicts. They are fifty years old or older who may have started using a prescription drug to relieve legitimate pain, perhaps from one or more chronic conditions. Unfortunately, many of these patients inadvertently have formed a severe drug dependency. They now find themselves needing to ingest more and more of the painkiller simply to navigate their daily lives. In other words, they're addicted. From a pharmacological perspective, that's not surprising. Chemically speaking, there's a fine line between an illegal opioid like heroin and a legal opioid like hydrocodone.

In 2012, adults aged forty-five to sixty-four had the highest rate of hospital stays for opioid abuse; twenty years ago, that distinction belonged to those twenty-five to forty-four years old. More than 5.7 million people over the age of fifty will need substance abuse treatment by the year 2020, according to government researchers.

Heroin vs. Prescription Drugs

Without a doubt, there has been a dangerous resurgence in the use of heroin. Between 2012 and 2013, heroin overdose deaths in
the United States soared by 39 percent from 5,925 to 8,257. Add deaths related to meth, cocaine, PCP, bath salts, Flakka, and every other illicit drug, and the best data shows they were responsible for approximately 16,000 deaths in 2014.

However, the much bigger problem is the abuse of prescription pills. Overdose deaths from controlled prescription drugs have increased significantly over the last decade and now surpass the number of overdoses caused by all illicit drugs combined, accounting for more than 38,000 deaths in 2010. Enough prescription painkillers were prescribed that year “to medicate every American adult around-the-clock for a month,” according to the Centers for Disease Control and Prevention (CDC).

To frame the problem another way, healthcare professionals wrote 259 million prescriptions for painkillers in 2012. Which demographic group was impacted most by this tidal wave of opioid drugs? Seniors!

More than one-third of the enrollees in Medicare Part D, which covers the cost of pharmaceutical drugs for seniors, used a prescription opioid. In 2011, 11.5 million Medicare beneficiaries, who by definition are at least sixty-five years old, filled at least one prescription for an opioid analgesic (painkiller), collectively spending more than $2.7 billion.

The rates of patients dying from prescription opiate overdose deaths for those aged fifty-five to seventy-four increased about sixfold between 1999 and 2013, according to CDC statistics, even as all other age groups saw the rate of increase slow or stabilize.

If there is a silver lining in the prescription pill epidemic, it
seems that beginning in 2010, it began to peak. Most experts attribute that to new restrictions on doctors from dispensing prescription pills. Unfortunately, and it appears not coincidentally, about the same time prescription pill use, or at least abuse, was beginning to decline, heroin use started to surge. Do you see the connection? With prescription pills increasingly hard to find and expensive on the black market, users began to turn to cheap heroin.

To add to the perfect storm, the new forms of heroin that have become available since about 2000 are so pure that they no longer have to be injected. The very stigma that had once defined the heroin junkie—shooting up (or intravenous injections)—was no longer necessary. Indeed, a study published in 2014 in the prestigious
JAMA Psychiatry
journal found that “80 percent of the people who had used heroin in 2010 had also used prescription pills,” and that these users turned to heroin because it was “more readily accessible and much less expensive than prescription opioids.”

Needless to say, the new users of heroin weren't kids but were older adults. Studies have shown that the face of the heroin user has changed over the last twenty years from young men in urban environments to older men and women located more in the suburbs.

The rate of death by accidental drug overdose for forty-five- to sixty-four-year-olds increased more than 10 times between 1990, when baby boomers were still outside the age group and 2010, when they were starting to fill the ranks of that age group. For the first time ever, deaths from accidental overdoses for
late-middle-age adults exceeded those of the twenty- and thirty-somethings. In 2013, more late-middle-agers died from accidental overdoses than from car accidents or from the flu or pneumonia for that matter.

Dependence vs. Addiction

Emotional stress (psychological factors) can trigger the onset of a disease, including the disease of addiction, because stress may activate the genetic, biological factor. Stress may also trigger the relapse of a disease in remission.

People often confuse addiction with physical dependence in the context of clinical treatment. Drugs that we often associate with abuse, such as opiates or central nervous system stimulants, are, in the proper context, beneficial medications.

Addiction is also not synonymous with recreational or social use of mood-altering agents, including alcohol. Once we clear up this misunderstanding, everyone understands why addiction is a true clinical illness and why addiction is classified as a disease by every clinical organization in the world, including the AMA, the World Health Organization, and the American Psychiatric Association. Obviously, if addiction were not a clinical condition meeting the clear definition of disease, my area of specialization—addiction medicine—wouldn't exist.

Now, let us suppose that you use cocaine, or another stimulant, and have used it regularly for several years. Stimulants such as cocaine can contribute to, or precipitate, stroke, seizure, heat arrhythmia, heart attacks, and hyperthermia (a potentially fatal
elevation of temperature). You go to the doctor for a checkup, and he tells you that because of the cumulative effect of your years of cocaine use, you must stop immediately or you will definitely have a heart attack or stroke. What do you do? Simple, you stop.

For most people, stopping heavy drinking or drugging, or other life-threatening behavior, is simply a decision they make in their own best interest. They might do so with the help of a psychologist, their primary care doctor, a family member or friend, a self-help group, or entirely on their own.

Most people who develop a substance dependency can simply end their habit. Because of all the consequences to their health and the safety of others and for the sake of their friends and families, their own financial well-being, their spiritual or philosophical beliefs, and their own sense of self and personal convictions, they choose to stop drinking or drugging excessively or altogether.

A Question of Choice

For the unlucky with the disease of addiction, it's not a question of choice. They can't simply stop taking their favorite drug (including alcohol). Likewise, they can't simply stop from relapsing.

Those scientifically proven facts about substance addiction still vex most Americans. They see addicts drinking and drugging, they know they themselves occasionally indulge in recreational drinking or drugging, and they know they can stop whenever they like. So, why can't addicts? If they just chose to stop, they wouldn't
have their disease. It's so intuitive that it is hard to shake the idea that there's an alternative explanation.

Let's remove the stigma of addiction from the discussion for a moment. Many people know they have high cholesterol and high blood pressure, but make no attempt to control them. Finally, they have a heart attack or stroke. That is their choice. Many diabetics are not taking medication, cheat on their diet, and are walking around with sky-high blood sugar levels. Again, that is their choice. People choose to have unprotected sex, share needles, and possibly contract HIV/AIDS. Would you say that they chose to get HIV? No, but their choices facilitated the disease.

Can a person make a poor choice by drinking heavily knowing they have a strong family history of addiction? Yes, and that choice can lead to alcoholism, which is a form of addictive disease. The disease of addiction is, in many ways, similar to high blood pressure. People can't control their blood pressure by force of will or decision. People with the disease of addiction can't control their disease by force of thought. Patients with drug and alcohol addiction want to stop, but they need professional clinical help and true understanding from friends.

Addiction Defined by ASAM

Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use and other behaviors.

Let's recap: Addiction, according to the American Society of Addiction Medicine (ASAM), is characterized by the inability to consistently abstain, by impairment in behavioral control, by cravings, by diminished recognition of significant problems with one's behaviors and interpersonal relationships, and by a dysfunctional emotional response.

The ASAM Patient Placement Criteria focus on six dimensions to define severity: (1) potential for acute intoxication and/or withdrawal, (2) biomedical conditions and complications, (3) emotional/behavioral conditions or complications, (4) treatment acceptance/resistance, (5) relapse potential, and (6) recovery environment.

In the maintenance phase of treatment, the goal is to match the patient's needs to the appropriate service by assessing the severity of the addiction as well as verification of the medical diagnosis.

Managed Maintenance

Contrary to what many rehab clinics promote, there is no thirty-day fix for addiction (pardon the pun!). You can't permanently stop the progression of alcohol or drug addiction during a one-month stay any more than you could with diabetes or heart disease. Successfully treating addiction requires long-term medical intervention by trained professionals who can supervise and coordinate all treatment options.

There is no one-size-fits-all, long-term maintenance protocol for addiction treatment. Each patient's case is different, so maintenance and the recovery from inevitable relapses must be individualized.

Most addicts require additional pharmaceutical and psychological intervention after their conditions are stabilized. As discussed in the previous chapter, the measure of success for addiction treatment is not simply abstinence, which is the result of successful treatment. Rather, success is determined—as with all chronic diseases—by the quality of life. With medically supervised disease management, can the addict live a relatively normal and productive life?

I have had patients whose disease management and maintenance have lasted a few months after their initial condition has been stabilized. For other patients, I have been maintaining their health with a combination of medications and psychological counseling for years. The benchmark—the only measure of success—is their continued high quality of life.

For most patients, long-term managed care mimics in many ways the treatment provided during the acute care stage, which stabilized their condition. So, for example, a patient with an opioid addiction treated with the medication naltrexone in acute care would continue with that medication during the long-term maintenance of his treatment. Over time, the dosage of the medication would be reduced until the point when it would be no longer needed to diminish the patient's cravings for his addiction.