The Anatomy of Addiction (12 page)

When treating alcoholics, it is unlikely that having them drink to excess would be beneficial. I doubt you would buy the
alcoholic a case of beer, a large bottle of Scotch, and several wine coolers, and then have him drink to get it out of his system. No responsible person involved in the treatment of addiction would tell drug addicts or alcoholics that they need to drink or drug as much as possible as a way to achieve health and sobriety.

Telling someone with a negative and destructive behavioral addiction not only to continue but also to amplify that behavior, strikes me as both absurd and negligent. After all, with any addiction, the continuation of the behavior ignites a self-stimulating, self-perpetuating system. The more you do, the more you want, even if every indulgence in the addiction brings more pain.

COMPULSION

When compulsion replaces control, the disease of addiction has taken over. There are short episodes of abstinence as a result of coercion or feelings of guilt, shame, or remorse. Those same emotions, however, provide the stress that triggers relapse into active addiction. Once the compulsion is triggered, all efforts at control disintegrate.

When you have an addiction, you look for opportunities to feed your addiction. When the addiction is to alcohol or other drugs, seeking and procuring the drug is part of the obsession; use of the substance is the compulsion.

With an internally stimulated and self-perpetuating brain chemistry, all the addict with compulsive anger issues requires is an insult, real or imagined, to instigate rage. A medical diagnosis, however, would reveal a significant biological factor to the
rage issue, in addition to medical problems engendered by the anger itself.

OBSESSION

Obsession is when you can think of only one thing at a time, and it is the same one thing
all
the time. Obsession is an irresistible force of thought that pushes everything else aside.

Obsession is followed by consummation in an unending repetition. For example, stalkers are obsessed with their prey. Fanatics are obsessed by their passions. Active addicts are obsessed with living their addiction.

One psychological attraction of addiction for the intelligent and well informed is the delightful prospect of not being in control. These are people who, due to their important positions of responsibility in life, wish to take a vacation from being in charge and place themselves in a subservient position. Of course, as with the person who pays to visit a dominatrix, they are only pretending not to be in control. In truth, they are in charge of the entire scenario. Sadly, when true addiction manifests itself, the game of “playing a drug addict” is no longer a diversionary vacation but a tragic health crisis.

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. These are reflected in a person's pathological pursuit of reward and/or relief through substance use and other behaviors.

The transition from casual substance use to addiction can be seen in changes in the chemical substances found in the brain, known as neurotransmitters, which transmit messages within the brain's reward system.

Special Considerations for the Opiate Addict

Suboxone, a once-a-day prescription tablet that can be administered only by a physician is a partial opiate, meaning that it gives the brain something similar to what it is used to, without the dangers associated with full opiates. Suboxone contains a combination of two ingredients: buprenorphine and naloxone. Buprenorphine is an opioid medication similar to other opioids, such as morphine, codeine, and heroin.

However, Suboxone doesn't produce the high of those drugs and is therefore easier to stop taking. This has advantages over methadone, although some patients with an exceptionally high degree of addiction are often better candidates for methadone, a medication that has been used effectively and safely to treat opioid addiction for more than thirty years.

HEROIN TREATMENT AND HARM REDUCTION

The heroin that is sold on the streets today is so potent that many patients can't stay away from it, even when under treatment with Suboxone or methadone. This is why nations that adopt a true harm-reduction model of treatment, such as Switzerland, have authorized managed maintenance using actual heroin, medically
supervised and dispensed. This reduces both medical harm and social harm by reducing crime and illness.

As we do not yet have this harm-reduction model in the United States, Suboxone is rapidly becoming the medication of choice for managed maintenance for the majority of heroin addicts.

Another advantage of Suboxone is that there is no tolerance developed, but there is a ceiling on the drug's effect. In other words, if you take more than your required amount, you won't get more high.

For extreme opiate-dependent patients, the managed use of Suboxone makes it possible for them to acquire the life skills and personal balance to ride out their addiction without crashing. When they have internalized and integrated the therapeutic tools given to them, these patients recognize the right time to taper off the use of Suboxone until it is completely discontinued.

Remember, we are dealing with a physical disease that can be treated in much the same manner as we treat heart disease, diabetes, or high blood pressure. Whether a patient should take medication for his or her condition, what medication would be most effective, and how long that medication should be administered are matters best determined by the treating physician in consultation with the individual patient.

The Measure of Success

In 1964, the World Health Organization noted, “There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them,
persuading them to continue its use even to the point of abuse—that is, to excessive or persistent use beyond medical need
.
”

More than half a century later, that pronouncement rings truer than ever. The speed at which new drugs surface to join the already copious ranks of evergreen substances like alcohol, heroin, marijuana, meth, morphine, and prescription painkillers is amazing. As I write this, the latest trending street drug is something called Flakka, a synthetic drug that produces violent, hallucinatory behavior. It replaces last year's trending drug that produces violent hallucinations, bath salts.

According to
Forbes
magazine, Flakka is imported from China or Pakistan and is either smoked, snorted, or injected. It “induces rapid body-temperature elevation, the need to disrobe and a psychotic paranoia convincing the user that he is being chased. It can raise body temperature up to 106 degrees, and like amphetamines, it creates a state of excited delirium.” It's even nicknamed $5 insanity.

Why would anyone take such a drug? Of course, there is no answer to that question.

In the field of drugs, if you build it, they will try it. And that's the point I'm making. We'll never stop the ingestion of addictive substances. We as a species lost that battle when we made the first wine about 6000
B.C.E.

Our society must switch the focus from trying to stop people from drugging and drinking (remember how well forced abstinence during Prohibition turned out) to providing effective, evidence-based treatment.

Yes, but how can we possibly know when we've achieved effective treatment?

The measure of the success of the outcome of treatment is
really quite simple: Does treatment improve the quality of life of the patient? Addiction treatment is successful if the patient can lead a fulfilling, productive, and relatively normal life. It's as simple as that because that is the measure for any medical condition for which there is no cure.

T
he process of detoxifying from alcohol or drug addiction is seared into the public conscience through popular culture. Even in the earliest days of cinema, movie producers grasped the drama associated with alcoholism and drug addiction. The 1902 French film
The Victims of Alcoholism
was the first feature in a string of Silent Era movies on both sides of the Atlantic to underscore the dangers of substance addiction and its withdrawal. In 1917, Charlie Chaplin jumped on the wagon with
The Cure
(1917), a film he directed and starred in about an upper-crust fop (a departure from his trademark tramp character), who causes mayhem when he arrives at a fancy hotel/spa resort, seeking help with his alcohol addiction, with a case of booze.

Chaplin had personal experience with the subject matter; his alcoholic father died at thirty-eight years old of cirrhosis of the liver. Although tackling serious social issues with humor—abject
poverty, child abandonment, racism, prostitution—was a hallmark of Chaplin's films, in reality, detoxing from alcohol and drugs, until recently, was a horrifying process resulting in extreme physical pain, anxiety, depression, and even psychosis.

Today, the advent of new pharmaceuticals has made the process virtually pain free. However, because alcohol and opiate drugs (heroin, cocaine, prescription painkillers) affect different receptors in the brain, their detoxification must be administered with different techniques.

Research studies and my own extensive clinical experiences have shown a high success rate in treating alcoholics while they go cold turkey with benzodiazepines along with gabapentin, topiramate, and clonidine. For opiate detox, the preferred pharmaceutical is clonidine, supplemented with muscle relaxers, antinausea drugs, and other medications. However, don't try this at home! Detox from a severe addiction without proper
medical
supervision can result in brain damage and death.

Severe Intoxication and Detoxification

The American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: (1) “to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free,” (2) “to provide a withdrawal that is humane and thus protects the patient's dignity,” and (3) “to prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs.”

Detoxification for those in severe intoxication because of
alcohol, opiates (heroin and painkillers), stimulants (cocaine, meth), benzodiazepines (Xanax, Valium), and/or barbiturates can be fatal, and each patient must receive personalized medical care. Opiate withdrawal is very physically uncomfortable. Seizures, while common in the withdrawal process, are not usually fatal.

Extreme stimulant intoxication can precipitate symptoms similar to those of heart attacks and can cause strokes, seizures, arrhythmia, or life-threatening hyperthermia. The nonmedical use of methamphetamine has severe destructive potential for the brain, including microstrokes, neurotransmitter dysregulation, and death of brain cells. The long-term psychosis resulting from extreme and continued nonmedical use of methamphetamine is often misdiagnosed as schizophrenia. There are no life-threatening withdrawal considerations when someone stops using stimulants, although there is a crash period of exhaustion, lethargy, and depression.

Treating the Unique Addict or Alcoholic

As with all aspects of addiction treatment, detoxification must be individualized for each patient. No two people are the same, and each must receive a thorough medical evaluation before being given the appropriate medical care in a compressive program incorporating all the therapeutic and/or curative methodologies available.

In the previous chapter I mentioned that I usually avoid giving patients stimulants unless it turns out that they have undiagnosed attention deficit disorder (ADD). In the majority of those cases, once they are prescribed the most effective stimulant, their
life is changed, and their drug misuse ends. For some diagnosed ADD patients who have a nonmedical stimulant dependence, even prescription stimulants trigger a relapse.

The point is this: Physicians need to keep an open mind and provide individualized treatment. The old belief that individual addicts are not different from each other is completely wrong. No two are exactly alike, and there is no one treatment that is appropriate for all patients. To overlook the individuality of the patient is a gross violation of both ethics and professional responsibility.

Detox vs. Treatment

Detox and treatment in the public's mind are synonymous, but in reality, that's not the case. Not every addict who seeks treatment needs to go through detoxification. It's only necessary for those patients whose dependence on a substance has reached such a critical stage that a sudden cessation—going cold turkey—could seriously endanger their health and possibly their lives.

This is the inherent problem in addiction rehab clinics that rely exclusively on nonmedical protocols and apply a one-size-fits-all abstinence model for treatment.

Detoxification is the removal of alcohol or other drugs from the body via metabolism and specifically through the liver and excretion through the kidneys. Medically assisted detoxification reduces the risk of discomfort and potential physical harm for patients in the throes of withdrawal. For those with severe substance dependency, detoxification is an often necessary step before moving on to immediate care and eventual long-term management of the disease of addiction.

Beside the fallacy that addiction treatment can be the same for everyone, another point of confusion needs to be cleared up: Detoxification is not the end of treatment but rather the precursor to it. I am reminded again of the death of actor Philip Seymour Hoffman. He reportedly checked himself into a detox center after a relapse in his drug addiction. He was released after ten days. In a few days he was back to shooting heroin and overdosed a few months later.

In my opinion, the ten-day detox, which has become a cultural ritual for the rich and famous, is more of a publicity stunt than bona fide medicine. When a celebrity gets in trouble and his career is in jeopardy, the knee-jerk response from his handlers is to exhort, “get thee to detox.” That's like bandaging the wounds of a gunshot victim and then showing him the door.

The Three Steps to Detox

As outlined in the landmark addiction report known as the Columbia University CASA Report, published in 2014, there are three main components to effective detoxification. I use these in my own clinical practice.

1. EVALUATION

Examine the patient and determine if symptoms are acutely present, ideally using standardized instruments to measure the severity of withdrawal. Assess vital physical signs that manifest themselves in substance dependency. Evaluate for the presence of cooccurring medical conditions and mental health disorders. And, finally, determine by medical analysis, such as a urine test, if
there are substances present in the patient's body or if substances were recently used.

2. STABILIZATION

The doctor and other trained personnel assist the patient through withdrawal to the state of physiological stability. Depending on the individual, pharmaceutical medications may be needed.

3. FACILITATION OF TREATMENT ENTRY

Guide patients with severe addiction to a bona fide addiction treatment center that uses evidence-based medicine and provides a continuation for the short-term care
and
long-term management of the patient's disease.

Alcohol Detoxification

Alcohol withdrawal is potentially the most dangerous of any substance addiction. For the successful and safe cessation of alcohol ingestion I recommend the use of certain medications to help prevent the harmful effects that may accompany it. Withdrawal from alcohol typically takes seven to ten days, but with medical management, stabilization can be achieved sooner.

During the first six to forty-eight hours, symptoms can include anxiety, nausea, agitation, and difficulty concentrating. In more severe cases, symptoms can include hallucinations and seizures. Alcohol withdrawal delirium, also known as delirium tremens (DTs), is the most severe and dangerous withdrawal symptom, and usually
appears two to four days after the last drink. Some symptoms of alcohol withdrawal, including DTs and seizures, can be life-threatening, so it is medically imperative that patients severely addicted to alcohol should undergo detox only with the supervision of trained medical personnel with ready access to hospital care if necessary.

There are a number of assessment tools that can be used to determine the severity of alcohol addiction, including Clinical Institute Withdrawal Assessment—Alcohol Revised (CIWA-Ar), the Clinical Opiate Withdrawal Scale (COWS), and the Finnegan Neonatal Abstinence Score.

The duration of detoxification varies with the severity of addiction. Withdrawal symptoms, such as sleep disturbances, can last for weeks. The severity of symptoms can increase in patients who have experienced prior alcohol detoxifications, a process known as the kindling effect.

Here's the good news: As I mentioned before, benzodiazepines, a class of psychoactive tranquilizers, have calming, sedating effects and can prevent the onset of certain alcohol withdrawal symptoms and acutely relieve such symptoms, including alcohol-induced seizures and DTs. This class of drugs includes the following drugs (brand names in parentheses):

• Diazepam (Valium)

• Clonazepam (Klonopin)

• Lorazepam (Ativan)

• Chlordiazepoxide (Librium)

Because the combined effects of benzodiazepines and alcohol can be life threatening, patients must be advised not to drink
while on benzodiazepine medications. Also, benzodiazepines have their own potential for addiction and so should be used only in the relatively short-term period of detoxification and closely monitored by a medical professional.

Although DTs occur only in about 5 percent of patients undergoing alcohol detoxification, the mortality rate is more than 18 percent for those who experience them. There's no excuse for anything but expert medical care for patients experiencing DTs.

Opioid Detoxification

Withdrawal symptoms from illicitly obtained or prescription opioids, including heroin, morphine, hydrocodone, and oxycodone, are not typically life threatening, but they can be extremely uncomfortable. Among the symptoms are abdominal pain, muscle aches, agitation, diarrhea, dilated pupils, insomnia, nausea, runny nose, sweating, and vomiting.

Withdrawal symptoms generally last from seven days to several weeks. Because medical complications can develop, patients must undergo regular physical examinations and psychological evaluations.

The goal of medical detoxification is a safe, comfortable and complete withdrawal from opioids. Sudden cessation of opioids, especially for a patient who has developed physical dependence on the drug, should be avoided. Rather, the patient should be weaned off the opioid gradually.

However, this procedure is not legally permissible with illicit opioids such as heroin.

Instead, the trained medical professional uses opioid replacement therapy, which substitutes FDA-approved medications that are then gradually tapered off. Nonopioid medications, such as clonidine, can decrease the agitation and discomfort associated with withdrawal. Other medications that can relieve the symptoms of acute withdrawal can also be used, such as nonsteroidal anti-inflammatory drugs (NSAIDs) to treat muscle pain, antiemetics for nausea, nonaddicting sleeping medications like trazodone for insomnia, and buprenorphine to stop the craving.

Medically prescribed opioids formulated specifically for addiction treatment work by occupying the opioid receptors in the brain, blocking or minimizing the effects of more addicting opioid drugs. A patient using buprenorphine is protected from inadvertent overdose and prevented from getting high.

Stimulant Detoxification

Detoxification from stimulants like cocaine and meth may result in withdrawal symptoms, but normally these symptoms are less severe than with alcohol and are rarely life threatening. Symptoms include lethargy, insomnia, agitation, anxiety, increased appetite, depressed moods, and drug cravings.

As with alcohol and substance detox, the preferred method is tapering the drug off gradually. But as with illicit opioids, stimulants like cocaine are illicit and cannot be used in detoxification. Tranquilizers can be used for agitation and anxiety, and nonaddictive sedatives are helpful with insomnia.

As noted in the previous chapter, there is promising evidence
supporting a medication called bupropion for curbing cravings and reducing the severity of withdrawal symptoms associated with meth addiction. Bupropion was developed to treat depression, including seasonal affective disorder, and has been proven to aid in quitting smoking. The drug appears to work by blocking the receptors of two neurotransmitters active in substance addiction: dopamine and norepinephrine. Another advantage is that it curbs the increased weight gain associated with stimulants withdrawal.

Similarly, the stimulant medication modafinil (brand names Provigil, Alertec, and Modavigil), created to treat sleeping disorders, can reduce the cravings and withdrawal symptoms associated with cocaine. Studies are inconclusive as to modafinil's effectiveness, but depending on the individual patient, it can reduce the stimulating effects of cocaine and aid in overall detoxification.

Depressant Detoxification

Benzodiazepines are commonly known as tranquilizers and are some of the most commonly prescribed medications in the United States. Brands like Valium and Xanax are household names and are found in tens of millions of medicine cabinets across the country.

Xanax, designed for anxiety, is the most commonly prescribed pill in the United States, with nearly 48 million prescriptions written in 2012. When used as prescribed, benzodiazepines can help in legitimate medical conditions, such as anxiety, insomnia, seizure control, and muscle relaxation. Indeed, earlier in this chapter we learned how benzodiazepines can be effective in alcohol withdrawal.