The Anatomy of Addiction (17 page)

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Humane values:
The substance user's decision to use alcohol and other drugs is accepted as his or her choice; no moralistic judgment is made, either to condemn or to
support use of substances, regardless of level of use or mode of intake. The dignity and rights of the person who uses alcohol and other drugs are respected.

•
Focus on harms:
The extent of a person's substance use is of secondary importance to the harms resulting from that use.

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Hierarchy of goals:
Most harm-reduction programs have a hierarchy of goals; the symptoms that are the most potentially harmful to the patient are addressed first.

The Harm of Social Consequences

Interaction with a punitive law-enforcement system is also harmful. Research has shown that the risks associated with drugs other than alcohol are far less than those associated with alcohol, especially for those associated with aggression and violence. The punishment handed out for illicit drug use is more harmful than the drug use itself.

Due to the relatively low harm potential of cannabis, one important aspect of harm reduction would be to limit testing for cannabis use in those jurisdictions where testing positive for cannabis would result in harmful punitive actions because of existing laws.

For example, if a foreign exchange student in America under a federal program smokes pot at a party, and his host family finds out, they are obligated to report it. Once reported, the student is never allowed to pursue a college education or career in the United States nor can he or she ever enter America again. The harm was
not done by smoking marijuana. The harm was done by the punishment.

None of these long-term concerns, be they consequences of health or punishment, has any meaning to a teenager who can't imagine life twelve months down the road, let alone the impact of current behavior on advanced educational opportunities, marriage, family, and employment in some distant future.

A successful technique for reducing the risk of teen drinkers becoming alcoholics is friendly advice offered to the heavily drinking teenager by someone he or she trusts. It is important that advice to moderate consumption not be confrontational or judgmental in any way. No criticism, no drama, no threats or stress. A very brief, simple moment of advice to reduce consumption and/or moderate behavior has proven far more motivating than lectures, scolding, or threats.

Removal of secrecy has also proven a powerful method. When teens are told by their own parents or guardians that if they really want to drink or drug, they are more than welcome to do it right there at home, the mystique of substance use being a secretive or rebellious act evaporates faster than alcohol.

Treating Teenagers and Young Adults

Teenage experimentation with alcohol and drugs is normative, no matter how much we pretend otherwise. In other words, it may not be healthy behavior, or behavior parents approve of, but it is normal behavior.

There are teens who excessively use drugs and alcohol, but actual teenage alcoholism is a rarity. There are thirteen- and
fourteen-year-old kids experimenting with all manners of mood-altering drugs, but they are not drug addicts. They may be at risk or have the potential for the disease of addiction, but they don't have it yet. It is as if the child has high cholesterol but not heart disease. And it is possible to prevent the onset of alcoholism or drug addiction in someone who has the telltale risk factors.

The risks of becoming an alcoholic increase with binge drinking, especially in the formative adolescent years. As biology forms up to 50 percent of one's propensity to develop drug or alcohol addiction, a family history of alcohol or drug misuse is a major red flag.

Other risk factors for teenagers developing drinking problems include low levels of parent supervision or communication, family conflicts, inconsistent or severe parental discipline, problems managing impulses, emotional instability, thrill-seeking behaviors, and perceiving the risk of using alcohol to be low.

Girls whose mothers have drinking problems are at severe risk of alcoholism, as are those who begin drinking before age fourteen. Family relationships, part of the social aspect of contributing factors, indicate that sixteen- to eighteen-year-olds are less prone to excessive drinking if they have a close relationship with their mother.

The treatment appropriate for a binge-drinking teen or a fourteen-year-old who was caught experimenting with cocaine must be entirely different from the treatment given to a middle-aged alcoholic with decades of continual consumption or a thirty-year-old heroin addict with hepatitis C and HIV or to the bipolar twenty-three-year-old who snorts ketamine on the weekend.

The most common reason teenagers end up in rehab is that
they got into trouble at school or home because of their use of alcohol or drugs. Their behavior could range from normal teen experimentation and recklessness to blatantly extreme intoxication and dangerous behavior.

Although drinking does not equal alcoholism and drug use does not equal drug addiction, there is significant pressure to treat the drinking or drugging teen as an alcoholic or addict who must, for his or her own good, be sent off to rehab, even if that treatment is coerced. A current advertisement for a drug and alcohol treatment center in California states, “Even if you have to admit the teen into the facility
against their will
, it will be best for them to be there.”

A 1979 U.S. Supreme Court decision gave parents power to commit children who are under age eighteen into a facility without judicial proceedings. This has been a gold mine for private “treatment centers,” private mental health facilities, and lawyers specializing in helping parents have their children involuntarily admitted to rehab centers or mental hospitals.

In the past few years, several states have revised their involuntary commitment laws, making it very easy to have loved ones treated for substance misuse, even if they don't want to be treated. According to guidelines in many states, insisting that you don't need treatment is simply proof that you don't realize that you need treatment.

This approach has been hailed by concerned parents as a blessing, because it allows them to get their kids or other family members the help they need. Yet, there is no recognized definition of “the help they need,” and many doctors who treat alcoholism
and addiction share serious concerns regarding the ethics and wisdom of the state being permitted to institute preventive therapeutic programs against a citizen's will.

Setting aside the ethical issue of coerced admission, there is documentation that drug and alcohol treatment may be equally effective whether admission to the program is voluntary or not. The educational and empowering experience of appropriate treatment can have significant value in helping the teenager consciously choose which behaviors to continue and which to abandon.

If the treatment experience serves only to reinforce an addict/alcoholic identity and continually places the teen in both emotional and social proximity to those with more advanced drug use, the risk of actually becoming an addict or alcoholic in his or her adult years increases.

A teen-only facility also has its challenges. Recent research cautions grouping high-risk teens in peer-group preventive interventions. Such groupings have been shown to produce negative outcomes, as participants reinforce each other's drug use. This must be taken into serious consideration when structuring the interaction of patients at an inpatient treatment center.

The most common drug and alcohol treatment for teens, and everyone else, is a twenty-eight-day program. However, there is no rational or medical reason for twenty-eight days; it is simply the number of days that most insurance companies will cover without objection. When a treatment center advises you that they offer immediate
evaluation
, they don't mean
diagnosis
of the patient's condition. If they meant diagnosis, they would say diagnosis. By
evaluation
, they often mean evaluation of your insurance coverage.

Addiction: False Assumptions

Once in a drug and alcohol treatment center based on the assumption that you are an addict or alcoholic, you are regarded as such, and any protest to the contrary is deemed denial. This approach is most common at 12-step programs or facilities that have a one-size-fits-all concept of treatment.

American psychologist David Rosenhan is known for an eponymous experiment in which he assigned a group of his graduate psychology students to admit themselves into a mental institution, reporting that they were suffering from psychotic symptoms. Once on the psychiatric wards, they behaved in completely normal ways that betrayed absolutely no psychotic symptoms. The medical staff did not realize that these students were normal, diagnosed their behaviors as psychoses, and in fact, refused to let the students leave until they acknowledged and accepted their diagnoses.

Having been sent off to rehab, where they are told that they're “crazy” addicts, a hair's breadth from being failures for the rest of their lives, teenagers return home to discover that everyone else believes the negative labels about them as well. They might as well wear a giant red “A” for “Addict” on their T-shirts.

Post-rehab self-consciousness and depression, accompanied by strong bouts of shame over being such a loser, can cause extreme emotional stress. The post-rehab teen always has one group ready to accept her—those who drink and drug.

“My parents sent me to rehab when I was 13 for issues that could have easily been solved with therapy, family therapy and
time,” a young woman commented in an online forum. “After I got home from rehab, at age 14, I felt like a huge outcast and was suspended from a school because they found out I went to rehab.”

The True First Step to Teen Treatment

Before a teenager is compelled into rehab, the parent or guardian should consult a physician specializing in addiction medicine and engage the teen in full participation with the physician. Consultation and diagnosis by a medical professional is always the best idea. If the teen isn't an alcoholic or an addict, the doctor will say so and will advise the patient regarding whatever medical issues are involved and how to decrease the risks of chronic illness. If the teen is an alcoholic or addict, an addiction medicine specialist is best qualified to recommend the treatment regimen best suited to the individual patient.

Not all teen drinkers will become alcoholics, but all teen drinkers are at risk for a wide variety of health problems and legal sanctions for dangerous behavior. The most comprehensive approach to the reality of teen drug and alcohol use is short-term harm-reduction and commonsense preventive measures to reduce the risks of alcoholism and addiction.

A Family History of Addiction

A wealthy woman had an eighteen-year-old son, Sean, who battled a severe cocaine habit. She had tried to get him into rehab for several years without success. Finally, an intervention was
performed, and he was checked into a high-priced facility, where all costs were nonrefundable. Over the weekend, when family members were allowed to visit patients, the mother brought her son a reward for going to rehab—a $25,000 Rolex watch.

You can probably guess what happened. He signed out of the rehab, sold the Rolex, and went on a cocaine binge. This behavior may be immoral, but it is perfectly understandable. Addicts and alcoholics have structural or functional damage to the reward and motivation centers of their brains, located in a part of the brain known as the limbic lobe. When working properly, this reward system causes us to remember and return to pleasurable, life-affirming experiences. When the reward center is damaged, we keep doing things even when the result is pain instead of pleasure.

When I met Sean shortly after his Rolex binge, he was noticeably high. His medical exam confirmed what everyone already knew—he was a cocaine addict but also drank alcohol, popped pills, and smoked marijuana. “I don't discriminate, doc. Whatever I can get my hands on,” he said with a grin.

As it turns out, Sean's family had a history of addiction. His maternal aunt died of a heroin overdose. A cousin on his father's side died in an alcohol-related car death; both of his parents were in recovery. I explained to Sean how his uncontrollable drinking and drugging were symptoms of a chronic disease and in his case, one likely with a very strong genetic basis. The fact that he couldn't stop drinking and drugging didn't make him a loser, and it wasn't his fault.

He was stunned and took a minute to absorb this. “Really?
'Cause the last rehab clinic that I went to said it was all my fault and if I really wanted to stop, I would,” he said.

I explained that while his disease was not his fault, unfortunately, he was at risk of profound brain damage if he continued drinking and drugging obsessively, because of his relative youth. “You're actually on a rapid pathway to lowering your I.Q., not to mention increasing your risk for need of a liver transplant and shrinking your testicles. If you continue, soon you will be a dumber, sicker, and more impotent version of yourself.”

I got his attention. With his parents' consent, I prescribed a regimen of pharmaceutical medications to stop his cravings for drink and drugs. I also arranged for him to begin motivational therapy and got him thinking about a lifestyle modification. We helped him focus on substituting an adrenaline rush through intense exercise (he favored rock climbing) for intoxication through drink and drugs.

Deep down Sean was motivated to quit. He had seen up close the damage substance addiction had caused to his family. Six months after our initial visit, he enrolled in college and is working toward a degree in criminology and forensics science. Yes, he wants to work in criminal justice.

Critical Thinking About Kids and Addiction

Families need to understand the disease of addiction and have realistic expectations of behavior change. This is accomplished when families are well-informed participants in their loved one's treatment.