Tag Archives: Addiction

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As you may recall, my last blog listed 10 reasons for the current heroin epidemic. Over the next weeks, I will be addressing who and what to blame for this epidemic and the changing demographics of today’s heroin user, which has migrated outside of our major cities to suburban and rural America. But before we engage a detailed explanation of who/what to blame, to better understand the complexity of the issue, let’s review the biological, psychological and sociological aspects of addiction.

beer bottle

Biological:
To understand the biological aspect of the disease of addiction, let’s look at it from the viewpoint of genetic predisposition. Years ago, Scandinavian studies demonstrated that your biological parents are the predominant factor whether you would develop the disease of addiction. The study followed identical (monozygotic) twins who were adopted into different families. The results demonstrated that the children most likely to develop addictive behavior were those from birth parents with the disease of addiction. Although environmental factors were also shown to be important, the predominant factor on whether determining who would develop the disease of addiction was most highly correlated with parents and genetic predisposition.

Metabolism is another example of a biological component that influences addiction. There is a segment of the Japanese population that rarely drinks alcohol and they also commonly lack an enzyme called alcohol dehydrogenase. In most of us, alcohol dehydrogenase is the predominant substance that breaks down alcohol in to metabolites, which are then excreted by the body. A small amount of alcohol is metabolized by an alternative pathway. However, if one lacks the enzyme alcohol dehydrogenase, the majority of alcohol is metabolized by the alternative pathway. The alternative pathway produces a toxic metabolite which can make one extremely ill.

The symptoms and effects of the toxic metabolite can range from mild nausea and dizziness to losing consciousness from low blood pressure, seizures, heart attacks or other significant consequences. Individuals who lack the enzyme alcohol dehydrogenase typically avoid these unpleasant effects by not drinking alcohol. In fact, the medication called disulfiram (Antabuse) is prescribed to some patients who wish to stop drinking. Antabuse blocks the enzyme alcohol dehydrogenase forcing alcohol to be metabolized by the alternative pathway, thus producing toxic byproducts. This type of aversion therapy using medication and recommended counseling can be effective albeit it does carry a risk if patients are not compliant.

Psychological:
Many substance users consume alcohol or drugs in order to eliminate or minimize feelings, fears, or symptoms. Unfortunately, medical services are not easily obtainable for many people suffering from mental health related illnesses, and they may self-medicate with alcohol or illicit drugs. In addition, people commonly fear the effects of withdrawal and this psychological response continues to drive addictive behavior. There seems to be a relationship between anxiety disorders and alcohol; depression and cocaine or other stimulants; bipolar illness and opiates; and ADHD and marijuana. Treating of underlying mental illness is an important component to curb inappropriate substance use. There have been reports that as many as 50% of patients with substance use disorders have underlying mental illness.

Sociological:
Where we live and how we live makes a difference in our choices. If we live in an environment where there is no alcohol or drugs then we are unlikely develop a substance use disorder, even if we have genetic predisposition or underlying mental illness. If we reside where drugs and alcohol are readily available and dependency is developed and then we wish to stop using, it is more difficult to refrain if we return each and every day to this same neighborhood with the same sociological cues. This is a major factor why Vietnam war veterans who became addicted to heroin abroad tended to do much better in recovery when they returned home, having left sociological cues behind in Vietnam; and why it is more difficult for a drug user to change his/her habits if living with another user of alcohol or drugs.

I wonder what role Mr. Bomer had in his son’s drug and alcohol use. It must have been difficult for Travis to grow up in a household with a father suffering from alcohol addiction. Yes, I am referring to the same Travis, who became dependent on heroin, and despite his addiction, saved a crewmate’s life on the high seas.

Kathy used this interlude to permanently separate the two men. “Frank, dear, why don’t you walk over to the Holiday Inn and get us checked in.” Kathy never confronted Frank about his unpredictable temper, which got worse if he either went too long without a drink or drank too much. It was a fine line between his drinking enough to eliminate the irritability of alcohol withdrawal and not drinking so much that he became belligerently drunk. “It’ll only take you about half an hour and then you’ll be back and we’ll be able to see Travis.”

Kathy knew that Frank would not be able to tolerate the overall situation, and in her heart knew her husband was an alcoholic who needed his beers and shots of whiskey throughout the day. Even if Kathy had been able to face the reality of her husband’s incapacity, this was hardly the time to confront it. All her energies were focused on protecting and supporting her son.

Hope you enjoyed this week’s segment, and next week we will discuss the difference between Tolerance, Dependence and Addiction; and explain why Aunt Tillie may be dependent on opiates but not addicted!

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As we all know, the holiday season brings joy to some and anxiety to others.  It is therefore not unexpected that at this time of year there is an increased feeling of loneliness for those who are alone, a heightened sense of hopelessness for those who have depression and an increased challenge by the temptations of the season for those who are faced with the disease of addiction. “Tis' the season to be jolly.  Fa la la la la, la la la la.”  Really?  So during a time when we are faced with the senseless deaths of fellow citizens for minor crimes and the rising up of voices, which reminds us of the disparity that existed between the discriminatory penalties imposed for crack cocaine versus powder cocaine, I thought I would share a few stories.

As a physician who has spent many holidays working in Emergency Departments treating those who come to the hospital for care as a place of last resort, it is clear that we as a society need not only to open our hearts and our wallets but our minds to ameliorate the suffering.  It is time to embrace mental health and substance use/abuse as illnesses no different than diabetes, high blood pressure or heart disease.  But until we are willing to accept that our neighbors, co-workers, friends and family members are equally affected by this illness, community resistance to establishing local treatment centers for addictive diseases will persist.

Treatment does make a difference, but it is not a one size fits all, as illustrated by two patients who live inside of me, especially at this time of year.  Both patients were in their mid-seventies when I met them as a young physician several decades ago.

I will refer to the first patient as “Joy”, as that is what she truly was.  Joy had been coming to see me for alcohol dependency for a few years, and she was able to remain abstinent from drinking except for the time between Thanksgiving and New Year’s - the time when families gather to eat, drink and be merry.  Joy needed some help to stay sober, a little more encouragement from her family and maybe a different approach than just an increase in her counseling visits during the holiday season.  Otherwise the pattern of this delightful and spunky woman “falling off the wagon” during the holiday season, resulting in this joyful person becoming joyless, was bound to continue.

So one day she asked me about the medication called Antabuse, which forces alcohol to be metabolized by an alternate pathway.  If one drinks while on Antabuse the alternative metabolism creates toxic byproducts that can make one very ill, resulting in low blood pressure, fainting, nausea, vomiting and even passing out - too dangerous to risk in an elderly woman with other medical illnesses.  But she insisted she wanted to try it.  So I prescribed an extremely low dose (really a sub-therapeutic dose) and was pleased that she never questioned why I had her break the tablets into multiple small pieces. Yes, I lied, or maybe just exaggerated, about the potentially catastrophic consequences if she took even the smallest sip of alcohol.  I think she knew I was fibbing a tad, but she never asked. “Now remember, you need to also stay away from the rum cake,” I would tell her with a smile.

So off Joy would go with her prescription for a sub-therapeutic dose of medication to last her from Thanksgiving to New Year's; and she lived on without ever again taking another drink!

The second patient I will refer to as “Happy” because that is just what he was - an extremely warm and positive man who also struggled to stay sober over the holidays. As a younger man, he was able to just say, “No” when offered a drink at his family’s multiple holiday events.  He came from a “large family of partiers” as he would refer to his relatives; who never believed anyone could have a problem from just a few highballs.  So despite Uncle Happy’s persistent refusals to drink, they never gave up hope!  At the prior year’s Christmas Eve event, he succumbed to the pressure of constantly be handed a drink.

When I saw him shortly thereafter, he had gone on a three week “bender” and needed hospitalization for dehydration.  Over the ensuing ten months, he always kept his medical appointments and remained sober, but had lost some of his happiness, replaced by guilt and embarrassment.  Just as he was starting to let go of these negative feelings, the holiday season was again upon us.  What to do?  “How about you make sure the first thing you do is make yourself a drink as soon as you walk in the door.  Put some tonic water and ice in a glass and be sure to add either a lemon or a lime.  Or maybe grab a martini glass, fill it with water and drop in a few olives.  That way everyone will see you have a drink and your empty hands won’t be empty.”  A big smile came across his face, as he responded, “And I could even take a sip if I wanted to.”

So during this holiday season I hope everyone can find Joy and be Happy just like my two special patients.  “Tis' the season to be jolly.  Fa la la la la, la la la la.”  As a special holiday gift to bring some additional pleasure, my book Addiction on Trial, is now on sale through January 8th and the ebook is just 99 cents!  And a special thanks to the many folks and organizations that have been supportive of my literary endeavors over this past year.

Happy Holidays and Healthy New Year 🙂

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September is National Recovery month, which is now in its 25th year!  "National Recovery Month is a national observance that educates Americans on the fact that addiction treatment and mental health services can enable those with a mental and/or substance use disorder to live a healthy and rewarding life. The observance’s main focus is to laud the gains made by those in recovery from these conditions, just as we would those who are managing other health conditions such as hypertension, diabetes, asthma, and heart disease.”

“Recovery Month spreads the positive message that behavioral health is essential to overall health, prevention works, treatment is effective, and people can and do recover.  This year’s theme, ‘Join the Voices for Recovery: Speak Up, Reach Out,’ encourages people to openly speak up about mental and substance use disorders and the reality of recovery, and promotes ways individuals can use to recognize behavioral health issues and reach out for help.”

So this month, I wish to again focus my blog on further destigmatizing and demystifying the disease of addiction. This illness has no socio-economic barriers and two recent articles definitely reinforce this.  It is time to abandon any and all preconceived stereotypical notions we might have!  Give it up!  We are all affected, regardless of skin color, race, religion, education or employment status.

Please check out these two articles and be sure to let me know what you think!  Vermont Quits War on Drugs and Whites Account for Rise in Heroin Deaths

I hope you will consider reading my book “Addiction on Trial” and remember that its subtitle could just as easily read “Tragedy Anywhere USA”.  Please also consider checking out a previous blog: We Need More Doctors Like Saul Tolson to better understand the biological, psychological and sociological components of addiction.  And just imagine what it must be like to be the parent who gets a call that your son is A Heroin Addict in Jail

September is Recovery Month – Spread the word!!!

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Unfortunately, life got ahead of me this summer as I went into a “full steam ahead” mode to get the word out about my book, interspersed with visits from three of my grandchildren.  I apologize for not having kept up with my self-imposed schedule of blog postings about my author endeavors and current addiction medicine related matters. To all of you who have read Addiction on Trial, thank you; and if you posted a review on Amazon, an extra thank you 🙂 

As you can see from my events listings, I will also be doing some traveling over the next few months.  I am looking forward to presenting at the Flight Attendants Drug & Alcohol Conference in Baltimore and at the Union League Club in New York City.  I must admit, the event in New York City is going to be a little extra special, as the Union League Club membership has included fifteen Presidents.  I am honored to be asked to speak about my book and the disease of addiction; and will be returning to the club in December for their annual book fair. The College of the Atlantic has also chosen my book as part of their curriculum for Psychology courses, and I will be visiting the campus this winter to meet with students, who I am certain will keep me on my toes.

Speaking of students, learning about addiction and related diseases need not stop after formal education.  I would like to share with you an article about how the National Basketball Association is educating its players about drugs and to again applaud the dedication and work by Chris Herren.

I hope everyone is having an enjoyable summer, and I again wish to thank all of you who have been so supportive of my book and my mission to entertain while educating through the back door … or maybe the side door 🙂  I will keep you posted on the progress of the next Shawn Marks Thriller, as I am currently working on the sequel, Lost to Addiction.  Shawn Marks, that egotistical but likable big shot Boston attorney, will definitely have his hands full as he attempts to defend the son of a wealthy shipping magnate. The adventures with Marks will continue as he travels to Europe and to the seedy underground of drug distribution centers in Guadalajara Mexico to solve this murder mystery.  Stay tuned!

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"The Scourge of Heroin Addiction"  

Op-ed published by the Boston Globe April 1, 2014  http://b.globe.com/1kAzt54

Governor Deval Patrick has appropriately declared the opioid addiction epidemic as a public health emergency.  The governor's directives will save lives and help to put some brakes on this run away scourge to society.  But questions remain and more issues need to be  addressed. 

For example, why is medication management for the treatment of heroin/opioid addiction scorned by so many? In a recent Boston Globe article, "Heroin Epidemic Exposes Deficiencies In Care System" (http://b.globe.com/1iNFmzo), Ms. Jacobs, Director of Substance Abuse Services for the Commonwealth of Massachusetts, acknowledged, "medications are not used as much as they could be for opiate addictions because of stigmas attached to them, she said."  We watch endless commercials about how to treat illnesses such as urinary incontinence or erectile dysfunction but public service announcements addressing the heroin/opioid epidemic and the proven benefits of outpatient cost effective medication management have been relatively sparse.  The governor's directives, which include public health advisories to educate the public about opioid addiction treatment options, will hopefully demystify common misperceptions, such as crime increases when there is a treatment center in one's community. In fact, there is a 50% to 80% reduction in crime by heroin addicts when in treatment. (http://bit.ly/OVVRfh ;  http://1.usa.gov/1dtb42B)

We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue – that we as Americans want instant results and we want total pain relief after an injury or procedure.  Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of oxycontin pills, so they could not as easily be used to "shoot up" or "snort", resulting in more persons turning to heroin as a drug of choice; the increased availability of opiates through the internet; inadequate mental health treatment services resulting in some patients "self-medicating"; and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction.  Despite the arrest of kingpins and drug pushers, big and small, we still have a supply and demand problem. The supply of heroin has increased and cost is down to as little as $4/bag. As fast as we take drug pushers off the streets, they are replaced by others - there is too much money involved.  Governor Patrick is right to focus on the demand side of the issue.

If outpatient treatment is not more widely accepted and available, inappropriate hospitalizations and incarcerations of patients will continue.  It is time for our locally elected officials to openly support establishing treatment centers in their communities?  We all know heroin addicts, albeit we may not know who they are. They could be any one of a number of patients I have treated: your plumber; the mailman; your kid's college professor; the IRS agent who audited your tax return; the person selling flowers at the corner; the principal of an elementary school (http://bit.ly/1m6XMbL); someone who works in a mayor's office (http://bo.st/1hbtN20); or a neighbor; or a family member.

A recent study has shown that less than 20% of individuals needing addiction treatment actually received treatment (http://1.usa.gov/1hYRzvX)..  Another study found that only 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment and that "most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge" (http://bit.ly/1o2l3Ax). Are we willing to accept as status quo the present system of  unnecessarily hospitalizing or incarcerating patients?  We are wasting tax dollars: it costs up to $50,000 or more per year to incarcerate (http://bit.ly/1iBKSlg ; http://nyti.ms/NW5dGQ) and approximately $5,000 per year for outpatient treatment (http://bit.ly/1rCh3G6). “There are things besides beds that are effective in this system,” Jacobs said. “More people should see this treatment as a viable option.”  (http://b.globe.com/1iNFmzo)

There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let's focus on the solutions. The scourge of addiction is in all of our yards.  The solution is to decrease the demand with bold public initiatives and a change in attitude.  It is both the humanitarian and fiscally responsible thing to do.

Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine.  He currently serves as Medical Director of Community Substance Abuse Centers and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.