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While most people without the disease of addiction can understand why someone would take something that made them feel better, few can understand why anyone would continue to use a substance once the pleasure is gone and only bad effects are left. The concept of compulsive use, use which seems to overpower the individual’s desire to not use, has always been both a core feature of addiction and a great mystery. In fact, when people with addiction are asked why they, for instance, drink past the 4th or the 5th drink when they get no additional reward but greater and greater impairment, most can just shrug their shoulders and say they have no idea. Like any symptom of an illness, compulsive use must have a pathophysiology, and that pathophysiology must be understood before the symptom can be addressed medically.

The home of the compulsive use pathology is the brain’s midbrain reward system. This system exists in mammals to discriminate important objects, events, and behaviors from the background of everyday life.The reward system does this by associating the object with the primary reward produced when the neurotransmitter dopamine is released at the Nucleus Accumbens. But this dopamine spike at the Nucleus Accumbens alone is not enough to explain compulsive use.

There is a positive feedback loop within the reward system consisting of the Ventral Tegmental Area that makes and sends dopamine to the Nucleus Accumbens and the Accumbens itself which makes and sends endorphin to the Ventral Tegmental Area. This is a positive feedback loop in that the stimulation of each promotes the stimulation of the other. Under normal circumstances, this feedback loop allows normally rewarding things to be rewarding.

This positive feedback loop, however, is also responsible in large part for the compulsive use seen in addiction. A large stimulus, like a drug, will cause a larger than normal release on one part of the feedback loop spinning the system up faster and to greater heights. The resulting dopamine spike can be measured in the lab and has given science great insight into compulsive use. Because this spike is beyond the limits expected by normal biology it exhausts what dopamine is ready for release, and the level then crashes.

It has been shown in lab animals that there is a dopamine level above which they do not seek drug. The crash that follows the peak is what precipitates that next use. Additionally one can measure a proxy for strength of craving by putting obstacles between the animal and the drug and seeing at what dopamine level the animal is willing to go through what obstacle. There is a line below which no matter what the obstacle, the animal will not stop until it gets to the drug.

So one can imagine, superimposed on this output spike from the Nucleus Accumbens, two horizontal lines.One is above the baseline, above which the animal feels fine and will not seek drug. The other is below the baseline, below which the animal will use regardless of what it takes. At some point between these horizontal lines is where the animal will use again if drug is freely available.

So it is the crash that causes the compulsive use regardless of whether the peak goes above the 1st line or not. In fact as the use continues there is less and less dopamine left for stimulation, so each resulting peak is lower than the one before it. After enough use, the peak is not even as high as the original baseline. At this point, the drug ceases to cause a rewarding feeling yet the animal, or the person, continues to use.

This biology may very well explain what William Silkworth MD called, in 1935, an allergy; that is, an abnormal reaction to alcohol, that does not occur in normal people. Silkworth said that only in alcoholics did taking one drink precipitate craving for the second. While this phenomenon may be explained by the biology described above it does not explain the other core feature of addition: why the person who knows he has this abnormal reaction ever takes the 1st drink. I’ll cover that another time.

To know what addiction is we need to start with the word itself. Addiction comes from the Latin “addictus” referring to one who is attached in slavery. It was a Roman legal term used in relation to debt slavery where someone would be attached to another against their will to pay off a debt. So addiction became a word in the English language because attachment against the will is a great description of what the illness is. There can be no better description of what someone with addiction feels. Addiction is not “liking” drugs or even wanting drugs. No one wakes up and says, “I think today I’ll work to become addicted to something.” No one wants their choices limited. No one wants to be a slave. No on wants to be addicted.

Attachment is not something that most people think about. In fact, it’s a pretty uncomfortable thing for most of us to think about. We refer to love at first sight, but don’t think of it as attachment. Attachment is an unconscious, sub-cortical process that occurs in the brain without our choice. We don’t like to think about being attached without choice, but it happens all the time. And for normal functioning mammals it works fine. It gives us things like favorite color, favorite food, and falling in love.

It is beyond the scope of this blog to detail all the biological mechanisms of the dopamine reward system and its function with attachment, but if your interested, google any of Thomas Insel’s work on attachment. Here are a couple of references to get you started: TR Insel, Le Shapiro PNAS Jul 1992 (89) #13 5981-5985 and Young LJ, et al Hormones and Behavior 40 2001, 133-138.

So what does this have to do with addiction? I think that attachment, being unconscious and uncomfortable for us to think about in this way, is so outside our normal social discourse that we don’t even consider it when thinking of addiction. We speak of “liking” and “needing”, but never attachment. It’s odd since the people who coined the word addiction seemed to understand that attachment was the key ingredient.

Instead, even Addiction Medicine doctors who understand the illness as an illness focus on two salient points: loss of control while using and continued use in spite of adverse consequences. Even these “core” features are really just the results of the attachment which is the ultimate problem.

One might say, “So what?” If you understand addiction as attachment, how does that help you treat it? Well, it is the key to understanding the original deficiency. Whether it’s oxytocin or dopamine, there is insufficient signal to the Nucleus Accumbens. With that deficiency comes the typical symptoms of addiction. When the deficiency is relieved by whatever “drug” works, the symptoms are relieved. In addition, the person can now make a strong attachment to the “drug”, an ability to attach which is normally not available to them. Hence the person gains attachment to the “drug” while not being able to attach to normally rewarding activities in its absence. Understanding addiction as attachment gives us the insight to treat the original deficiency so that the person is able to feel attached to normal day-to-day rewards in the absence of the “drug.” This will also make the “drug” less of a standout reward. Rather than the person becoming increasingly biologically attached to the “drug” against their will, they can become free to choose to open up their lives to other possible attachments.

Of course, now you’re thinking, “Great, sign me up. Am I low in oxytocin or dopamine? Which medicine will work for me?” Well, if I had all those answers I’d not be sitting here writing right now. But we are much closer than we were 10 years ago and in 10 years we’ll be closer still. Understanding addiction as attachment gives us the framework to create a biological typology that will give us the ability to provide person specific treatments to a much greater degree than we ever have before.

I’m currently attending the annual Medical-Scientific Meeting of the American Society of Addiction Medicine (ASAM). I’ve seen a number of really great things to write about, but one appalling emergency comes first.

There have been a number of presentations on the epidemic of deaths from accidental opioid pain medicine overdose and an exponential rise in the last decade. Currently overdose deaths have eclipsed auto accidents as the number one cause of accidental deaths in the US. In addition, if you look at a graph of overdose deaths, the number of deaths from prescription opioids in the last year when data was available dwarfs the number of deaths during the “heroin epidemic” of the 70’s and the “cocaine epidemic” of the 80’s; in fact, the current number of deaths dwarfs the deaths of both of those combined. As horrible as this is, it’s not really what I found so appalling.

The worst thing for me has been what I’ve seen as the response from the Federal government. I heard talks from representatives of CDC, NIDA and SAMHSA and none focused on addiction treatment as a priority solution to the problem. It’s pretty common to see NIDA and SAMHSA at an ASAM meeting, but having CDC here is unusual and a measure of how fast and to what extent these deaths have occurred.

In fact, the number two person at CDC came to address the policy plenary session. She was the second person I heard in the last few days present CDC’s comprehensive strategy for combating the problem and the second person I heard to miss the point.

What is clear is that the increase in deaths have been in lock step with the increase in prescriptions of opioid pain medication. But what is not clear is why. CDC has one theory: that the prescriptions are driving the deaths and the primary intervention should be to focus on fixing the doctors who prescribe them and restricting access to the medicines. I have a different theory which I got from one of their own statistics.

They presented that for every opioid death there were over 100 people suffering from addiction who was using prescription pain pills in the context of their illness. That means that the deaths are not normal people trying opioids but represent a subset of a larger population of addicted patients who’s use resulted in accidental death. Rather than see addiction as an illness and the deaths as an outcome of the illness, they seem to think that both the addictions and the deaths are the consequence of poor prescribing.

After Dr Arias’ talk, person after person from the audience got up to talk about the lack of mention of addiction treatment in CDC’s response plan. Her responses were kind and seemingly sympathetic (though she took no notes so I wonder if there will be any action on any of the ideas she received). In spite of the sympathy she expressed, all of her responses used the words substance abuse and overdose. Even when one ASAM member begged her to stop using the term abuse, as it increases stigma and discrimination, she could not do it.

The Federal response seems to be “What did someone else do wrong that we can fix or punish?” I’d rather them ask,”Is there anything we’ve done to cause this?” I guess a lack of self examination isn’t limited to the Federal government, but they seem to be very very good at it. Let me point out, in case anyone cares, what previous Federal response may have worsened the situation.

When buprenorphine was introduced as a treatment for opioid dependence, some special limits were put in place. Before prescribing buprenorphine a prescriber has to have 8 hours of extra education, get a special DEA number, be limited to 30 patients for the first years and one hundred patients thereafter, keep an up to date list of their buprenorphine patients and be liable for a visit from the DEA to audit the list. Meanwhile, anyone with a  regular DEA license can prescribe long acting high potency pain medication without any limit to number of patients or requirements beyond keeping the normal medical record. This in spite of the fact that buprenorphine, a partial agonist, is far safer in terms of overdose than the full agonist opioid pain medications.

One of the effects of this limit is that providers limit treatment because if they didn’t, they’d fill up and not be available for new patients. This means that people often get shorter treatment than necessary. They also get lower doses than necessary because many providers are cowed into small doses for fear of a DEA audit or even so afraid as to not prescribe at all even though they are able. Would you like a visit from the IRS even if you’ve not tried to do anything wrong with your taxes? So fewer doctors than can, actually prescribe buprenorphine for their patients. The effect is that people with addiction who used opioids in the context of their disease were exposed to buprenorphine treatment but were not able to continue with it.

The graphs show that the epidemic started shortly after buprenorphine came on the market, though very few, if any, of the deaths involved that chemical. It could be a coincidence, but there’s another possibility. What if making inadequate treatment (low dose, short term) actually caused people with addiction to realize how good they could feel on long acting opioid agonist treatment and then the limitations on buprenorphine made it impossible for them to stay on it? Is it possible that such people would seek out pain doctors willing to prescribe methadone and Oxycontin for pain? Is the increase in long acting opioid prescriptions all because of bad prescribing or could some of it be people with addiction looking for more affordable and available symptom suppression?

Now some might say that because buprenorphine is a partial opioid agonist itself that it needs regulation to keep from becoming part fo the problem. I have no doubt, but these limitations also apply to Addiction Medicine specialists. Can you imagine CDC, at the height of the HIV epidemic, not fighting limits on an Infectious Disease specialist’s ability to treat only 100 infected patients? And if the limit actually drives people out to use other long acting opioid agonists that they can get cheaper and more easily from a pain doctor, how effective is that limit?

Addiction is a primary illness of the brain and most cases aren’t caused by substance abuse. In fact, it’s addiction that is responsible for substance abuse, not the other way around. Addiction treatment is substance abuse prevention, but the distinction seems lost within the Washington beltway.

Robert Kiyosaki wrote a book called “Rich Dad, Poor Dad” where he put forth a fascinating way to tell the difference between an asset and a liability. An asset, he said, was something that put money in your pocket. A liability was something that took money out of your pocket. He added a third category that he called a doodad. A doodad seems to be something that you can afford at the moment, doesn’t produce income, and be hard to maintain without your income. So in short a doodad is something that isn’t an asset and may become a liability. I think Kiyosaki has possibly hit on one of the laws of the universe with this typology. I find it true everywhere I look, even in areas having nothing to do with money.

Take time, for instance. There are time assets, things that free up your time, and time liabilities, things that cost you time. There are, of course, also time doodads. It seems to work for personal energy too. You can think of your own examples rather than hear mine. For people in recovery from addiction, a state in which serenity is of paramount importance, it’s critical to know that this works for serenity as well.

There are serenity assets in our lives, things that give us serenity; think going to meetings and doing step-work. There are serenity liabilities; think lying or being afraid. Of course, there are also those serenity doodads. Those things that look like we can afford them and don’t seem to cost much as long as everything is going ok. They are indulgences that sometimes turn into liabilities.

Serenity doodads come in a lot of forms: the boyfriend who’s usually okay but every once in a while has a drama attack, the friend who is mostly kind but likes a bit of gossip now and then and likes you to listen, the job that’s fine most of the time but is occasionally punctuated by periods that remind you of being small and helpless, etc.

Now there’s nothing inherently wrong with a doodad. If you can afford a boat and the upkeep, and you want a boat, get one. But Kiyosaki’s point was that if you want to be wealthy, don’t by a boat, buy an asset and then when you’ve amassed enough assets to pay for the boat, let the assets buy the boat. So whether you can afford doodads has to do with how many assets you have and how much money they are producing. The same is true for serenity doodads.

If you want to be wealthy in serenity start collecting serenity assets. But most of us, in early recovery, love to hang on to our old serenity doodads, like a guy in bankruptcy trying to keep his boat. Or we get our heads a little above water and then start buying doodads again with what little serenity we’ve collected. We all come to recovery in serenity debt and have a lot of work to do to clear the books. Many people make the mistake of, as soon as it looks like they’ll make it, run out and get themselves a serenity doodad.

To help, it would be nice if there were serenity wealth counselors who could show us the way, point out the doodads, and give us advice. The good news is there are such people, and you can find them at meetings. They’ll be the calm ones. They’ll be the ones that have what you want. They’ll be the ones that seem at first glance to have been born with a lot of serenity. But if you talk to them they’ll tell you they started in serenity debt just as bad as yours. If you ask them to be your sponsor, they’ll show you exactly and precisely how they got out of serenity debt and built serenity assets. And if you follow their directions the likely outcome is that you will be rich in serenity. More good news: these people also have a book you can read, and, if you get it at a meeting, it will probably be cheaper than “Rich Dad, Poor Dad.”

I have a colleague who was the drug czar of the country early in the history of that office, and he’s very focused on the law and order aspects of addiction. One day he was explaining to me why we could not see smoking as addiction. His point was that you don’t see the same kind of antisocial action from smokers that you see from drug addicts such as all the illegal behavior, the illegal selling, the shootings and drug wars, etc. My response was of course you don’t see any anti-social behavior from smoking: no one’s ever seen a smoker flick his lit cigarette out of the window of a car passing a forest never even imagining that he might be starting a forest fire; no one’s ever seen a smoker who has lit up in front of a child knowing that smoke isn’t good for the child but really not caring because he needs his fix; and of course there’s never been a case of anyone tampering with a smoke detector on an airline because if there had been there wouldn’t be a law against it. He opined that I might have a point.

But another common argument of his is that anyone wanting to talk about addiction as a whole disease separate from drugs and alcohol, as I’m fond of doing, or anyone talking about medical use of substances that have been banned by government, as some others have done, really are just out to legalize all drugs. Well, I must say that so far I haven’t seen a whole lot of reason for the criminalization of certain drugs.

I don’t quite understand myself why alcohol is legal while cocaine is not. I don’t understand myself why cigarettes are legal and heroin is not. There was a time in this country when there were no illegal drugs. We seemed to make out pretty well from 1776 to 1905, including some of the most rapid economic growth we’ve ever had, without any kind of drug laws whatsoever.

I think the difference between my colleague and myself is that he imagines that those who are for the decriminalization or even legalization of currently illegal drugs just want such a law to pass so they can use drugs. Not much could be further from the truth. I’ll bet that there are a lot of people who would vote for someone who argued for removal of criminal penalties from pot but wouldn’t vote for him if he smoked pot. I’d be one of those people.

In the current Republican primary there is a candidate who argues for the legalization of drugs and an end to the drug war. It’s not that this 77 year old senator wants to use drugs, but that he can’s see why the federal government should be involved in deciding what someone puts in their body. Contrast that kind of candidate with the more common candidate who says, “Let’s definitely keep all those drugs I don’t use illegal while keeping the drugs I do use legal.” I see that second person, not as law-abiding, but as hypocritical.

What many people who have a focus on law and order aspects of addiction forget is that addiction is a disease, not simply a drug use. It would be as if we had a law against metabolizing sugar badly, or a law against bronchospasm, or perhaps more accurately in the case with diabetes, a law against frequently going to the bathroom, and in the case of asthma a law against reaching for an inhaler.

When most people think of drug related antisocial behavior, they think of the violence related to drug selling rather than anti-social actions related to the use of drugs. But that behavior is almost entirely related to the drugs being illegal in the first place. When’s the last time you heard of a convenience store manager doing a drive by of another convenience store selling cigarettes on “his turf?”

Of course, not all violence associated with drugs is related to their illegal sales. I don’t think that anyone who’s ever been to a European soccer game would suggest that the violent aspects of alcohol have anything to do with its legal status. In fact, alcohol has more of an association with violence than almost any other drug. In a study done of 12,000 arrestees, those arrested for violent crime were more likely to have alcohol rather than other drugs in their system. Those arrested for non-violent property crime were more likely to have non-alcohol drugs in their system. The fact is, there is no scientific reason why the drugs that are legal are legal and the drugs that aren’t legal aren’t legal. But when was government ever based on science?

So what does this have to do with externalities? And what do externalities have to do with addiction?

An economic externality is when the two parties involved in an economic action are not the only ones who pay the price. An example would be John who mines coal and Sam who buys coal. Now John digs the coal up, sells it to Sam, Sam gives John the money he’s earned, and it all looks like a pretty fair transfer. However there are things that flow out of John’s coal mine that get into Betty’s water. Betty doesn’t profit from either the coal or the mining of it, but she pays a price for John and Sam doing business. Betty’s situation is an economic externality. Economic externalities are usually addressed by government by using taxes or fees on those in the economic arrangement to pay for the harm done to those who were not in it. Taxes on cigarettes used to pay for the increased healthcare costs of tobacco use are an example of this.

So what does this have to do with addiction? Anti-drug use laws get started to try to address economic externalities. If you look at the arguments made by the law makers during the decision to make drugs illegal back in the early 20th century, you’ll see that they were motivated by wanting to decrease the economic effects of drug use on those other than the people selling and using drugs. That their arguments were almost wholly made up, somewhat racist, and would be laughed at today not withstanding, the fact is the goal was to reduce economic externalities.

The problem is though that once government makes something illegal, it loses the ability to use taxes and fees to address the externalities. The business is driven underground where it can’t be taxed and there are no longer any licensed sellers who can pay fees. And I think we can see over the last hundred years that we even have more externalities from drugs than we did in 1905 in spite, or perhaps because of, the prohibition against them.

Let me state clearly that I’m not in favor of anyone putting any chemicals in their body for non-medical purposes. My reasons aren’t driven by legal status, but rather by biological reality. For people with the chronic brain illness of addiction, the use of any euphorogenic chemical or behavior will cause the disease to progress faster than it would with normal aging. And for those without the illness, the use of any euphorogenic chemical or behavior will decrease their midbrain dopamine tone faster than would normally occur with age and possibly increase the likelihood of their getting addiction.

Taking a law and order position on addiction has carried its own economic externalities. Generations of people have grown up thinking that because they were legal, alcohol and cigarettes were not as harmful as illegal drugs. Billions, if not trillions, in tax dollars have been spent wastefully rather than put to productive use, and we now have the distinction of being the country with the highest proportion of its population in jail. Meanwhile we spend a pitifully small part of the money used in the “war on drugs” towards treatment of addiction. Unfortunately, there’s nothing government can do to compensate us for THIS economic externality.

Though we don’t like the fact, periodic cataclysm is the way of all life at all scales. On a planetary scale there are major meteor strikes. More locally there are volcanoes, hurricanes, and earthquakes. Cataclysms at the family scale include such things as death and illness. While at the personal scale we have cataclysms daily. If we take a step back from the personal scale we can see two things about period cataclysm.

The first is that the smaller the scale, the more frequent the occurrence. Millions of hurricanes and earthquakes have struck since the last world-ringing meteor strike. Since the last cataclysmic hurricane in my community, thousands of families have undergone the personal tragedy of the death of a loved one. And as I mentioned before cataclysms at a small scale occur almost daily, but more on that later.

The second thing you can see about periodic cataclysm when you look at it from a distance is that regardless of the scale on which they occur, they are all leveling phenomena. It’s as if they are the personification of the saying, “If you see something wobbling, tip it over.” Whatever isn’t steady when the cataclysm hits is removed, and what is left is a firm foundation. So while we don’t like it, over time, periodic cataclysm makes the system stronger because a firmer base is built up.

We don’t like this knowledge to such an extent that we walk around in complete denial of it. An example of this is the experience of a friend of mine. He was looking for a house in a small town near mine and saw that the old structures were selling for $75/sq ft. New construction was going for $100/sq ft. The real estate agents told him that was because they were new and had more conveniences. From my friend’s standpoint he wondered why he’d want to pay $25/sq ft more for a new house of poorer construction that has not stood the test of time when he could more cheaply get a house that has survived 5 major hurricanes. My friend understands about periodic cataclysm; the real estate agent isn’t even consciously aware of it.

So now back to the personal scale and what periodic cataclysm has to do with addiction. We deal with “being leveled” every day. Someone says something mean to us; a girlfriend leaves; we’re fired; or even, things just don’t work out the way we planned. Each of these can be our own personal cataclysm. They can shake the things that we’d built on a shaky foundation and level them. At the time it seems like a catastrophe, but from these things we find out what is steady, what is firm foundation.

Like the cataclysms of a larger scale, say a hurricane or a volcano, we can’t get through these small daily cataclysms alone. In recovery from addiction, as in all life, we are leveled frequently. If we try to pick ourselves up and rebuild alone we almost always get it wrong, making it easy for the next thing to come along to turn into a cataclysm. When we ask for help from those around us we get better advice about where to rebuild. We get better help clearing away the wreckage left on top of the foundation. We get a clearer picture of what is firm and what is not. The end result of this help is that it takes a bigger push for something to shake down our building. We are stronger together than we are separately. That’s one of the universe’s rules.

We fear periodic cataclysm because we imagine we’re alone, and they are all too big to handle alone. The help we need each time depends on the scale of the event, but luckily most of the leveling events we face will be small, and help is just a phone call away.

Urine Drug Testing has a storied history. Starting during the Vietnam era as a way to find and detox servicemen on drugs before their return to the US, drug testing began in an authoritative environment with a specific mission. From there it spread to transportation, safety sensitive positions and legal environments, and with this spread it ran into new challenges that had to be overcome. Several decades of legal action, compromise and technical achievements have led us to the present, but, like any evolutionary process, there are leftovers from the origin of drug testing that may still be hanging on with no current purpose. It’s time to take a new look at drug testing. Rather than there being one way to do drug testing, we should use what we know to construct specific programs for specific purposes. As I treat addiction, I’ll focus on drug testing in addiction.

What differentiates drug testing in addiction from, say, drug testing in workplace drug use, is the presence of an illness. In doing drug testing to monitor an illness such as addiction, one is not trying to “catch” someone doing something wrong. One is monitoring one aspect of the illness. So rather than providing a means to a legal deterrent, drug testing becomes a medical tool, and I prefer to use the term Medical Monitoring for Adherence (MMA), where adherence refers to adherence to the plan of care, which includes abstaining from using drugs or alcohol.

Since we’re talking about a medical situation, let me give you another one to compare with. Let’s say you have an infection. The doctor tells you to take 10 days of antibiotics and cautions you not to stop before the 10 days are up. The reason you should take the whole course of 10 days is that some bacteria are more easily killed by the antibiotic than others, and if you just take it until you feel better most, but not all, of the bacteria will be dead. The only ones left will be those most resistant to the antibiotic, and they’ll grow to create an even worse infection if left alive. Now imagine there was a test that would measure the number of bacteria in the body, and you could do it every day during the 10 day course. When that number reached zero you could safely stop the antibiotic. What that test would do is give us patient specific information rather than population specific information. What we have now is the latter. The same is true with Medical Monitoring for Adherence in addiction.

Now, understanding that we are not yet into patient specific indicators for MMA, let’s look at two programs based on population that have documented success rates. Surprisingly, these two programs have much higher success rates than those reported for the general population and are considered the “gold standard.” Since they are very different they should give us some sense of what the important factors are. The first program is that of Navy pilots and the second is that of physicians.

The high rate of treatment success in these programs have been criticized as not being applicable to other populations because of the high educational achievement of the participants and the fact that they all have professional licenses (to fly or practice medicine) that gives coercive power over them. In fact, the physician monitoring programs have been replicated in less well educated populations with no significant decrease in effectiveness. In addition, illness, when understood as illness, provides its own coercive force on behavior. So I think these are good programs to look at.

Both Navy pilots and physicians have a greater than 90% five-year success rate at achieving and maintaining abstinence from drugs and alcohol. Both have 5 year MMA programs. Both have random testing. Both have wide panels including indicators for alcohol. Both utilize a tapering frequency of testing over the years of participation. Both programs require other behavioral changes in addition to abstinence. Both are still based on population; that is, there is no measure when someone is ready to leave the program at three years or needs to stay seven.

One might be tempted to look cynically at these programs and say, “Sure they’re sober for five years, but you’re testing them for five years.” What happens in year six? There is some evidence to suggest just that, and some state physician health programs are looking at extending their contracts to longer than 5 year periods of monitoring. However, this “monitoring period” idea is one of those vestigial aspects that no longer makes sense. When drug testing began, there was no understanding of addiction as a chronic illness; it was seen as a habit that you just had to break long enough to stay away from. The period came from what was necessary for the vast majority to “break the habit.”

But if we see addiction as a chronic illness then there’s no habit to break. The symptoms that caused the drug use in the first place are there until treated. So does that mean that if we had a medical treatment for addiction we wouldn’t need the monitoring? No, because there are behavioral aspects and no treatment is perfect, but a combination of medical treatment, MMA, and other medical surveillance should give us a more personalized approach to the length of time MMA is needed.

So let’s construct the “perfect” MMA program for medical treatment of addiction. We’ll have to compromise because of cost in some places, and for other reasons in other places, but “perfect” gives us something to shoot at.

Frequency: Frequency should start out at twice a week (because the most common things tested for can be detected at 3 to 4 days) and should be random. Each day should be liable for testing so that the person doesn’t know what’s coming. It should be truly random so that two days or even three in a row are possible.
Matrix: The matrix is the substance tested (urine, hair, saliva, etc). Urine is the perfect matrix for MMA as its collection is non invasive, it can be tested frequently with changes in state (unlike hair which doesn’t change much over time), and increases the time of detection (saliva can only detect what is there at present). There are some challenges to using urine: certain medical conditions, the fact that urine is chemically “dirty” because its a waste product, and others. Technology and modern lab techniques can overcome all of these challenges.

Test Panel: It should be very wide and constantly changing as new drugs become problems. The original drug test called the “DOT 5″ included THC, PCP, Benzodiazepines, Cocaine, and Barbituates. Developed when PCP was a growing problem, it made sense. Today PCP is something rarely used by itself, but most testing programs can’t stop looking for it because of it’s place in the canon of federal testing. Meanwhile, synthetic cannabinoids, a growing problem today, are not in most panels because they don’t change fast enough. As long as users have access to new drugs for significant periods before they are looked for, MMA will be limited in its effectiveness.

Testing Method: Some screening method to include screening for adulterants followed by Mass Spectrometry (MS) confirmation with quantification and normalization to individual hydration level with medical interpretation is the gold standard. Let’s take each of those factors in turn. “Screening followed by confirmation” - It may soon be possible to test for everything via confirmation testing but it is still more expensive and so we use screening techniques to find those samples most likely to be positive. The screening technique chosen should be overly sensitive so that positives aren’t missed. The confirmation gold standard is some kind of chromatography (liquid or gas) followed by MS which allows for the quantification of the various metabolites present. “Adulteration testing” - as long as there is MMA there will be those who try to defeat it by various methods. All screening should include screening for adulteration and dilution of urine in attempts to avoid monitoring. “Normalization” - in serial testing early in treatment or following a relapse into drug using behavior a dichotomous result becomes unimportant. It is necessary to do serial measurements to follow the falling level of metabolites in order to determine that drug using has stopped. This leads to the problem of nominal levels that rise because of concentration of the urine due to dehydration. Techniques have been developed to create normalized values to do serial comparisons. “Medical Interpretation” - MMA is a medical procedure and while other entities (courts, probation officers, employers, etc) have taken it on, it remains something best interpreted with the individual’s medical condition in mind. That is why federally regulated programs include a Medical Review Officer (MRO) and why all programs using MMA should have a physician interpret the results. Given the complexity of metabolic pathways, normalization coefficients, and interpretation algorithms, it is not likely that the layman can accurately interpret MMA results.

So now we have the “perfect” MMA scheme: daily randomization of twice weekly testing the first year, followed by two years of weekly testing, a year of monthly testing and a year of testing every two months. The panel should include: ETG/ETS (ethanol metabolites); THC; synthetic cannabinoids; amphetamine; methamphetamine (with the ability to test for d and l forms); cocaine; the substituted cathiones (bath salts); a list of benzos too long to list here; barbituates; opioids and opiates including buprenorphine, methadone, and oxycodone; the “Z-drugs”; and what ever addiction medication the person is taking. The confirmed, quantified, normalized results should be back in the office the next day with medical interpretation to allow for fast intervention.

Now back to reality. No one is going to go for more than once a week testing unless they are in intensive treatment. The most you’re going to get out of outpatients after treatment is weekly, and a true randomization scheme will aid in mitigating the decreased frequency. Some will say they can’t test weekly for the first year, and that may be so, but less frequent testing has not been shown to provide the behavioral fence around the illness that at least weekly testing has.

Some programs will say they can’t afford confirmatory quantified testing. They will always wonder if that positive was really positive, and when someone’s job or freedom is on the line, using non confirmed tests opens one up to considerable liability. Even in a pure treatment setting with no forensic implications, a non-confirmed test will open the program to losing the patient’s confidence by acting on a false positive. Some will say they need no medical interpretation, but they will also open themselves up to liability in interpreting the results if they get it wrong.

Labs focused on work place testing or pain clinic testing just don’t have the same focus or understanding what what an addiction treater needs in a lab. Personally, it’s taken me a long time to find a laboratory that is focused on helping those who treat addiction and need MMA. It’s taken a long time to find a lab that will pick up our samples and get the confirmed, quantified, interpreted results back to us quickly. The more people who treat addiction focus on what we need from a lab rather than settle for what the lab wants to give us the more prevalent will be the labs that can really help us treat patients.

It’s been more than 100 years since Congress passed the Harrison Tax Act starting the process of changing society’s view of addiction from chronic disease of deficiency to willful anti-social act. In that 100 years we’ve come full circle to the point where modern neuroscience has confirmed the view taken by 19th century physicians, that addiction is a chronic, and still, incurable illness different from voluntary abuse of substances. The evidence shows that more of the variance of who becomes addicted has to do with genetics than choice of drug and that the illness can exist even when no “drug” is used. Still, however, society and the law treat addiction and substance abuse as the same thing.

I have a hard time imagining a topic that is more likely to be agreed to in a bipartisan, tripartisan, or omnipartisan way than the need to recognized and treat addiction. Yet, no matter what political party is in power, there seems to be a collective mental block to seeing it for the disease it is. From the stand point of a party that wanted to fix societal ills with government power, it’s a no brainer to diagnose and treat addiction as it contributes or causes the top three or four causes of death in the country. From the stand point of a party that wanted to limit government spending, it’s a no brainer because there’s more waste and non-productive societal cost from addiction than nearly any other single cause and every dollar spent treating addiction saves about $7 in costs to the larger community. Even for a party that puts individual liberty first as the highest goal, it’s a no brainer as treatment returns personal liberty to a person who has been enslaved by the illness. So why is it that this no brainer idea never gets accomplished?

The largest single reason I see is that we were all raised to believe addiction and substance abuse are the same thing. We were all raised to believe that people with addiction are normal people who chose to start using something, like it, and start misusing it, and selfishly continue to do so even past the point of hurting others and themselves. While there probably are people with addiction who were normal to start with, it’s not my experience that they represent the majority of the people with the illness. I’ve written on this topic so much that to try to show you the evidence here, yet again, would be beside the point.

The point today is that I just finished reading a list of proposed laws for this up coming legislative session in my state, Louisiana. Remember that all these bills are being proposed by educated representatives of the people. And yet, in spite of their education, or because of it, most of these bills seem to continue to be based on the identity of addiction and substance abuse. There seems to be no recognition that addiction is a brain illness that creates symptoms, and that it is those symptoms that lead the person to the characteristic seeking of reward. (Please see ASAM’s definition of addiction at asam.org) Rather, addiction seems to be seen as having been caused by the drug use, and so all the attention falls to the use and the behavior. I wonder how much longer we’ll continue to try to punish away behavioral result of this illness, jailing its victims, and being addicted ourselves to an increasingly non-functional solution to our most expensive problem.

I was flying across the country today and the program guide in the inflight magazine listed an action movie I’d been wanting to see. But it turned out that the movie was Dolphin Tale, the story of a dolphin that was injured and required her tail to be amputated because of infection. The story also focused on the people who helped her survive and named her Winter. I was disappointed and almost turned it off, but it caught my attention. I was crying by the time the movie ended. Just goes to show how what we want isn’t always the best thing for us.

To say the story is inspiring is an understatement, and what was most touching to me was the connection that human amputees had to Winter. I was struck by their bravery and Winter’s, and by the tenacity needed to get up every day and face the world without all of your parts.

Then I realized I meet such people every day because addiction is like an amputation. The patients I see in recovery get up everyday and face the world with a part of them missing.

Most people only see addiction from looking at behavior, but from talking to people with the illness I’ve long ago come to realize that the symptoms of the illness are independant of drug use. Most of my patients can identify the missing piece was missing long before the first drug, and they can all recall with great clarity the feeling of getting that back with their first use.

For them, recovery is getting up every day and voluntarily going without a part when they could readily go get a temporary prosthesis. True, the prothesis wouldn’t work for long, but it’s an amazing temptation when your brain knows what will make everything easier, even if only for a little while.

But recovering people aren’t, as they say, “a glum lot,” but actually quite at peace with the situation. There’s a line in the movie where one of the human amputees is depressed because he can no longer do the one thing he always wanted to do. Morgan Freeman’s character tells him, “Well, you’ll just have to pick something else to want to do. Luckily, there’s about a million things to choose from.”

That’s the attitude I see in successfully recovering people. They’re not depressed because of what they can’t do, but are grateful and glad to have the rest of the world to choose from.

A lot of peple will have difficulty seeing addiction as a disability or like an amputation. Many may feel offended that I’m likening people with addiction to people who have lost a leg through no fault of their own. Well, such is my experience, and this is my blog, so I guess you’ll just have to be angry. But, in case you have an open mind let me share with you some of the things I’ve heard from patients:

“I never knew what ‘have a nice day’ meant until I had my first cigarette.”

“My whole life, I knew I could never measure up to other people, and then somebody gave me a pain pill, and I felt normal for the first time.”

“I’d just sit there thinking of nothing and getting nothing done, paralyzed by my own brain. Then I found speed.”

“Nothing made any sense at all. I couldn’t concentrate. It was like everyone was speaking another language and they were all mad at me for not understanding. But when I drank I could understand them and respond to what they were saying.”

“The first time I felt part of the world around me was when I took my first Lortab.”

Most people get to be with other people, fit in, understand and feel part of the world around them. Most people can concentrate and remember and feel joy in daily living. But if there’s not enough dopamine tone in the midbrain, these things are missing. They’re not missing because the person wants them to be missing or because the person did something to make them go away. These things aren’t missing because the person is bad or weak or missing some element of character. These things are missing because of a deficit in the brain, a physical problem, a thing that is missing.

I forget sometimes what bravery and determination it takes for my patients to get up every day and face the world. I forget the fortitude it takes to redirect one’s brain to the parts of the world that are available and happliy focus on them. I’d still like to see that action movie, but I’m glad today that the universe had other plans.

Recently I had a conversation with a colleague who asked for a recommendation for a therapist for one of his patients with addiction who was having family problems. I responded by asking how vigorous of a recovery program she was working? His response was something like this, “Oh, she’s in recovery. But the problem is that some people have intraspsychic conflicts and interpersonal deficits that make it difficult for them to engage support networks.” That really didn’t answer my question, or maybe it did.

My colleague doesn’t see the difference between being in recovery from an illness and working an addiction recovery program. Yes she’s not using; yes, she’s attending her appointments; yes, she even goes to a few meetings; but she’s not working a recovery program.

Recovery, as the word is used in 12-step fellowships, means a great deal more than going to meetings and not using. It involves work and so is most spoken of as “working a recovery program.” Of course there are people who don’t work a program who consider themselves in recovery, but they are missing out on some of the best things recovery has to offer. So what is it to work a recovery program? We’ll take 12-step recovery as an example.

In 12-step recovery, it is the steps that are worked, not just once, but on a daily basis. We can break that down, and I have in other writings, so I won’t repeat it here. But what is important to reveiw is some of what happens when someone works the steps.

The first thing that generally happens is that the person stops trusting the thinking that got them into trouble. They start to uncenter themselves as the driving force in their life and start opening up to others. They start to gain friends and fellows whom they trust and with whom they gain trust by being honest on a consistent basis. They have many methods to deal with day to day feelings and start to trust the universe that things will work out now that they aren’t running the show. They stop being afraid of things and can face their challenges honestly.

I thought about that when my colleague told me that his patient had become depressed and non-functional after her husband left her, that she felt alone and was moving in with her father to be taken care of. I thought of the family difficulties that I’d seen handled by people in recovery and how they responded. I thought of situations like his patient’s that I’d seen in people in recovery. I thought of the bands of recovering women I know who support each other, and I couldn’t imagine how someone in recovery could be alone. I imagined what would happen to the women I knew in recovery if such a thing had happened.

They would have known from working the steps what was theirs and what was their husband’s and would not take his selfishness personally. They would express their feelings with their friends and would be surrounded by their recovery community. They would have worked the steps on their anger and their fear and found relief and peace. Of course they would still have feelings, but they’d have many tools and methods of dealing with them. They would not be helpless, alone, or unable to function.

So what about those that can’t get into a 12-step recovery program? When the symptoms of the illness prevent the person from engaging in 12-step recovery, we work with medications to aleviate those symptoms. Rather than decrease participation in recovery, I have found that correct application of medication increases participation in recovery. Once symptoms are relieved, we use cognitive approaches to help people change their point of view about the illness and the barriers they have to working a recovery program. Finally, for some, the 12-step approach is a barrier. They just won’t work that method. For them, we recommend other forms of recovery.

I’ve watched people get the same benefit from these other forms of recovery. What good recovery programs have in come is this: a reliance on taking life on its own terms rather than self will, a community without a hierarchy, a mentor who serves rather than bosses, honesty and confession, personal amends, helping others. If a recovery program has those things, the person working the program will likely get the same benefits.

Most of those benefits are spiritual. There is a calm that comes with acceptance of how the world works. When we are running the show, there’s a constant fear that we’ll mess up or that someone will figure out that we can’t do it. We’re alone and isolated, spending our energy to erect and maintain a false self that we present to the world. When we are working a recovery program, we can relax, because we aren’t running the show. We don’t have to be afraid of others or the universe. It doesn’t mean that we’ll get our way or that everything will work out well, just that we’ll stop making things worse. We find that the world isn’t nearly so scary when we aren’t at the wheel.

There are neurobiological benefits as well, especially for the person with addiction. When we are running the show and feeling isolated or afraid of being found out, we actually lose dopamine receptors. We feel less of our brain’s own dopamine. Working a recovery program literally makes us feel better. That’s why people in recovery don’t use drugs or compulsive behaviors; not because it’s wrong, but because they don’t need to. In addition, studies have shown a lot of other health benefits of a spiritual life from less brain loss with age to lower blood pressure.

As someone who treats addiction, I don’t think stopping drug use is sufficient as an endpoint. It’s a necessary beginning. The real endpoint isn’t a point or an end at all. The real goal of treatment is to create a person who is working a recovery program. Once that’s done, most other psychological treatment becomes unnecessary.