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I’ve recently had reason to ponder this difference, because I belong to a professional medical organization of Addiction Medicine physicians. There is controversy in our field about how and when medications should be used. A group from that organization recently launched an effort to reemphasize psychosocial treatment in general and the 12-step approach in particular. As I think the steps are important, and not spoken of enough in mainstream circles, I joined. What I found after I joined was a little more “anti-medicine” than the original literature suggested, and was thinking about this when I saw a headline on a news site that scientists had cloned embryonic stem cells. What got me thinking was the idea that one day stem cells would be useful in curing diseases of deficiency. That got me thinking a really big “what if;” what if one day we got a cure for addiction from injection of stem cells in the midbrain. I wondered about the different responses from organized Addiction Medicine and this new sub-group of doctors.

Before I say more about this I want you to understand the entire thought experiment here. What we’re imagining is a complete cure. This is not a method for, let’s say, alcoholics not to drink, but an actual cure that would take away the illness and allow people with addiction to use just like normal people. This is because the imagined cure takes away the symptoms and the special response. They feel like normal people, and they’d have a normal person’s reaction to, say, a couple of drinks. It wouldn’t do for them what it does for the person with addiction. I’m not saying such a thing exists or that stem cells would or even could provide such a cure, but it’s my thought experiment so I get to make up anything I want.

So what would the mainstream Addiction Medicine doctor think of this? Well, to be honest, their first response would probably be fear for their job or resentment that neurosurgeons would get all their business, but after they got over that they’d realize that their greatest wish had come true; addiction would be gone. I think they’d be deliriously happy… as soon as they found another job.

But what about some of the members of the group I joined? Would they be happy? I doubt it. When discussing addiction treatment with them I heard such things as the necessity of suffering, the primacy of the spiritual experience, the necessity for gratitude for the illness as a way to a better relationship with God. I heard some of these doctors say that medication for addiction was counter to the point of recovery, because the patient would then be robbed of the opportunity to turn their pain into spiritual growth. This has really weighed on me. There are some out there that seemingly would rather 95% with the illness die of it so that 5% can achieve spiritual enlightenment than save more lives. It’s a foreign idea to me, and I was shocked to hear words associated with such a worldview from the mouths of physicians. I think these people I’m referring to would “just say no” to the idea of a one shot cure.

I think we who value the 12 steps run the risk of romanticizing this illness. Let’s be frank. This thing is a terrible killer that stands behind the top five causes of death in America. If I could wipe it off the face of the earth, I would, in a heartbeat. The world and human experience has given us many ways to enlightenment; we don’t need a disease like this to help us to the true path. I hate this disease every time I meet a child who lost a parent to it. I hate it every time I see another generation repeating the pattern. I hate it every time I see a human with great potential turned into a endless pit of need. And I hate it every day.

To some scientist out there: find a cure for this bastard of an illness. I’ll happily find another job, and another path to enlightenment.

Goodhart’s Law: Any measure that becomes the object of policy ceases to be a good measure.

Goodhart’s is a universal law. It essentially says that if you measure outcomes and focus on those outcomes as the point of the exercise, then they’ll cease to be good numbers. Instead, one should measure outcomes and then focus on changes to the system that do not include the outcome. If one focuses on changing the outcome, it will no longer be a useful outcome to measure. Examples of this can be found at all levels

For instance, a couple of decades ago American Medicine and the Joint Commission began to focus on pain as an outcome. Practices were established to measure pain and then decrease pain. The point of most of the efforts was not to find and negate the source of the pain, but rather to decrease pain itself. Now, two and a half decades later, we have an opioid overdose epidemic and measured levels of pain in our society that are higher than 25 years ago. This, in spite of good evidence that opioids don’t work for pain for more than about 3 months. We are so focused on the outcome that we cannot see the system that brings it about.

Let’s take another such outcome, drug use. Many have noticed that there are rising levels of drug use in our society. The War on Drugs has been a major response to that. It was not a War on the Causes of Drug Use in America; it was a War on Drugs, a war on the outcome. Our government has been measuring the outcome since that time, and it’s only getting worse.

So what is the alternative suggested by Goodhart’s law, and why do so few people choose it? The alternative is to measure the outcome and then consciously not attempt to change it. Rather, one looks at the system that produces it and attempts to form hypotheses about how the system brings about the outcome. Then one would change the system and remeasure the outcome to gauge the effectiveness of the change. Unfortunately, this method usually includes things one would rather not look at.

So, instead we focus on the outcome. Too many people wanting to smoke pot? We’ll make it illegal and then less people will want to smoke it. That didn’t work? Oh well, we’ll increase the penalties and then less people will want to smoke it. That didn’t work? Oh well, poison the crops so that anyone smoking it will go blind. That didn’t work? Oh well, we’ll increase border protection to keep it from coming in. I think you get my drift. Never do we ask, “Why do people want to smoke marijuana?”

Prohibition doesn’t work because it is counter to universal laws. It is an attempt to determine an outcome by focussing on that outcome. It never works.

So what could we do about people wanting to use drugs? One thing we could do is to notice that in the lab, normal animals don’t use drugs. They have to be trained to use drugs or bred to use drugs. There are some people in our population that, while not consciously bred, have an abnormal baseline so that drugs fix something in them that others don’t notice. This is genetic, and these people will have the same drive to continue to use as a normal person would to use something that keeps them from going blind. But what about people who are not born this way? If they are not born to use drugs we can teach them to use drugs. In the lab this is done by either assigning the drug to an already important state such as eating or, at least in primates, by making them mimic the genetic predisposition through the application of isolation or subjugation. This works in humans too. Take a genetically normal human who doesn’t like drugs and make him isolated or feel less than and he’ll have a good reason to start using drugs.

If we want drug use to go down or to even stop we have to treat addiction in those people who have it, whether born with it or developed it later. We have to stop people from having a need for drugs by focusing on how our systems and society cause the brain changes that mimic the genetic condition. Finally, for the minority of people in neither of these conditions, we need to increase education of the effects of drugs on the normal brain so that they don’t bring about the condition through damage via substance use. What will happen if we continue to focus on the drug use? We’ll actually not only make ineffective policy decisions, we’ll continue to make the problem worse.

I’m reading a book by Wasik and Murphy called “Rabid: A Cultural History of the World’s Most Diabolical Virus”, and I’m finding it particularly interesting in its description of historical medical perspectives on the disease rabies. It’s a fascinating book that gives a true cultural perspective of the history of the illness, most of which is prescientific. The book contains many historical lists from distinguished contemporary medical authorities that we today, in the light of our more modern knowledge, read as completely ridiculous. Yet these lists of treatments and causes were highly plausible at the time of their writing and were universally accepted and lauded by the medical community of the time.

I’m reading this book at the same time I’ve just returned from the annual meeting of the American Society of Addiction Medicine where I heard similar laudatory comments about the new ASAM criteria for addiction treatment based on what is thought to come out in the new version of the American Psychiatric Association’s Diagnostic and Statistical Manuel (DSM). This is in spite of the fact that ASAM’s new definition is biologically based rather than behaviorally based as is DSM. Based on the world view embraced by the DSM, the new ASAM criteria cannot rise beyond it. That world view is the same one first written down in 1980 before any of the modern brain research that established the basis for addiction as a common illness was done. It can therefore be thought of as pre-scientific. And yet, from the podiums of this conference, I heard many people speak of it as if it were the pinnacle of understanding, to the point that it should be enshrined in law as the requirement for addiction treatment.

Anything entering law should be correct. Science is ever evolving and only with the greatest certainty should anything be called correct at any particular point in time. I wonder if the future writers of “Hooked: A Cultural History of the World’s Most Misunderstood Disease” who looks back on us from a future point will echo our sentiments about our own thinking or will list them along with some of the treatments of only a few decades ago, which we now find laughable. I can’t write the definitive book on addiction or addiction treatment today, and neither can anyone else. Until we can, it’s doubtful that anything we come up with will be correct enough to enshrine in law or regulation. I’ll attempt to stem my rabid enthusiasm for my own thoughts; I hope the experts behind the new ASAM criteria and law makers do the same with theirs.

What if there was a disease that was the scourge of humanity. What if it destroyed lives and spread itself through society destroying, not only lives, but families and institutions. You’re probably thinking I’m going to say that there is such an illness, and that it’s addiction. That’s a good guess, but I’m actually referring to TB from about a century ago.

TB was an unstoppable killer. There were no antibiotics – no life saving treatment. The only thing we had was isolation of TB patients into sanatoriums so they could not spread the disease. TB scared the pants off of society, and huge amounts were spent on trying to control this destroyer of families.

What if, in the midst of all this, someone had created a medication that took the societal fear out of TB. I’m not talking about an antibiotic that would treat this illness and relieve the suffering of the patient. I’m talking of an imaginary drug that, if taken by the sufferer, would render them not contagious. This imaginary drug wouldn’t stop the progression of the persons illness, but would allow them to be in society again. Society would no longer need to spend millions isolating TB patients. The TB patients would no longer be excluded from being productive members of society.

People would see a great benefit in such a medicine, because, while it did not treat the disease, it would solve society’s greater problem. The terrible drain on the economy that was TB would lessen, but the individuals still suffering and dying from TB would largely be forgotten, except when they stopped taking their medicine and again became a threat to society. Instead of this imaginary medicine, we got life saving antibiotics. So, we never needed to see what would happen if we did have this medicine. While I’m busy inventing this imaginary medicine, I might as well name it. Lets call it naltrexone.

For those of you who don’t know what the real naltrexone is, it is an opioid receptor blocker that has been shown to be useful in stopping compulsive use of opioids and alcohol. It’s been touted as the next great thing in addiction treatment. There’s only one problem – it doesn’t treat addiction.

What naltrexone does is stop the abuse of drugs that operate through the opioid receptor. As it blocks the opioid receptor completely then any drug that stimulates the receptor doesn’t get through. As the receptor is blocked; there is no dopamine release; no dopamine release, no reward; no reward, no continued use. It doesn’t relieve the primary symptoms that caused the drug use in the first place, but it does stop the drug use, and from society’s point of view that would be enough.

But let’s consider the patient with addiction. Like the person with TB, his own illness will continue to progress. The primary symptoms that caused him to use in the first place will still be there. Society need not be afraid of him, but he will not feel better. That’s not to say his life will not be better – it will be. If one is dying of a chronic terminal illness, whether TB or addiction, life will be better with ones family than without.

But if you had such an illness and you had a choice between two treatments, one of which gave society everything it wanted and left you to die with the illness and the other that would give you full relief and a normal life span while still giving society what it needs, which would you choose. So how many current TB patients would choose the imaginary drug when they had antibiotics available? The answer to that question is probably the reason that three drug companies have lost a lot of money trying to sell naltrexone to people and why the latest formulation is a depot shot that lasts a month and doesn’t need the patient to want to take it daily.

I’m not saying that we shouldn’t ever use naltrexone. There are people for who it is the right choice, but it shouldn’t be marketed as the answer to addiction. There are patients who need agonist treatment, and the important thing for us is to find out who needs which treatment.

I meet a lot of people who’ve stopped drinking and using drugs. Some I’ve met because they work in this field; some I’ve met because they came to this field for help; and some I’ve met just because they showed up. No matter how I’ve met them, they all had one thing in common: they had stopped using something that they or others had perceived as a problem. They all called themselves sober.

I’d love to tell you that this crowd was uniformly well, but I can’t. Though they all had stopped using what they or others had found problematic, cessation was not enough. Some had taken the additional step of working an active program of recovery, and the results were personality change and a peace of mind they had never known. The others remained what I think of as stark raving sober.

This state has also been called dry drunk, but I like stark raving sober better. The state is characterized by abstinence from at least one drug or behavior and by a lack of very many other changes. Often the person picks up another drug – usually something that most people don’t think of as a drug such as overeating or righteous indignation. In any case, they remain as compulsive and controlling as they were when using. Their family life doesn’t get any better and while work sometimes improves for a while, the lack of real change usually catches up with them there as well.

Most readers familiar with recovery will at this point be pounding on the desk saying: “If only these people would work a program everything would be OK.” And that’s likely true. What most will fail to realize however is that some, in fact most, of these people will not be able to work a program.
The symptoms of addiction are self-perpetuating. Nature could not have designed a better parasite.
The illness is one of low dopamine in the mid-brain the symptoms of which are restlessness, irritability and discontentedness along with an inability to feel normal reward. Many people with addiction cannot feel a rise in dopamine from such things as fellowship, acceptance and love like others can. The promises of recovery seem so far removed from possibility and the efforts required seem so threatening to the remaining methods of raising dopamine that these patients cannot begin working such a program. It is the symptoms themselves that can keep someone out of recovery.

Many see sober people who are not working a program as worthy of condemnation. After all, they didn’t cause the illness, but they are refusing the simple acts that could relive their symptoms. I think this thinking is erroneous. It is these same symptoms that caused the original drug use. Many cannot feel the benefit of recovery until they are symptom free. Unfortunately our field is dominated by those who got sober and could feel the benefits of recovery without the aid of medication. Because of this our field thinks this path is open to all for the taking. That is not my experience. I have met many stark raving sober people who desperately wanted recovery to work and who made valiant efforts for it. I’ve met people who did what they were told but could not feel the relief without medication. Once treated medically, they did not drop their recovery program but embraced it, because it worked where it didn’t before.

It is the opinion of most of our field that those who get sober and remain without the relief brought by recovery are themselves to blame. These practitioners would say such things as: “He just isn’t ready” or “I guess he didn’t want it enough.” There is among these practitioners an idea so seductive that it causes no pause for reflection or challenge. That is the idea of the bottom. The myth of the bottom is that when suffering is great enough the person will surrender and accept a recovery program. It is a wonderful idea, but it has only one problem. Most people never hit bottom and bounce; they just keep falling to their death.

So our field tolerates the stark raving sober. We see them not as patients in need of some treatment, but as a developmental stage on the road to something better. Enough survive this road to perpetuate the myth so that our field doesn’t change. People with addiction, sober people with addiction, continue to die while we keep doing the same thing. Someone once said that doing the same thing and expecting different results is the definition of insanity. I guess that makes us in this field stark raving sober.

I’ve just looked at a paper by Ersche et al in Biological Psychiatry (http://www.biologicalpsychiatryjournal.com/article/S0006-3223(12)01004-9/abstract) that compared 52 “normal controls” with 27 non-dependent cocaine users with no family history of the illness, 50 cocaine dependent patients and 50 of the dependent patient’s non-dependent and non-using sibs. They did fMRI scanning to look for differences and found some really interesting ones.

Compared to the “normal controls” the cocaine users, that is the non-dependent users and the dependent users, shared some personality traits and fMRI findings. They showed increased sensation seeking and abnormal orbitofrontal and parahippocampal volume. Now most people would have stopped there and said, “See, cocaine changes your personality and your brain.”

But what’s really interesting is that this group didn’t stop. They found differences that the cocaine dependent patients and their non-cocaine-using siblings had in common. This group had increased levels of impulsive and compulsive personality traits and limbic-striatal enlargement. Impulsivity has been linked to low dopamine in the midbrain and “compulsive” in this context has a lot to do with the increased attachment one sees in addicted individuals to anything that increases the dopamine signal, because normal activities don’t. Therefore the affected individual focuses on those few things that do. This finding about the striatum in non-using individuals shows that it is not the drug use, but a pre-existing issue that addicted patients are dealing with.

What they did not tell us is the nature of the lives of the “unaffected” sibs. We don’t know if they were overeaters or gamblers or used one or more of a number of other dopamine increasing behaviors. We’re only told they did not use drugs. The study suggests that the ASAM definition of addiction is more accurate than the DSM paradigm which assumes everyone is “normal” until they become attached to a substance and that all symptoms are due to that substance or another co-occuring disorder. The ASAM definition states that there is a brain problem that leads to symptoms, and that it is these symptoms that lead to use.

We need more research like this to differentiate between the biology of the illness and the biology of the epiphenomena of drug use. Hopefully replications will take into account the disease of addiction and not just the dependence on one drug.

I’m not a big fan of music, but I do have a few songs on my iPod. A good chunk of them are by Dr John and other musicians of the New Orleans tradition. But what I learned from Dr John’s new album, Locked Down, was from an entirely different tradition.

Before I tell you what I learned let me say that I don’t know Dr John, and don’t know anything about Dr John. I have no idea if these songs mean what I think they mean, and he might say they meant entirely different things when he wrote them. But they mean what they mean to me when I hear them. That’s the nature of art; once it’s created it belongs to the beholder, not the creator.

The first song I learned from is “When I’m Right, I’m Wrong.” It’s a marvelous depiction of terrible sponsorship. It’s such a realistic portrayal of what many newcomers get when they first arrive in 12-step fellowships, that it’s frightening. I hear many patients tell me that this is what they think of when they think of 12-step fellowships. I’m sorry that anyone has to experience such a message, and it’s all too common: “sit down, shut up.” Everyone in recovery should hear this song and listen for its words when they are trying to pass on the message. The memory might stop us before we hurt someone.

And then there’s “My Children, My Angels.” This song is such a wonderful description of good sponsorship that I wish everyone could hear it, just to know that such sponsorship exists. The refrain is the most elegant statement of sponsorship I’ve ever heard. The message is basically this: I love you, tell me what you want, don’t trip trying to get it, I’ll show you how. It is so filled with love and support, that it’s hard to imagine anyone having a chance at such sponsorship passing it up.

Let me repeat that I have no idea what Dr John was actually writing about. If any of you know him and ask him, he might tell you that the first song is about a bad break up and the second is about his children. I have no idea. But to me the songs are representations of both the best and the worst I see in recovery. They remind us all that everyone carries a message. Whether it’s a message that will save someone’s life and be of real usefulness is up to us.

I have been participating in 23andme’s exome beta study. The exome is that part of the genome that makes proteins. Out of the 3 billion nucleotides in our DNA, only 50 million are used to actually code proteins. The rest has been called “junk,” but it’s far from that. These areas of our genome that don’t code for actual proteins have many functions such as regulating the production of proteins from the genes in the exome and coding for where the breaks will occur during recombination. So there is no junk in our genomes, but the exome should hold some pretty exciting information for us as it will determine the shape, and therefore the function, of our proteins.

So I’ve gotten my results back, and here’s the math. Of the 50 million base pairs in the exome, I have 66,186 that are different from the “reference build.” That reference build is what is considered normal, or in genetic parlance, wild type. 66 thousand sounds like a lot but that’s only 0.13% of the the total. So I’m different from “normal” at a little over one tenth of one percent of the base pairs. Still, that’s 60 some odd thousand places where I’m not normal! Should I be sweating?

Not yet.

23andme have broken down my results by impact, that is, how important they are. Genetics is so new that fully 74% of my variations from normal don’t have a known impact. That means no one has seen one, but also that there may not be one. That’s hopeful thinking, isn’t it? Of the 17,101 variations that have a known impact (0.03% of the total exome), half have low impact, almost the other half have moderate impact, and 232, or 1.3% have high impact. High impact would mean that the protein would have a different shape or not get formed at all. That’s 232 proteins my body makes wrong. Why don’t I have two heads? Maybe I should start sweating now?

Not yet.

They also listed for me just how rare my variants are. It turns out that 60,884 or about 92% of them are seen in more than 5% of the population. Well you don’t see 5% of people walking around with two heads, so I should be okay. Almost 4,000 were somewhat rare, meaning that they are seen in less than 5% of the population, but 736 are listed as unknown; that means that they are listed as having been seen in humans but are so rare that no one has figured out how rare. Another 760 were listed as novel; that means they’ve never been seen before and aren’t listed in any database. Wow, maybe I am unique! At least at 760 out of 50 million base pairs. Ok, so I’m 0.0015% unique. So my mother was right; i’m pretty special. But should I be sweating?

Not yet.

Now, you have to understand, I’m relatively normal. I have the average health issues of a 53 year old man, but my life is pretty good. And I have 232 proteins my body makes incorrectly. It teaches me two things. The first is how resilient the human body is. We must have a lot of redundancy built in. Second, if someone with the relatively normal things going wrong has this many exomic mutations, then everyone has around that many, and if everyone has around that many, then we are in for an interesting next few decades. Once sequencing becomes widely available and we have the option to participate in research (as in 23andme’s model) we’re going to have an explosion of medical discoveries that will make the last hundred years seem like kindergarden. The only thing that will slow us down is all the people who make their living in the current paradigm that are afraid for it to change. Should I be sweating?

Not yet.

23andme put all this data together in an algorithm they’ve produced to pick out some of the important variants to look at. It will take me a long while to work through each of them and figure out if they are worth writing about. They picked about 30, and disappointingly for me, none were in the genes I commonly look at for addiction. But on the bright side, none for having two heads, so I’ve decided not to sweat.

The story of Addiction in America could start any time or any place because addiction has always been here. But we’ll start our story today in 1869. The Civil War has been over for four years and reconstruction has begun. President Lincoln has been assassinated, and his successor, President Johnson, has survived the country’s the first attempt at impeaching a president. America is beginning to put the war behind it. Railroads are going up at an amazing rate, and with this new-found ease of transportation, the population is booming and spreading out.

By 1879, America has repaired its finances enough to go back on a gold standard. The “Greenback” was once again freely convertible with gold. This begins the biggest and longest economic expansion in the country’s history. With the booming economy the need for labor rises and immigration booms. Now the population isn’t just rising but diversifying as well.

While that sounds good to us today, it starts to bring other cultures and other ways to the shores first colonized by the Puritans. America had been founded on tobacco and alcohol, but new people from all over the world have brought new and exotic drugs to our shores. Those who had addiction had many more choices for relief than their grandparents, and science got into the act also.
In 1898, Bayer introduced a new pain reliever – heroin. And if your pharmacist was out of syringes, you could get them from the Sears catalog. As the cultural friction continued the country’s power elite became uncomfortable. By 1900 movements arose to try to bring America back to its roots; there are attempts to fix all the social ills of the time with a return to better, simpler times.

Whenever a group in power wants to fix a problem, it usually looks outside itself for the source. The elite leadership of America was no different. “If only those Chinese hadn’t brought opium to our shores.” “If only those German scientists hadn’t corrupted our medical doctors with these newfangled pain relievers.” “If only that morphine-addicted confederate veteran hadn’t added Peruvian cocaine to his patent medicine, Coca Cola.”

To the old guard it just seemed there was a culture of drugs everywhere they looked. And of course, it wasn’t the drugs they used that caused the problem. By 1908 the idea had gained enough traction that President Roosevelt appointed Dr. Hamilton Wright the first opium commissioner of the United States. In 1911, Dr. Wright was quoted as saying, “Of all the nations in the world, the US consumes the most habit forming drugs per capita.”

What really seemed to bother these elite power brokers and guardians of American culture was that most people addicted to opioids in America at the time were white women buying from their local pharmacist or from Sears. Newspapers ran editorials condemning the opium importing Chinese who used the drug to seduce white women. There was testimony before congress that cocaine given to southern blacks was the main cause of violence against white women. While the movement stated it was about getting rid of drugs, there was, from the beginning, a strong racial overtone in the arguments and a sense of a need to protect white women. In 1914 this movement culminated in Harrison Narcotic Tax Act which led not only to the criminalization of drug use, but also to the criminalization of treating people with addiction as if they were ill.

Between 1915 and 1920, 20,000 US doctors were jailed or fined for treating people with addiction and doctors soon learned to stop such heinous behavior. Six years later this prohibition movement overtook its founders with the passing of the 18th Amendment. Now, even the Senator’s whisky became illegal. While alcoholic prohibition lasted only 13 years, the Harrison Tax Act and the criminalization of treating people with addiction as if they were ill lasted until the 1960s.
Even today, even now that the neurobiology of addiction is known, even now that we can see the genetic underpinnings of the illness, the old arguments still arise:
“If you treat addicts as if they were ill, they won’t want to stop.”
“You’re just mollycoddling weak people.”
“Calling it an illness is just an excuse for bad behavior.”

So doctors are not yet free to treat the illness. Only doctors with a special waiver can use certain medications to treat people with addiction. And even then, each doctor can only prescribe for 100 patients. Even if the doctor is board certified in Addiction Medicine, the limit is still the same. Drugs other than alcohol and nicotine are still seen as somehow causing more death and destruction that those two. They are still illegal but still used as they probably always will be. And as long as we keep thinking a drug, or a group of drugs is the problem, and keep ignoring the biological brain illness of addiction, our problems will remain.

We can blame immigrants and blame minorities. We can blame politicians and academics. We can blame anyone we want. But when we’re ready for a solution, we’ll look at ourselves. It is said that when the student is ready, the teacher is there. That’s because the teacher has always been there. All the information we need to solve the great social problems stemming from addiction including the top five leading causes of death in America is there in front of us. Every tool we need, we have. All we need now is to be ready.

I’m taking the week off from writing and offering this link in its place:

http://www.abc26.com/videogallery/72445825/News/The-411/Dr–Howard-Wetsman/National-Recovery-Month/Addiction-Treatment#pl-62861363

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