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Can we just get rid of the drug?

That’s a pretty common idea and a pretty common solution to attempt. Our culture tried that with alcohol back in the 20’s. The argument is that alcohol prohibition decreased drinking and decreased alcoholism even after prohibition ended. Here’s a chart of gallons of alcohol consumed by every 10 people. It shows that, indeed, prohibition (the area of missing data) decreased drinking behavior. Before prohibition on average every 10 people drank 20 gallons a year; after prohibition every 10 people only drank 10 gallons a year.

But what happened to the alcoholics? Did they disappear? Did they stop drinking? Did they use something else? What other common drugs might they have switched to now that they couldn’t get alcohol? Here’s a graph of cigarette use per person. This graph is in 100’s of cigarettes so that in 1920 the average American was smoking about 600-700 a year. By 1934 the average was over 1000. There’s no blank on this graph because there was no prohibition of cigarettes and we have data for every year.

But what if we got the same thing from alcohol as cigarettes? What if the disease of addiction is a brain disease that doesn’t particularly care what drug we use? What would be the effect of alcohol prohibition then? In science when you want to see if two variables interact, one simple way to do that is to multiply them. Since people drink to get dopamine and they smoke to get dopamine, we can see the effect of alcohol prohibition on this made up “Dopamine Load” which is the combined use of cigarettes and alcohol.

I made the preceding graph a close up so you can see that making alcohol illegal didn’t change the combined use of cigarettes and alcohol at all. Just as much of the combination was used after prohibition as before. But you may also notice that the combined use rises a good bit after prohibition. We need to know that there is good evidence that dopamine receptor levels decrease with certain stresses. Remember the equation I showed you; lower dopamine receptors mean lower dopamine signal. Take a look at the next graph in relation to the great depression and World Wars. Notice the drop off at the end of WWII and the blip during Korea, then the rise during the social upheavals of Vietnam and the inflationary spiral of the 70’s.

But did life get a lot easier in America in the 1980’s? We worked on nicotine suppression, and we continued to tell people how dangerous alcohol is. So if they stopped using these drugs as much, did they just need less dopamine? Was Ronald Regan that good a president that no one needed extra dopamine anymore? Or did they switch to something else?

The USDA keeps track of the calories that are taken in per capita every year. Before the 1950’s the data is erratic due to the depression and the rationing during the wars. But you can see that when we got the message about alcohol and cigarettes around 1980, we just went out and found a new reward—excess food.

So what generally happens when we get rid of a drug is that people with addiction are not going to relax and say “Oh well, I guess I’ll just not use it anymore.” They go find another drug.

From “Questions and Answers on Addiction” by Howard Wetsman MD (copyright 2007)

© Howard C Wetsman MD FASAM

If Addiction was a Disease … We’d Treat It.

In my line of work I meet a lot of people who treat addiction. Some are doctors but most are counselors. That’s not unusual as doctors have been out of the addiction treatment business for the most part until recent years. In the absence of physicians treating addiction as an illness, several non-medical lines of thought have become primary in the addiction treatment arena. What seems odd to me is that these lines of thought are spoken of by the same people who say they use a “disease” model of addiction, but they are lines of thought that are completely at odds with that model.

Treating Addicts With Medication is Bad for Them – Actually many people have no problem treating addicts with medication, they just want me to call it medicine for something other than addiction. If the patient is having trouble feeling normal levels of pleasure after stopping drug use (a primary symptom of the illness that caused the drug use in the first place), these therapists would be happy for me to call the patient depressed and give a medicine for depression, but let me say that I’m treating the brain disease of addiction and it’s a no go. The thinking seems to be something like, “If you give addicts medicine they’ll feel better and if they feel better they won’t be miserable enough to work a 12-step recovery program.” That’s actually not been my experience at all. In fact, unmedicated people who have just stopped using drugs are pretty miserable and not just because they stopped a little while ago. Most addicts will tell you that it seems pretty pointless to stop because they know what they feel like without drugs (low self-esteem, low motivation, unable to feel pleasure, no attachment to others, poor attention, and other symptoms). They don’t feel this way because they used drugs, they felt this way before they used drugs and started using frequently because, at first, the drugs solved these symptoms for them. The Nancy Regan “Just say ‘no’” leaves them with the brain they had before drugs and it is usually not a brain that can sit with a group of people and tolerantly listen to what they need to hear. They also can’t remember most of it a few minutes later. So it’s been my experience that when given a medicine to suppress the primary symptoms, they not only stop using drugs as much or all together but also feel better then they’ve ever felt and become more able to work the necessary recovery program.

Addicts Don’t Want to Get Better- The funny thing is that I hear this mostly from addiction treatment professionals who are in recovery themselves. I think this comes from the projection of their own experiences onto that of their patients. They remember how hard it was to “want” treatment before modern medicines were available, and, rather than see their own reticence as an uncontrollable symptom of the illness, they, like most of us, would rather feel in more control and remember that they didn’t want to get better. This is why AA’s first step is powerlessness, because the last thing addicts want to give up is the sense of control. People would rather believe that they are bad than so sick they have no control. Again, my experience is just the opposite. When we treat addicted people with the correct medication they feel more motivation to get into recovery rather than less.

Medicines Will Just Make the Addict Feel Better – Well, we can’t have that! Somehow we think that misery helps. I don’t know if you’ve noticed but this is the only “disease” that’s treated this way. Has any doctor ever told you that if we give you pain medicine while we set your broken arm it will not set right? Anyone ever suggested surgery without anesthesia? How about not using that walker after your stroke, don’t you think you ought to learn to crawl? After all, if God wanted you to walk he wouldn’t have given you a stroke. How many people would continue to see such a doctor or therapist? Yet the idea of not relieving suffering is rampant in addiction treatment. It seems almost a badge of honor. If addicted people had more choices (and they will soon if insurance parity legislation gets passed this year) they’d vote with their feet, just like any other patient would. Unfortunately, they don’t have a lot of choices yet.

So I think addiction is an illness. It’s a primary illness; that means that you don’t have to have another illness to have it. It’s a chronic illness; that means it’s not going way and will need treatment throughout the life cycle. It’s a progressive illness; that means it’s going to get worse with time, not better. And it’s a terminal illness; that means that without treatment it will kill you. Oddly enough I don’t find all that depressing at all. In fact, medicine is filled with diseases that match the same description that people live with and get treatment for all the time. Let’s take just one example: diabetes. It’s primary, chronic, progressive, and terminal if not treated. But it has an excellent treatment which consists of medication and behavioral changes which may make medication unnecessary. Exactly like addiction. So when someone says something to you about addiction, ask yourself this question, “Would that statement be true about diabetes?” If the answer is no, take another look at the information, because, after all, if addiction was a disease, wouldn’t we treat it like one?

Howard

© Howard C Wetsman MD FASAM