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It would be nice if addiction could talk, or rather, speak in a language we could understand clearly. It would be great if it would just say, “Excuse me, I’m a little low on dopamine tone, please see your doctor for this problem.” Even a dashboard light would be enough, maybe a little read LED under our thumbnail that would light up to tell us we need professional attention. It would be nice, but it doesn’t happen, so we’ll probably have to learn the language addiction does use: symptoms.

Symptoms, I’ve found, come in two varieties. The first are primary (sorry, no pun intended) symptoms directly caused by the neurobiology of lowered dopamine tone in the midbrain reward system. The second are secondary symptoms caused either by secondary neurobiologic changes or that are learned. I’ll give examples of the primary and secondary neurobiologic symptoms I usually see but it’s the learned symptoms I want to get into in greater depth.

I’ve mentioned in other entries what the primary symptoms are: poor attention, poor memory, inability to attach to others, relative anhedonia, restlessness, and feeling like there’s something missing or we don’t have enough. These cause secondary symptoms directly from the neurobiologic changes or by the way we interpret them and translate them into our social and family environment. Examples of secondary biological symptoms are low motivation, feeling inadequate and irritability. What I’d really like to spend some time on are the translated or learned symptoms, basically what our brain learns to say to try to get the message across.

If you think of the midbrain as someone who speaks a different language and the cortex as a translator this may start to make a little sense. The midbrain doesn’t speak English; it speaks Symptom. But the people around us who could be of any help at all are all speaking English (at least in my case) so we try to get the cortex to translate. How that translation sounds depends on a lot of things. Age at onset of the disease, social background, cultural influence, family illness history are all some but not all of the influences on this translation. Think about it this way. If you’re hearing Arabic translated into English, might you not get a different translation from a native speaker than from someone who learned Arabic as a adult. And might you get a different translation from someone born in Indonesia than from someone born in Morocco? So let’s take a look at some of these factors and how they may change the translation we hear.

Age at onset

What I mean here is not age of onset of drug use but age of onset of the primary symptoms. Of course that onset is usually followed immediately by frantic efforts to raise dopamine tone but the first of these is rarely drug use if the onset is in childhood. So what would someone use to raise dopamine tone at the age of three or four? An incomplete list includes: foods high in sugar or fat, getting someone to show us praise, novel stimuli, and feeling more powerful than those around us. So those could get expressed as a sweet tooth, people pleasing, bullying, or thrill seeking for instance.

Of course drug use does occur in very young children. I grew up with someone who was exposed very early to paregoric, an opioid preparation that used to be used for colic and upset stomach in children. He very much liked the effect produced by the paregoric and complained of intestinal problems a great deal. Of course his mother, not understanding he was asking for increased dopamine took him to the pediatrician who didn’t understand he was asking for increased dopamine and treated a spastic intestine that didn’t exist. The midbrain quickly learned that when it needed more dopamine it should have a stomach ache. More about learned symptoms later.

As we lose dopamine tone with age, many people can get the symptoms after they become an adult. By that time they’ll have learned words that express some of the events in the midbrain. They may be able to say they’re anxious or depressed. They may be able to say their feeling picked on because they don’t have enough of anything. In general, they’ll have more resources to express verbally what’s happening in the midbrain, but, of course, they won’t be able to say, “Doctor  I have a low dopamine tone in my midbrain.”

Social Background

How could social status or background matter? Here’s one I’ve noticed. Most kids who can’t pay attention well get pretty sick and tired of getting kicked around for it. “Why can’t you do anything right?” “You never follow directions.” “Your brother doesn’t leave his things laying around.” Who wouldn’t get sick of that? So kids react differently in different situations. The child of two professional who prize educational achievement above all else may learn to compensate with obsessive neatness and note-taking. If you can’t order your mind, at least order your external world so you can’t forget much. The same child born to a family that doesn’t prize education or that can’t afford to support the obsessive reaction will have to develop a different strategy. That’s probably why when I meet a low dopamine person who is obsessive they are almost always from an upper middle to upper class family with highly educated parents. It has nothing to do with the child’s intelligence or attributes, it’s just an epiphenomena of their social environment.

Cultural Influence

Different cultures will allow different expressions of the symptoms. For instance that kid that had to have stomach cramps to get paregoric would have had to find a different way in a more stoic culture or one that didn’t have access to modern medication. Some cultures will allow the kinds of drugs that kids in our culture can get pretty early, caffeine, nicotine, sugar. Others will not allow those drugs for children. Some behaviors will be acceptable and others not. So while the family is the basic unit of culture, the culture at large can have an effect on the developing illness equal to or greater than that of the family.

Family Illness History

It’s probably easier to be an alcoholic if you grow up in an alcoholic home. Your parents are more likely to see drinking as acceptable and you observe people using alcohol to medicate their emotional state early on in your life. However family illness history doesn’t just predispose to the use of a particular drug or behavior; in some cases it can protect against it. Another boy I grew up with grew up in a home where his mother chain smoked. He’s never picked up a cigarette in his life, not because he had normal dopamine but because he was so disgusted by his mother’s use of the drug. I can’t tell you how many people I meet using heroin or cocaine who’s fathers were alcoholic and who never drank. They hated the idea of turning into their father and thought if they only avoided his drug they’d avoid the outcome. Of course, it didn’t work like that but still that’s their thinking.

So once you see addiction in terms of a biological brain disease you have to start noticing things more subtle than what we usually term a drug. In about 80% of the people I see we can identify something they were using to increase dopamine tone  before they picked up the first thing society would call a drug. I think this has important implications for treatment. Up to now, most treatment programs have focused on “drugs or alcohol” to the exclusion of other drugs like nicotine. So a person with addiction may just leave treatment using a drug that will progress his illness more slowly but still progress his illness. It also effects “relapse” rates. It’s been shown that people who stop smoking in rehab go back to using their primary drug less than those who continue to smoke.

While the issue of nicotine and, to some extent, sugar and overeating are becoming more recognized in treatment programs, some of the earliest behaviors are considered part of the patient’s underlying personality and not addressed at all. I think we, as a field, would improve our service to our patients and society if we addressed these early rewarding behaviors as drugs in treatment. We’d get a more complete treatment and a more sober patient. Once we make the decision to address these issues, of course, we’re going to have to go looking for them, rather than wait for the patient to identify them. It would be easier if addiction could only talk.

I was just at the annual meeting of the National Association of Addiction Treatment Providers (NAATP) and participated in a panel discussion on the question that is the title of this article. In the context of this panel the meaning of the word recovery is, “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” The question is prompted by many people in the addiction treatment community that recognize that merely not using drugs is not full recovery from the illness and are concerned that the medicalization of addiction treatment will actually detract from treatment outcomes. I understand their worry, but I disagree.

I think it’s the wrong question. The one I’d ask those who are worried is, “Is not drinking the same as recovery?” I’ll bet they’d all say that it was not, that recovery was much bigger than not using. So why would we ask if taking a medicine is the same as recovery? Doesn’t make sense.

I think a better question that addresses their concerns is, “Will taking a medication prevent addiction recovery?” What I heard from some on the panel was that patients who were in recovery aided by medication were in a different kind of recovery from those who manage without medication. Others pointed out that medications can be abused and that doctors shouldn’t do anything that could cause harm.

Do no harm: Let’s take that one first. Approximately 90% of people with the disease of addiction cannot walk into an AA meeting, sit down, get sober, get a sponsor and work the steps. For me, to do or not to do are equally active decisions. To fail to address the large group of people who die because they cannot work a recovery program without medical help is to do great harm. In fact, it is much greater harm than could possibly be done to the few people who do enter treatment who got medication they didn’t need. Of course the counter argument could be made that some of those people on medication might leave treatment because of the medication. What most treatment programs don’t look at is the very high attrition rate (in patients who aren’t coerced) early in treatment. More patients leave because of lack of medication than would ever leave because of it.

A different kind of recovery: Is one person’s recovery different because he takes medication? I doubt it. Of course, not being God, I really can’t answer definitively, but I still doubt it. Is someone not in recovery because he’s taking insulin? “Of course not,” these people would say, “We were saying that taking a medicine like buprenorphine that works at the opiate receptor is what causes people to have a different kind of recovery.” I still don’t see why. Because by stimulating the opiate receptor the patient has greater dopamine tone in his midbrain and can concentrate and enjoy his life? The fear is that if he isn’t suffering he won’t work the steps. My experience is just the opposite. I’ve seen many people struggle to work a 12-step program and not be able to do it until they get on medication. But lets say that it is different to be on medication that increases dopamine tone. What about addicts in recovery that smoke? Aren’t they in medication assisted recovery? Even worse, they aren’t taking a dose as directed but are choosing when to use the drug. Sounds much more like drug use to me than taking a prescribed dose of buprenorphine. One of the panel members introduced themselves as working at an “abstinence based program” meaning that they didn’t allow medication assisted treatment. But they do allow smoking. The irony was not lost on me.

For me recovery is about surrender, accepting that the illness one has is beyond one’s own control. That leads to understanding that one must live by certain principles that prevent the disease from flairing up. I think taking a medication as directed is as much surrender as not using a drug. Surrender is, in large part, about following directions from sober brains, not so much about what the recommendations specifically are.

My own feeling is that it’s really none of my business, or anyone else’s, how someone else is in recovery. I mean that both personally and as someone who treats addiction. We are treaters of an illness not super-duper sponsors. I think the field hurts itself by asking this kind of question. Third party payers just hear that we’re less interested in data about treatment than we are in ideological arguments. Patients hear that they have limited resources to get treatment and won’t be accepted in some places. Judges and law makers who hear arguments about addicts having an illness see treatment providers treating it more as a moral question than an illness. Society in general gets confused.

So is there a role for any statement about recovery from those who treat the illness of addiction? Yes, there is. Studies show that people who engage in a recovery program after treatment do much better than those who who do not. What kind of recovery? It doesn’t seem to matter. If it’s 12-step recovery or a recovery that comes from another culture, it works if the patient works the recovery program. That’s what I tell my patients. Why is it true? Because addiction is a chronic illness and recovery programs of all kinds produce a supportive environment for actual change in the brain that can result in the amelioration of symptoms. It’s the working of the program that does the trick, not what medication the patient is on when they are working the program. For all those addiction professionals who are scared about this medication because of what they’ve heard from other non-physicians, I refer you to the appendix of AA’s Big Book, “There is a principle that is a bar to all information … that principle is contempt before investigation.”

Recently the results of trials of a medication called Acomplia were reported and the increased incidence of depressed mood and suicidal ideation in participants who took the medicine led the FDA to refuse approval to market in the US. Acomplia is available in Europe and was to be used as a weight loss drug. It is a CB1 blocker, that is it blocks the cannabis receptor called cannabinoid receptor 1. In fact it doesn’t just block it, it reverses the action of it. Sort of an anti-cannabis. Rather than getting the munchies Acomplia leads people to have a lower appetite and, hence, lose weight.

The reason I’m writing about this isn’t that it’s a good drug or bad drug; I have no idea. What I think is missing is the understanding that they were treating a group primarily of addicts. This was a group of people who eat more than they need to to maintain body weight. Some of them are addicts with overeating as an expression of the illness. Because that isn’t taken into account in studies such as this we’ll never know if he patients who got suicidal ideation were the same ones who were depending on their CB1 receptor for what little dopamine tone they had. Could they have been given Acomplia safely if they were given another agent to raise dopamine levels? We’ll never know.

I’ve heard some researchers say that it’s okay, that there are other cannabinoid molecules in the drug development pipeline for future research. My concern isn’t a small pipeline; it’s the view we have of the disease and the lack of understanding of the disease as a disease in every study done. Until we get that right, the science on treatment will come very slowly.

“It’s a revolution dammit! We’re going to have to offend somebody.” - The character of John Adams, 1776 (movie)

There’s a lot right about the current state of affairs in addiction treatment, but like any system that’s been around awhile, there’s a lot wrong as well. Everyone from Congress to HBO is starting to recognize addiction as a disease, but the bulk of current addiction professionals, while they use the word disease, do not act as if they are treating one.

To see what I mean, let’s take a look at the language the field uses. My colleague in New York, Ed Salsitz, has been on the band wagon to clean up our verbiage for a long time. In his talks he shows a picture of a full urine cup with dirt poured over it, “Now that’s a dirty urine.” His point is that patients don’t have “dirty urine” any more than a diabetic patient who has glucose in his urine has a “dirty urine.” What they both have is a medical test positive for a certain result. Using the term “dirty” adds an element of judgment that we would never use in any other medical illness. Here’s another one: detox. What a crazy word to use in this context. The original medical meaning of detoxification is “a metabolic process by which the body rids itself of toxic chemicals.” The way the addiction treatment field uses the word started only in the 1970s: to get someone off of intoxicating substances. We aren’t “detoxing” anyone. The “toxin” is already gone. What we’re doing is medically withdrawing a person from a particular substance. Ed’s point is that by using “street” language rather than medical language, the addiction treatment field is holding itself back from professionalism and professional recognition.

Here’s one Ed doesn’t mention but that I think is pretty silly: aftercare. It suggests just what is meant, that the person doing the treatment believes that the “care” is over and that this is a period after care. It’s not; it’s continuing care. The illness of addiction is chronic through the life span, why should care end for addiction any more than it should end for diabetes or high blood pressure. But the majority of people treating addiction today are not medical professionals and many are not even counseling professional, and the field has hijacked some medical terminology that suggests meanings that aren’t inherent in current practice. In fact, it is current practice to believe that a period of inpatient or intensive outpatient treatment is a complete treatment and that the care has been given. That comes from the current practice of focusing on inpatient treatment facilities that often need to take people from many miles away because of the expense of treatment. Could you imagine treating diabetes like that? Go off to Atlanta to get your diabetes regulated with insulin, then, now that you’re treated, go back home and get after care usually not including insulin. No wonder treatment has such high relapse rates.

That brings me to the revolution. If addiction is a chronic medical condition that is now being treated with acute treatment and aftercare, what would happen if we did it differently? Diabetes is often suggested as a model of a chronic disease like addiction: chronic, progressive, incurable, fatal if untreated. They have similar relapse rates (50-55%) and both involve medication treatment along with lifestyle changes. When the state of North Carolina started treating its diabetic medicaid patients with a chronic disease management model the relapse (return to uncontrolled glucose) rate fell from 55 to 33%. And they didn’t include any treatment for alcoholism or compulsive overeating, two expressions of addiction that lead to diabetic relapse.

To understand how we can use chronic disease management in addiction we’re going to have to define the word relapse. Currently it is used, like so many other medical terms, ina non-medical way in the addiction field. In every other branch of medicine relapse means return of symptoms. In addiction what is meant is lack of adherence to the care plan. In diabetes the care plan includes not eating cake but eating cake is not a relapse; it is a lack of adherence to the care plan. In addiction the care plan includes not using drugs or compulsive behaviors, but it’s called relapse as if the drug use was the symptom of the illness. The symptom of addiction is not drug use, it is the symptoms that cause drug use.

What are the symptoms of addiction? All drugs of abuse (including behaviors that can be expressions of addiction) cause an increased dopamine tone in the brain’s reward system. Lowered tone of dopamine in the reward system has a specific set of symptoms that precede drug use: relative anhedonia, poor attention, inability to attach to others, irritability, and others. The brain with addiction remembers that those symptoms can be alleviated for a brief spell with the use of the drug; of course it’s going to want to go get them. So what would be different if we looked at symptoms in relation to relapse rather than lack of adherence to care plan?

One thing that would happen is that problems would be found sooner when they are more manageable. Instead of finding out that Johnny has problems when his monitoring urine test comes back positive we hear about it a month earlier while screening for the primary symptoms by phone or during continuing care meetings. Another thing that happens is that it gives us the cause to treat rather than the result. How successful should it be to treat the result of an illness (drug use) rather than the cause (symptoms)? I don’t think any doctor would have much of a success rate with putting a pneumonia patients in an ice water bath to reduce their temperature. I can envision quite a few funerals and malpractice suits with that one. Instead of trying to stop drug use (like giving an opiate dependent patient an opiate blocker) we’d give medicines that actually relieved the symptoms so that the patient’s brain wouldn’t tell him to go get opiates.

I don’t want to get into the details of what such a program looks like. But think about the future if someone built one. Patients would come in for a specific program of stabilization and intensive treatment to prepare them for lifelong chronic disease management and then transferred to continuing care with appropriate monitoring and continuing education and support. The barriers to getting to care should problems arise will decrease and “relapses” will be handled much earlier with few complications lowering total costs to insurers and society. Like most other better mouse traps, the third party payers (who are about to be forced to pay for addiction treatment) will beat a path to this door.

So who will be offended? Well it’s going to be somebody, but it won’t be the patients, insurers or society in general. The only people offended will be those dogmatic believers in the “we always did it that way” approach. But, then again, that’s who gets offended in every revolution.