AddictionDoctor.Org

First, let me say that I’m a big proponent of 12-step recovery. I don’t think my field of psychiatry has come up with a tool as effective as 12-step recovery, certainly not one that has worked for 70 years. That said, there are some things I have to take issue with concerning my care for my patients with certain people now presenting themselves as experts in 12-step recovery. Please understand that I’m not taking issue with AA or NA or any other 12-step fellowship. These fellowships do not take a stand on outside issues, and my care of my patients is definitely an outside issue.

Unfortunately, not all members of such fellowships share that view, even some with considerable experience. Here’s an example. A patient of mine had a difficult time staying sober, even on the medication which usually has a great effect. I asked him what was happening, and he told me that he wasn’t taking the medicine after all, because it made him sleepy. Please understand that in my experience this would be a very rare occurrence. Opioids generally don’t make opioid addicts sleepy; they give them energy. This medicine, buprenorphine, is a partial opioid agonist and as such is unlikely to cause an opioid addict to get sleepy.

Now this particular patient is also a compulsive over-eater and is quite overweight. I asked him when he was taking his last dose of medication: 5 pm. His complaint was that he was falling asleep in evening NA meetings. I suggested that it might be his still uncontrolled eating and the binge he had for dinner that was more responsible for his sedation but he thought it otherwise. I thought that he should take his buprenorphine as it would likely decrease his craving to overeat as well as for opioids and, in time, make things better. See, he had talked to other people in NA who saw that he was falling asleep in meetings and told him that buprenorphine was probably the culprit. I told him that was unlikely, but he was sure they were right. He did agree to an experiment though.

I asked him to take his last dose of buprenorphine, not before the meeting, but after meeting. If he was right he’d get a good sedative effect and go to sleep as he wanted to. He’d also get to stay awake in the meeting. If I was right he’d probably still fall asleep in the meeting. Two days later he called and said the buprenorphine kept him up. Was he still sleepy in the meeting? Yes.

This patient’s story illustrates two problems I see a lot. First is that the old wives tale of “one addiction at a time” is alive and thriving in the 12-step community. The second is that there is, concerning some medications for addiction, a rash of “contempt before investigation.”

I don’t know where the idea comes from that we can only deal with one addiction at a time. The concept of one addiction being different from another is so foreign to me that I have a hard time understanding what the phrase means. Does someone who compulsively gambles, compulsively masturbates, compulsively overeats and is an alcoholic and opiate addict really have 5 diseases? We have very good evidence that if someone starts using one drug to stop using another, or even continues using one drug while trying to stop another, it doesn’t work very well. Why would we think it would be different when one is trying to continue a behavior that acts like a drug in the brain while trying to not use another drug? Because overeating is legal and encouraged by the fast food industry? I don’t think our midbrains are aware of congress, food packaging or even what we’re doing to boost our dopamine levels. It only sees that we are or are not getting the dopamine.

The philosophic reaction, without experience with the medications, of some people in the recovering community to medications for addiction is astounding to me. Especially when it comes to buprenorphine. I’m struck with how this medication somehow got a special place in the minds of some recovering people – like the devil incarnate. I’ve heard, “it’s just like heroin,” “I’ll just be addicted to that now,” “he isn’t clean.” I’ve even had the experience with an addictions counselor who said to me, “If you’d only seen the horror stories I’ve seen, you’d never use the drug.” When I asked he’d seen two people who didn’t do well and couldn’t tell me if they had gotten proper addiction medical care or not, but was unwilling to believe that I had seen scores of people who had never before been able to work a 12-step program who could now function well enough to do so.

The whole issue of buprenorphine is too large for this article, but I’m also struck with the number of people in recovery who think it’s okay for me to give a patient buproprion because it’s “an anti-depressant” but not buprenorphine because it’s “a pain med.” Again, I don’t think our midbrains care what words people made up to describe other uses for these medications. The midbrain reward system truly has singleness of purpose and it is this, “Am I getting the dopamine or not?”

© Howard C Wetsman MD FASAM

It’s very common to have sleep problems in early recovery, and it is also very common for people with addiction to have had sleep problems all their lives. This has less to do with the past drug use than it does with brain functioning, so I’d like to explain a bit about that and how your doctor can help.

In general, there are two kinds of sleep troubles: trouble falling asleep and trouble staying asleep. Trouble staying asleep is most often a direct result of not having enough dopamine tone in the midbrain. Dopamine is the “I have enough” chemical. Low dopamine is the same signal your body uses to tell you you’re in a famine and in a famine you aren’t supposed to sleep soundly. Someone may come and take your food. So your ability to sleep soundly is a marker your doctor can use to know when the medication prescribed for you has returned your dopamine level to normal. If you take a sleep agent, you’ll mask that marker, and it will be harder for your doctor to know when you’ve reached a good dose of the medication.

Trouble falling asleep in addiction is generally not a night time problem; it’s a problem of the whole day. As we go through the day without vigorous recovery work, we accumulate little things here and there that play on our minds. As we’re busy and keeping ourselves distracted with day to day business, we don’t notice. When our head hits the pillow however, the distraction is gone and all that stuff comes rushing back. So the part of us that is keeping us awake can be thought of as the healthiest part that’s saying, “Hey, don’t go to sleep. We have recovery work left to do.” If you just lie there awake in bed, you’ll be practicing being awake in bed. Remember, you get more of whatever you practice. If you take a sleeping pill, you’re shutting up the healthiest part of you. Sounds like a lose/lose situation. Instead, if you can’t fall asleep in 20 minutes or so, get out of bed, sit in a chair, and read the Big Book, Alcoholics Anonymous. Don’t read in bed, don’t read a novel or a magazine. One of two things will happen. You’ll either get tired and go to sleep – you win. Or you’ll get good recovery work done – you win. You may stay up all night reading the Big Book. I’ve given this advice to hundreds of patients and not one (who didn’t nap the next day) has ever told me he didn’t sleep the next night.

Of course there are other causes of not sleeping besides addiction. Some are medical and associated with the brain and some are medical and not associated with the brain. Also, the normal human trauma response disrupts sleep and will generally pass in a few weeks if there are no reasons for it to become chronic. A chronic trauma response is pretty common in people with addiction so it’s a big one to keep in mind. In general, the key is that not sleeping is a symptom, and the principle is not to treat the symptom but find and resolve the underlying disorder.

© Howard C Wetsman MD FASAM

I recently received a commentary from the Institute for Behavior and Health, an organization dedicated to developing new ideas to decrease illegal drug use. The subject of this commentary is “Canada Cracks Down on Drugged Drivers with ‘Zero Tolerance’ Per Se Drugged Driving Legislation,” and it’s quite positive about what Canada has done. From the commentary it appears that Canada’s law makes it a punishable offense to drive with any detectable levels of drugs in the driver’s body. Let me say first that people should not drive under the influence of any drug that impairs performance. I also think that people shouldn’t drive while doing things that impair performance (I mean talking on a cell phone, get your mind out of the gutter).

The problem with a law like this is not that it limits the rights of impaired drivers. Impaired drivers don’t have a right to drive. The problem with the law is that it doesn’t address impairment and the commentary from IBH seems to take pride in that fact. The commentary states that under “… the new law suspected impaired drivers will no longer be able to refuse roadside sobriety tests and those testing positive will face stiffer fines and longer jail times.” What used to happen before the law was that the person could refuse the sobriety test and administratively lose the right to drive. So if the goal was to get impaired drivers off the road the old law worked fine and so does the current law in most US states. The difference now isn’t that the roads will be safer but that the punishments will be harsher. I could have missed it but the commentary doesn’t mention assessment or treatment, just fines and jail time.

As we come to understand that addiction is a brain disease and not a social problem, that drug use and drug addiction are not the same thing, we’re going to have to come to grips with the fact that our old simple concepts just don’t work. Here’s another example from the IBH commentary: “….that  police will have the right to take any driver suspected of being high on drugs to a police station to take blood, urine or saliva samples.” What if they didn’t use to get “high” but used to calm obsessiveness? Aren’t they still impaired? As long as we stick to our old ideas that all people use drugs for the same reason and all drugs have the same effect, we’re not going to be able to come up with good public policy.

So what would be good public policy? Well first we have to ask what the public goal is. I’m assuming that the public goal is roads as safe as can be, given the general bell shaped curve of driving ability available in the general public. It would be nice to say that the goal is safe roads, but not all of us are good drivers and no matter what we do there will always be some people who are worse drivers than others, so until we have computers driving for us, we’ll have to accept some risk. But we want to limit that risk to the minimum.

So how can we make the roads as safe as possible given the abilities to drive in our population? There are several factors: environment both in the car and out, factors decreasing driver ability, and driver distractions both internal and external are some of them. The first is the area that highway engineers and car manufacturers concentrate on. Are the signs far enough away from the exit to allow for an orderly change of lanes, are the roads striped and signed well, does each care have seat belts, and the list goes on and on.

The next two are what most of society thinks about when we think of safe roads, and, in the case of drug use, the second takes a paramount role in our thinking. But drugs and alcohol aren’t the only factors that decrease driver effectiveness. Studies have shown that driving having taken cold medicine that is available over the counter can be impairing as can be the cold itself. Sleep deprivation is a common cause of driver impairment as well. So if the goal is roads that are as safe as possible we want to avoid impairment of innate driving ability from all causes. So what’s more common, people using drugs and driving or people driving with colds and not having had enough sleep? But we never want to look at ourselves as part of any problem. We don’t want to say, “You know I’m not feeling well today, I don’t think I ought to drive.” That would be inconvenient. It goes down a lot better to say, “You know those people who do things I don’t do? They shouldn’t drive.”

This leads us to the third factor, distractions. Of course a common one is cell phone usage. Currently in Louisiana where I live it is a new law that young drivers cannot drive while using handheld cellphones but can drive with hands free cell phones. The studies of cell phone use and impairment show that using hands free phones don’t improve performance at all and it’s the mental not physical distraction that causes impairment. The studies also show that driving while talking on a phone is as impairing as having a 0.08 BAL which is the legal level of drunk driving in all US states. I’m not suggesting that we let drunk people drive, but I am suggesting that if our goal is safer roads and not punishing drunks then we need to institute all measures to ensure that safety. Who do you think there are more of, people driving while talking on cell phones or people driving drunk? Just take a look around; it’s not even close.

Then there is a group of people much larger than illegal drug users who are, in good faith, seeking care from their doctors to treat an illness. Many medications, for both brain and non-brain problems, can cause alterations in some of the necessary physical abilities that make us a good driver. Vision changes, cognition changes, balance changes, attention changes are just some of what can go wrong even in the best of care. Most doctors have no training whatsoever in how to evaluate whether someone is impaired as a driver or not, yet it is the doctor who bears the greatest responsibility under the law.

Of course there are people whom medications make better. That is the point of them after all. This is why I have an interest in the whole situation; my addicted patients are often better on, than off, some medications. When you study the symptoms of addiction that precede and cause drug use you will encounter a list of symptoms that will generally impair driving ability. Many people will notice they can pay attention better on nicotine than off. Would we be including smokers in that group of per se impaired drivers with drugs in their systems. In fact patients will say the same thing about most of the drugs they use at first and in small quantities while the same drugs in greater quantities will perhaps then lead to impairment. Is the addict who uses cocaine a worse driver when his dopamine level is normal or when it is falling as the drug is wearing off? Now one knows; we’ve never looked. Of course we would never think about this because we believe addicts are normal people who choose to use. Once we recognize that the vast majority are not normal and actually can be made chemically better the real question becomes what chemical, how much, how often and for how long. I’ll agree that nothing over the counter or on the street is going to act as a good medication for long. If it did, I’d be out of a job. But it’s much easier for us to believe that it’s the ones who are using that are more impaired, rather than that the ones who aren’t and are already on the wrong end of the bell shaped curve. So what can we do to address this problem?

The solution is inherently technical and doesn’t involve drug testing. Remember our social goal, not chemical free roads, safer roads. So we need not look at what someone is taking but rather how good a driver, and do they get better or worse when they are taking it. Driving simulators exist today for that purpose and could be put in police vans or police stations as well as doctor’s offices to address the question. That is, in fact, how we know that alcohol at any blood level is likely impairing. Instead of having to guess if someone was a danger, we could actually measure it. Was this possible 20 years ago? No, not even ten, but it’s possible now. The Supreme Court has occasionally ruled that the State can violate someone’s rights when no better solution exists, and so those who advocate a per se standard (you are guilty of driving having smoked cannabis 72 hours ago even though you aren’t under the influence or impaired anymore at all) do not want to address a technical solution that would make our roads safer and protect the personal liberties Americans hold dear. Under the per se standard, one can be convicted of drugged driving having smoked cannabis 72 hours previously with no active drug in their system but metabolites in their bladder. This isn’t about letting people drive drugged. It’s about making sure that people who are driving are driving safely. Do I want myself or my loved ones to be in an accident with a drugged driver? Of course not, but neither do I want them in a an accident with a driver impaired by high blood pressure medication or by talking on a cell phone. If I thought a per se drugged driving standard would be an improvement in safety, I’d go for it. However, modern technology gives us a better, more robust way to ensure safety, if we’d only use it.

© Howard C Wetsman MD FASAM

A friend sent me his notes on a lecture he attended at the American Psychiatric Association meeting in May by Dr Thomas Brown of Yale University. The subject was adult ADD. Remember, this is from my friend’s notes so I don’t want anything I say to reflect on Dr Brown if I’m misinterpreting him.

Here are a couple of paragraphs from my friend’s notes: “ADD is an extreme presentation of a continuous variable: like high blood pressure or decreased glucose tolerance, it’s a continuous variable, and cut-offs distinguish ‘normals’ from ‘abnormals’ based on statistics. Cases are thus not discontinuous from controls. However, when someone is in the ‘abnormal range’, they definitely experience a significant alteration of functioning. ”

“Most people with ADD can function well, with good focus, in one or more areas of their lives: if they’re really interested in something, or if they are under extreme pressure to perform (‘they have a gun to their head’), they can perform well. Given that there are times/situations in which they can perform well, and others in which they cannot/do not, it appears to others like their dysfunctions are volitional, are a matter of them simply not invoking adequate willpower or personal responsibility to follow through and perform.”

As I maintain that the neurobiology of ADD and addiction are very similar if not the same then everything said above should be true for addiction. Let’s take the first thing first. Addiction is an extreme presentation of a continuous variable. We’re all on a bell shaped curve for almost every trait we have. The same could be said for dopamine tone in the midbrain and hedonic tone. There are some who have great tone and many more who have okay tone. Of course, there are also some who have very poor tone; they are the extreme end of the curve and comprise about 10-20% of the population. So we’re all put somewhere on this bell shaped curve, and if we move too far to the wrong end for reasons of genetics, stress, aging, or any other reason we’ll start to have symptoms. And how do we know when we’re at that end of the curve? Just like the examples above, we have a alteration in functioning.

The examples that my friend or Dr Brown picked were quite interesting: high blood pressure and blood glucose levels. The beginnings of the alteration of functioning in these cases is very hard to find. After years of high blood pressure or high blood sugar there is clear damage, but in the beginning the patient may feel nothing at all. So it may be at the beginning with low midbrain hedonic tone. At first I just eat a little extra food or go on a rollercoaster, and my dopamine level increases. Perhaps I can change how people feel or finish a hard job and get a boost of dopamine there too. Or, to echo Dr Brown’s talk, perhaps I’m one of the people who can make my brain release dopamine by running around in a hyperactive fashion. As I use any of these methods to increase my midbrain dopamine tone several things are happening. My brain is aging and I’m losing tone more and more all the time. As I use something to raise my hedonic tone it becomes less useful as my brain doesn’t calculate reward itself as much as positive reward disconfirmation; that is, if I expected it I don’t get as much dopamine from it. So over time I need more and more new things to make myself feel good. At some point the “alteration in functioning” becomes obvious when the donut becomes a dozen or I lose a relationship because I can’t stop playing a video game. Eventually I need bigger and bigger things and my altered functioning begins to effect more and more people. One day someone will look at me and say, “That guy’s an addict.” It will usually be when I’ve used more of something to feel better than the other guy needs.

My friend’s second paragraph says something about ADD that people with addiction have long known: time is not a constant. People think that the alterations in behavior in addiction are volitional because they aren’t constant. In fact the example of having a gun to one’s head is often used to say that addiction isn’t an illness. “He wouldn’t use if a policeman was there with a gun to his head. See it’s a choice.” Aside from the comparison of drowning a woman in the middle ages to prove that she wasn’t a witch, threatening to kill an addict to make him prove he’s ill actually changes the experiment. “Well, look at that, Your Honor, he really was sick. A shame he’s dead now; we could get him some help.”

Here’s how the experiment changes. When something novel happens to us (and I hope that having a gun put to your head would not be something you’ve had to experience up to this point) we will get a surge of adrenaline and dopamine released to the midbrain. Think about that rollercoaster and multiply that by 10 or so. Even if an addict is craving and has low dopamine tone, the fact that he doesn’t use because we’re threatening to kill him if he does doesn’t mean anything. By issuing the threat we’ve actually raised, temporarily, the midbrain dopamine tone and actually made the craving better for a while.

I hear the same thing about kids with low dopamine. “He can’t have attention problems. He pays great attention to that video game.” At a visual refresh rate of 30 to 60 times a second, a video game will qualify as a novel visual stimulus and increase dopamine tone. He’s not paying attention to the game, he’s medicating with the game. Usually if someone with low dopamine is interested in something, you can bet he’s getting dopamine from it.

Dr Brown’s comment about motivation is true as well. People with addiction often procrastinate and don’t do things until they are “under the gun.” This does not mean that there are conscious choices involved. When we are working under pressure there is more adrenaline and more dopamine and we actually do function better.

So back to what makes an addict an addict. I guess it’s like beauty and is in the eye of the beholder. If I don’t like your way of getting more dopamine I’ll start calling you names. If I don’t mind how you get more dopamine, I probably won’t even notice much less dissapprove of it. I think if we all had light emitting diodes placed on our foreheads that shone red whenever we were low on dopamine life would be a lot simpler. We’d be able to see when our words were “bringing someone down” and we’d be able to understand why someone wasn’t remembering to do what we told them to. We would notice that when they were engaged in certain activities their biology was changed as well as their behavior. We’d be able to know when we should and shouldn’t bring up that subject we are afraid of discussing. In short, we’d be able to behold the functional alteration of addiction in a much different way than we do now. Until we all get that LED implanted, we’ll just have to keep this information in mind when talking to everyone, remembering that addicts are ill whether they’re making us mad or not.

© Howard C Wetsman MD FASAM

When I think about it, there are few terms in the addiction treatment field that are more silly than “Drug of Choice.” As if we get to choose which drug makes the brain go BAM. When you talk to an addict and ask, “What’s your drug of choice?,” what you get is the answer to “What drug that is available to you lately at a price you can afford that makes you feel better with the least side effects?” Quite a mouthful, huh?

Would we ask a diabetic if their toxin of choice is sugar? How did they choose sugar? Why didn’t they choose to have an abnormal reaction to arsenic instead of sugar? What a stupid choice! Using the concept of choice, as in which would you choose if they were all lined up, can confuse us and strengthen the stigma and the idea that addicts are normal people who choose to use drugs. If we asked an addict if they chose to have cocaine work the way it works with them or if they chose to have an abnormal reaction to alcohol we’d hear a resounding “no.” “If I had the choice of what my brain reacted to I’d have picked something a lot cheaper and easier to get than cocaine.” Something like wildflowers or dandelions, no doubt.

What is it we really want to know when we ask the question? And why? Well, up to now we really haven’t had a good reason. We just needed a word to write down in the “Drug of Choice” box on the assessment. In many cases it meant something, for instance when the person used only one drug. Most of the time however it doesn’t actually mean much with regard to choosing treatment. However because researchers like things that come in boxes there has been a lot of research on “Drug of Choice.” It’s been used to predict treatment outcomes with regard to which treatment is used. One example of such a research question would be, “Do alcoholics or opioid addicts do better when given naltrexone?” By dividing people up by “Drug of Choice” we manage to make one population (alcoholics) which is heterogeneous sound different from another (opioid addicts) which is heterogeneous in a different and overlapping way with regard to neurobiology. It’s really no wonder most addiction research doesn’t make much sense.

But still insurance companies ask the question and the government asks the question so we ask the question, as if we get to choose. But modern science actually gives us a new reason to ask a question about “Drug of Choice.” It’s just not the question we’ve been asking.

We don’t have lab tests that we can use clinically in addiction medicine. It would be great if we had rapid, inexpensive genetic testing or PET scans that actually could predict something in individual patients instead of groups of subjects. But we don’t and they don’t, yet. In the meantime we get to ask the patient about the drugs he’s used and with the knowledge of how those drugs work in the brain we can make some informed choices about which medications might help the patient. The problem is that people use the drug they use for a lot of different reasons and we need to know those reasons as well for it to mean anything clinically.

For instance, we may ask a person if he likes to use cocaine? He says no, that he hates it. If we take it that far and no further we think that cocaine doesn’t work for him and that a dopamine reuptake blocker such as buproprion wouldn’t work as a medication for him. But if we ask him why he doesn’t like cocaine, we may get more information. He may tell us he doesn’t like the crash or the paranoia, but that he can feel normal for about 10 minutes when he uses cocaine. If it was the only drug that worked for him he’d use it but fortunately alcohol works as well and lasts longer so he drinks. It tells us first that he would likely do better on buproprion and second that he’s not likely to respond to naltrexone as some alcoholics do.

So we do need a question; it’s just not, “What’s your Drug of Choice.” It’s more like “What drug or drugs work to make your brain feel normal at the peak of the experience regardless of what side effects or time course may make you not like the experience in general.” You know, the DODWTMYBFNATPOTEROWSEOTCMMYNLTEIG. We need a shorter acronym; the government wouldn’t even use that one, and they thought up SAMHSA! And while we’re at it we need a term that doesn’t make people think that addicts get to choose what makes them feel better. Cocaine doesn’t have a street value because a lot of people choose it; it has a street value because it works to make a lot of people with addiction feel normal for a brief period of time. When we use the word “choose” society gets the wrong idea and will come up with the wrong solution.

© Howard C Wetsman MD FASAM

A second interview concerning addiction research is posted here:

http://www.reachmd.com/xmsegment.aspx?sid=3119

I love finding scientific studies showing “new” information that people with addiction have long known. A very good example of this, and a very good study, came out earlier this year. Here it is:

Childress, AR et. al. Prelude to Passion: Limbic Activation by “Unseen” Drug and Sexual Cues. PLoS ONE (www.plosone.org) Jan 2008 (1): e1506.

The authors used fast functional MRI to measure brain activation to visual stimuli of a rewarding, averse, or neutral nature. The bottom line is that the reward center of the brain responded to rewarding visual stimuli even when the stimuli was presented so quickly as to bypass conscious awareness. So, “triggered” craving can appear to come out of the blue with no trigger at all. I want to quote from page 4 of the article:

“The brain can strike up a prelude to passion in an instant, outside awareness, and without heavy policing from frontal regulatory regions. By the time the motivational state is experienced and labeled as conscious desire, the ancient limbic reward circuitry already has a running start. This dilemma may be reflected not only in our daily human struggle to manage the pull of natural rewards such as food and sex, but also in the chronic treatment resistant disorders for which poorly controlled desire is a cardinal feature (e.g., the addictions).”

Of course, society has just wanted people with addictions to realize the anti-social nature of their urges and stop before they act. People with addiction have long maintained that craving can come out of nowhere and be strong beyond reason before the person knows what’s happening. Examples of this were quite well known by people with addiction long ago. Even in AA’s Big Book:

“Where had been my high minded resolve? I simply didn’t know. It hadn’t even come to mind. Someone had pushed a drink my way, and I had taken it. Was I crazy? I began to wonder, for such an appalling lack of perspective seemed near being just that.”

Science and society would like there to be a way to make the “frontal regulatory regions” to be stronger in people with addiction so that they can fight the urges to use. The reality is that the trigger to crave and use can be so fast as to bypass that region entirely no matter how powerful it is. Power isn’t useful if it can’t be brought to bear. So rather than running the show, our frontal cortex is actually chasing behind the reward center making up reasons for what’s happening.

Relatedly, almost in a footnote of the study, the authors note that there was no significant group effect for “unseen” aversive stimuli vs neutral stimuli, but that the response of a part of  the brain, the insula, predicted the emotional response to the stimuli when it was “seen.” What’s interesting to me here is that the insula is related to managing the recognition of stressful and aversive conditions. You may remember that it was in the news a few years ago that people with a damaged insula after stroke stopped smoking. It was hypothesized that in some way there was another addiction/reward pathway not involving the midbrain. Again addicts have long known that there are those who use to repair something missing in their ability to feel rewarded by life and those who use to avoid feeling bad. It seems that the stress relief function of addiction can be triggered without being noticed as well.

In another example of something addicts have suspected all along, someone sent me an article today about a study (Dan T.A. Eisenberg, Benjamin Campbell, Peter B. Gray and Michael D. Sorenson. Dopamine receptor genetic polymorphisms and body composition in undernourished pastoralists: An exploration of nutrition indices among nomadic and recently settled Ariaal men of northern Kenya. BMC Evolutionary Biology, (in press)) that showed that a mutation in a dopamine receptor which is associated with ADD and addiction has been shown to actually improve the survival chances of the individuals who carry it in a nomadic population. This is equally important for society’s understanding of addiction.

Once people I explain it to get past that addiction isn’t a choice, I’m usually hit with something like, “Well if we do genetic testing then don’t let them have kids we’ll be rid of addiction in one generation.” It’s as if there is something morally wrong with the condition. What society needs to understand is that our entire population is quite varied and that that variety is what got us to survive to this point. Some of us have genetics that work in a hunter gatherer society and some have genetics that work best in a corporation cubicle. It’s not that there is something superior about either lifestyle or either biology; it’s just a matter of fit.

Does that mean that all the addicts should move to the forests and start hunting for berries? No, but it does mean that addicts could understand that they aren’t the way they are because they’ve done something wrong or that they are the way they are because they are less than others. There is a difference, yes. But that difference has a great value to society. It’s the variety that keeps our species alive. We can’t always count on our environment staying the same (though it is a pretty fantasy). We should all remember the Irish Elk, a species that lived during the ice ages. It had a 12 foot spread of antlers which worked great on the tundra. Then the weather changed and trees grew and the big antlers became a death trap. Every member of the species had antlers that were too big to survive and in a short time, they were all dead.

Is the problem that there is a genetic difference or that in denying the difference people find other ways to solve the challenge that lead to behaviors that the rest of society doesn’t like?

I’m not saying that addicts are the future of our species, but what I am saying is that we need to value the diversity. Having addiction biology is a challenge in this society and this culture. I’m not asking the culture or society to change, but wouldn’t it be great if kids born with this biology could be told that they have a way of being that is very valuable in certain circumstances and difficult to manage in others. Wouldn’t it be great if we taught them how to manage it rather than pretending it doesn’t exist and letting them find drugs so they can feel better? It would be a lot better than what we’re doing now.

© Howard C Wetsman MD FASAM