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Fiat is an economic and legal term that isn’t often used in science and medicine, so it needs a bit of explaining. A fiat currency is a currency that has no actual value and is only money because the government says it is. Many years ago a dollar bill said on it that it was a debt to the holder and if you wanted, you could go to the bank and exchange for money made of silver or gold. The paper money then was backed by metal. It had value because the metal had value. Now, the paper is just paper and it has value because the government says it’s legal tender. That’s fiat money. If the government didn’t say it was valuable we wouldn’t use it.

So what is fiat medication? Fiat medication is medication that people wouldn’t use unless someone made them.

Let’s assume a reasonable person who wants to get better and is given a medication. He’ll generally take it unless it causes bad side effects or doesn’t work. Everyone has a cost/benefit analysis going on in their head all the time. If it doesn’t do me any good or is causing more harm than good, I’m not likely to continue to take it. People generally suffer from illnesses themselves and so society lets them make this choice. But, not always.

In cases where the illness threatens society and the person won’t take medication, for instance, tuberculosis, the government can mandate treatment even to the point of confining a person if necessary to ensure that they are treated. This would be an example of a fiat medication. It’s not a medicine because I want it or it has value to me. It is a medicine for me because the government says it is.

In our democratic society, there are a lot of hoops to jump through before you can take away someone’s rights and make them take a medication. That’s as it should be. And in the case of tuberculosis, it’s pretty clear that the person doesn’t feel worse with the treatment and gets a benefit too even if they don’t see it at the time.

There are other examples of medication that is used or formulated for people who won’t take it. People with schizophrenia for instance, who are so psychotic that they can’t take their medication, can be given a monthly shot of depot medication to ensure compliance. In this case the patients do sometimes feel worse with the medication but, again, society can override their objections with arguments that they may pose a danger if unmedicated. And so the same logic is used for addiction.

There is a depot once a month shot that is marketed as treatment for addiction to opioids and alcohol. It’s attracted a lot of interest especially among people who are tasked with legal aspects of addiction. In fact, I recently heard that the head of the addicted professionals board for a major southern state has stated that she wants every pharmacist who is on contract with the board on this medication whether they have addiction to the drugs it indicated for or not. It’s a very attractive prospect, sort of like a shoot and forget weapon. There’s only one problem. While it stops drug use, it doesn’t make anyone really feel better. They had to formulate the once a month shot because most people who have addiction just won’t take it when it’s up to them.

So now there’s a fiat medication for addiction. It’s not medication because most people experience that they are helped by it but rather because someone else said it is medication for addiction. You can see why someone else would say that too. If you experience someone else’s addiction as drug taking and the consequences, but have no insight into the symptoms they feel when they aren’t taking drugs, you’ll define addiction as drug taking, and any medication that stops drug taking will look like treatment for addiction. This leads us to fiat diagnosis.

Addiction stands alone in medicine as a diagnosis imposed by others for the purpose of others. Nowhere in DSM IV are there biological symptoms of distress that addicts complain about early in the disease. The diagnosis of addiction in modern psychiatry is made very late in the course when behavior is greatly changed by the need to suppress symptoms that are disturbing. What no one seems to have asked people with addiction is, “When did these symptoms start?” When you do, you’ll often here that they have never felt right, never felt well, until they took the first hit of whatever did the trick, and all of a sudden they felt like they think the rest of the people around them feel. When you ask addicts what the symptoms of addiction are, they don’t generally talk about how they feel when they are loaded but rather how they feel when they aren’t, and rather than this being a response to voluntary drug use, most can relate to the symptoms coming before the first drug use.

Recent genetic studies seem to bear that out, and my own experience with looking at the genetic data of some patients bear it out as well. Most addicts are different before their first drug. If this was any other disease in medicine we’d be trying to find medications that alleviate the primary symptoms rather than stop the behavior that the patient perceives as the only relief from the symptoms. I really can’t blame those in power who create fiats for treatment given how the medical world has defined addiction. Hopefully, with more people reading and learning about the primary neurobiology of the illness, more will come to understand the primary chronic nature of the illness.

© Howard C Wetsman MD FASAM

I had a conversation with a colleague recently in which she took issue with my saying that addiction was largely a genetic illness. She pointed out that in studies of alcohol dependence and cocaine dependence and other DSM IV substance dependence diagnoses that the heritability accounted for about 50%. So how could I say addiction is a largely genetic illness when only half of the variance is explained by genetics? Good question. We have to start with the fact that alcohol dependence, cocaine dependence and any other DSM IV substance dependence diagnosis aren’t the same as addiction. Here’s a case that is an example of why this is important.

A young man of 24 enters treatment for addiction. He has been using a lot of cocaine and all efforts to stop have not availed. He feels terrible whenever he stops and immediately relapses. His history is negative for heavy drinking, “I wouldn’t touch the stuff.” It seems his father was a violent alcoholic and the son swore to himself that he’d never be like his father, never touch alcohol. After all, if you don’t drink you’ll never become an alcoholic. But his never drinking did not protect him from the illness of addiction.

So if this young man was in one of those heritability studies on alcoholism what would he add? He would be the biological son of an alcoholic father and his data would serve to decrease the estimated heritability of alcohol dependence. But what if we measured for addiction? He would be the biological son of someone with addiction who has addiction and his data would serve to increase the estimated heritability of addiction.

We really don’t know what the heritability is of addiction because no one has ever looked! Science has split the illness up into the “addictions” and a bunch of stuff not even allowed to count in the addiction field and measured the heritability of each of those, but never as a single entity.

This young man’s case is not at all unusual, though it’s more common to meet someone who is an opioid addict, compulsive overeater or gambler with an alcoholic father than a cocaine addict with an alcoholic father. So in general I think the heritability of addiction is under estimated by current studies in the literature.

To be fair let’s consider the opposite example. What about the people in an alcoholism heritability study who were born of non-alcoholic parents but have addiction. Wouldn’t they decrease the heritability of addiction if we looked at the disease as a single entity? Perhaps, but remember the parents were non-alcoholic. No one asked them if they had addiction, only if they used alcohol in the illness of addiction.

In truth I rarely meet a person with addiction who doesn’t have a family history of the illness though they may not think so at first. If you only include “drugs” in your definition you may not see Mom’s compulsive shopping/spending as the illness and think that you are the only one. Usually the family goes along with this as Mom doesn’t want to label her shopping the same as Junior’s drinking.

There are people who get addiction without any genetic component but it isn’t easy and it isn’t common. There has to be pressure on them and the social setting to bring it about. That pressure exists in our society and it does happen, but for the most part, addiction is a largely genetic illness.

Recently the board of the American Society of Addiction Medicine voted on a new definition of addiction. That definition will be out later this summer after the Society has a chance to write up talking points that will help explain it. With a new unified definition of addiction, a new era of addiction studies and treatment can begin. The definition will actually catch up with clinical practice and allow scientists to start addressing the questions that need answering. Ones like, “What’s the heritability of addiction?”

© Howard C Wetsman MD FASAM

I attended the Annual Med/Sci Meeting of the American Society of Addiction Medicine (ASAM) in Washington DC. Having the meeting in this city, the home of federal dollars and federal regulation is an eye opener for me. Addiction sure looks different from here.

The first thing I noticed is that those who live in the federal government, the word addiction doesn’t seem to have a meaning. Addiction and substance abuse and even substance use seem to all mean the same thing. I heard a talk by David Mineta, deputy director of the Office of National Drug Control Policy (ONDCP) in the White House. Obviously, they are focused on drug use, and want to prevent it, but don’t seem to understand that not all drug use is the same. It’s sort of like trying to prevent blindness without addressing diabetes. When they do talk about actual treatment for the illness, it seems they are focused on non-medicalizing it. Sounds like after a couple of decades of learning about the brain, they want to go back to the 50′s.

From what I got out of Mr Mineta’s talk, it seems that the future of addiction treatment, as directed by various branches of the federal government, is to spread it outside the specialty of addiction medicine. Rather than addiction being treated like an illness by specialists who are trained, they aim to train non-medical people and get the majority of cases treated by teams led by doctors who aren’t specialized in the disease. It will be everyone getting their addiction treated by the same primary care doctor and team that they get their hypertension treated by.

While this may just sound like sour grapes coming from someone who is a specialist, let me say that the primary purpose of my life is to put myself out of business. And as treatment for addiction gets better and better that will happen in a free market. Right now, treatment is so difficult that it is hard to manage when an experienced specialist is doing it all the time, much less a non-specialist doing it as a sideline. As we develop better treatments and, more importantly, better algorithms for deciding who needs what treatment and in what order, non-specialists will take the cases they can handle. It’s happened with every other disease so far, and it will with addiction too.

But what I heard sounds like an organization that doesn’t even understand the nature of the illness making decisions about how it will be treated. That’s not going to lead to the wonderful world of less addiction that they have in mind. What will happen is poorer treatment, worse outcomes, and more stigmatization of people with addiction. Because you don’t think the government is going to say, “Well it didn’t work because we screwed up;” they’ll say, “It can’t be us who got it wrong. Those addicts just don’t want to get any better.”

Maybe, I’m wrong. Maybe they do understand the illness, but I won’t be able to tell until they stop using the terms substance abuse and addiction interchangeably.

© Howard C Wetsman MD FASAM

Psychologists have a way of looking at emotion that is not like other people’s way, especially negative emotion. So if you’re not a psychologist this may be a little weird.

Let’s say there is an emotion generation process; something happens and then this process takes over and out pops your emotion. It’s sort of like those old cartoons when you dump the raw ingredients on a conveyor belt that rolls them into a big black box, and like magic, the finished product comes out the other side. What goes in is our experience, and what comes out is our emotion. What goes on in the big black box is that emotion generation process.

So someone calls us a bad name, and we get angry. Why? We don’t know, something that happened in the big black box, I guess.

Well psychologists have been looking in the box, and while they still haven’t figured out how it works, they have figured out what we do about it. They’ve outlined two strategies people use to change negative emotion. These are called reappraisal and expressive suppression, and they work at different points in the process. Reappraisal seems to work inside the black box somewhere and expressive suppression is like standing by the conveyor right outside the black box taking things off before they can be packed and shipped.

We’re all familiar with expressive suppression, at least those of us who live with other people are. That’s where you have a negative emotion and you just hold it in or tell yourself you don’t feel it. We all also know how little it does to actually make things better.

But most people who haven’t been in cognitive therapy don’t know what reappraisal is so let’s take a look at that. Reappraisal has several steps. First you have to recognized something happened and you had a reaction. Second, you question your reaction. Third, you look at why you had the reaction, and fourth, you look at the underlying assumptions that led to your reaction. By the time you get that far, you’ve gone a long way to reappraising your reaction to whatever happened. Of course most people stop there if they get that far, and most people figure out they were right after all. But we could take it one step further. We could talk to someone else. Why? Because if we are unwilling to talk to another person, it’s probably because we use the reappraisal process to just fool ourselves into reinforcing the original assumptions. If we are willing to talk to another person, it’s much less likely that we’ve done that. And if we did, the other person has a shot at catching it and pointing it out to us.

Lest you think this all may sound nice but be completely made up I want to tell you about a study published a few years ago in Biological Psychiatry by Goldin, McRae, et al. In the study 17 women looked at video designed to either elicit a neutral or a negative reaction. They did this while either using either suppression or reappraisal. They were asked about their emotional experience and their facial expressions were video taped. Both reappraisal and suppression decreased emotional behavior and experience. But here’s the kicker. They did the study with everyone’s head in a fast fMRI machine. The women who used reappraisal had very early (less than 5 seconds) response in their front cortex and decreased response in the amygdala (where emotional memory is stored) while those who used suppression had a late (10 to 15 seconds) response in the frontal cortex but increased response in the amygdala.

So using reappraisal seems to give us just as good a result faster and more permanently than suppression that leaves those negative emotional memories piled up in the amygdala. Well, why don’t we all just use reappraisal? Probably because suppression is easier. You get what you pay for.

Since I don’t write about psychology but do write about addiction and recovery, you’re probably wondering why I’m writing about this at all. It’s because the 4th and 5th step as outlined in Alcoholics Anonymous is as good an example of reappraisal as you’ll find anywhere. The more we practice it the quicker we get at it and as it becomes a second nature thing, it happens in seconds. Suppression is something we can do when we are not engaged in recovery. We can suppress alone, even isolated. In fact suppression probably works better when no one is around to remind us of the garbage backing up in our amygdala. We can just pat ourselves on the back for not hitting that guy with the baseball bat and think everything is fine. The only problem is that the amygdala doesn’t like to hold on to garbage for long and it leaks out on someone else pretty quickly leaving us wondering why they’re mad at us.

Reappraisal, taken all the way, requires a community to do it in. It requires someone to listen in a non-judgmental way. It requires acceptance. It requires love. You can get that in therapy, but it’s so much better when you have 10 recovering friends for free than one therapist at an hourly rate.

So what if we never learn what goes on in the big black box? Who cares? If we have a way to reappraise what happens and how we feel, a way that can lead us to all the benefits of suppression with none of the side effects, we really don’t have to know why it works. Because it does.

© Howard C Wetsman MD FASAM