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I just read an article (Grattan, et al. Depression and Prescirption Opioid Misuse Among Chronic Opioid Therapy Recipients with No History of Substance Abuse. Annals of Family Medicine 2012; 10(4):304-311) which purports to find that depression is a risk factor for misuse of opioids in those patients given them for pain control. There are a number of problems with the article, but most aren’t the fault of the authors. The article suffers from the times and paradigm we live in. The problems come down to definitions. The underlying paradigm of the article is that opioids can cause addiction, and that pre-existing substance abuse is a risk factor. The authors want to know, once they get rid of substance abuse, is depression still a risk factor.

The first problem is that no one actually screened these patients for addiction, only a history of substance abuse. If the patient had addiction and their most effective reward was sugar or gambling, this study would not have screened them out with the “substance abusers.”

The second problem is that the authors use the PHQ-8 to screen for “depression.” While this may not be a problem by itself, it’s clear that people reading this article are going to think that what the authors have found is an association between treatable Major Depression and opioid misuse. What the authors screened for was not the illness called Major Depression that has a treatment, but rather the symptoms of depression which can come from many causes, including pain.

If they had a neurobiological understanding of addiction they would have noticed that low dopamine in the midbrain is also a cause of many of the symptoms listed on the PHQ-8. So the screening device isn’t wrong; what’s wrong is the paradigm through which the answers are interpreted.

So rather than saying: “Some people have addiction and are so constructed as to get relief from the symptoms from opioids and those patients are at risk for unauthorized dose increase,” the authors say,”Clinicians should be alert to the risk of patients with depressive symptoms using opioids to relieve these symptoms and thereby using more opioids than prescribed.” The problem with this is that clinicians know only one way to aleviate depressive symptoms and that’s with anti-depressants. Currently there are 12 SSRIs and Wellbutrin as the most commonly used.

So if someone has a decreased endorphin response, let’s say because of a polymorphism of the mu receptor, they won’t release enough dopamine with normally rewarding activities. When they take an opioid they get energy because dopamine release returns to normal. The study suggests that these people have depressive symptoms which the average clinician will probably treat with an SSRI. Increased serotonin from the SSRI will, over time, actually decrease dopamine release and make the person worse. If they use Wellbutrin, it probably won’t be effective because, as a dopamine re-uptake blocker, it works best with good levels of dopamine release, something people with mu receptor problems don’t usually have.

Definitions are important in medicine. The words we use inform and even decide our actions. ASAM’s new definition of addiction based on the biology of the illness hasn’t made it into the addiction literature yet. In fact, there is no addiction literature yet. There is a body of substance abuse literature and a body of literature on various substance dependencies, but I’ve yet to see a study where the population was a population people with addiction or that excluded those with addiction. If you find one, let me know.

“…and for us, to drink is to die.” -Alcoholics Anonymous, page 66

Everyone who lives in New Orleans, for anywhere on the Gulf Coast, knows there are two options for a hurricane: stay or go. The decision is not a simple one.

Leaving means finding a place to go, the expense of travel, the risk of being away when nothing happens and your job expects you back. Sometimes, you leave and the storm changes course and hits you where you went making it impossible to come back to a city that was never touched. Staying also has its own risks which no one needs reminding of since August 29, 2005.

Regardless of the decision to stay or go there are preparations to be made. If oyu’re leaving you need to take important papers, medication, cash and valuables from your house. You need to take any other important records you’ll need. While most people pack for only a few days, if the worst happens, you have to be prepared to start over.

If you stay, there may even need to be more preparation. Filling the car with gas, not for the last minute decision to leave, but because if there’s no power after the storm, there’s no way to pump gas. Do you have ice? Batteries? 3 to 4 gallons of water a person? Portable AM radio?

These are the normal things that everyone living in a hurricane zone must think about, but the recovering person has additional considerations for survival. If you’re leaving, where are the meetings where you’re going? Have you made contact to let them know to expect you? Do you have the cell phone numbers for your home group? Did you pack your program literature?

If you’re staying, how will you work your program in the dark? Is your Big Book on your Kindle? Are all your contact numbers on your cell phone? What happens if there is no electricity for a recharge and you run those out of power? What will you do with all the meeting places closed?

Hurricane Isaac and the period of no electricity we lived through reminded me that people worked this program in the 1930′s with no cell phones, no recovery apps, no internet, and sometimes, no sponsors and no meetings. When AA started there were so few recovering people that it was a frequent occurrence for someone to move to a town with a Big Book and be the only AA in that place.

So to survive a hurricane is not enough, recovering people need to not just protect their bodies and their families, but their recovery as well. Remember that people worked this program with nothing but a Big Book and a sincere desire to be of help to others. Whether you stay or leave there will be people to help. And don’t forget to get an actual paper Big Book, the kind that doesn’t need batteries.

This is a long standing controversy in the field of addiction treatment. On the one hand, it seems a silly thing to suggest. After all, we don’t require our cardiologists to have had heart attacks and we don’t require our psychiatrists to be depressed. But on the other hand, there has been a phenomenon noticed, from the very early days of addiction treatment, that people with addiction seem to do better talking to other people with addiction.

This idea is reinforced by this quote from Alcoholics Anonymous:

“Highly competent psychiatrists who have dealt with us have found it sometimes impossible to persuade an alcoholic to discuss his situation without reserve. Stangely enough, wives, parents and intimate friends usually find us even more unapproachable that do the psychiatrist and the doctor.

“But the ex-problem drinker who has found this solution, who is properly armed with facts about himself, can generally win the entire confidence of another alcoholic in a few hours. Until such an understanding is reached, little or nothing can be accomplished.” [italics in the original]

But one wonders why. Especially in this day and age, as we’ve discovered so much about the biology of addiction and have new treatments to offer. Does it still make sense that only “the ex-problem drinker” can get a patient with addiction to really open up. I think not. And my source for this thought is the very next sentence in Alcoholics Anonymous:

“That the man who is making the approach has had the same difficulty, that he obviously knows what he is talking about, that his whole deportment shouts at the new prospect that he is a man with a real answer, that he has no attitude of Holier than Thou, nothing whatever except the sincere desire to be helpful;”

That sentence gives us 5 qualifications to gain and keep the attention and confidence of someone with addiction. Let’s look at them:

1. That there is a common problem

2. That it’s obvious that he knows what he’s talking about

3. His whole deportment shouts that he has a real answer

4. No Holier Than Thou attitude

5. Nothing but a sincere desire to be of help.

If you are someone who thinks it’s better for counselors to have addiction you’re probably saying right now. “I gotcha. Look at number 1. Common problem.” Yep, you got me. But what is the common problem? It doesn’t have to be drinking. In fact focusing on drinking as the common problem is what keeps people in AA from helping cocaine addicts. The common problem for the patient and the counselor without addiction is that they are both humans with limitations. It doesn’t matter how young or healthy the counselor is, they have limits. We all do. The bottom line truth for anyone starting addiction treatment is that they have something they don’t want to have. They have a limit placed on their lives they don’t want. That is a problem common to all humans and any human can relate.

Maybe you’re relenting at this point, but maybe you’re just getting your second wind. “Wait a minute. What about number 2. If he’s never had addiction how can he know what he’s talking about?” There’s a lot to know besides the common problem of feeling the pain of meeting a limitation you can’t get past by your own will. Addiction has a known neurobiology. It’s a real illness with a known natural history. Anyone wanting to attract and keep the attention of a patient with addiction will need to be able to have the answers that person needs. Not academic answers to the question of why, but real practical answers and those aren’t limited to counselors with addiction.

And how will the patient know that his counselor has the answers? Because the counselor’s whole deportment shouts that he has a real answer. How would that look? Well, behavior as well as words would have to say that the counselor understands that they are an equal child of the universe no greater or lesser than the patient. They would be calm because everything is going to be alright. They would be honest which means they’d answer quickly because they don’t have to remember the last lie they told. They’d say, “I don’t know,” when they didn’t know. And they’d treat the patient with respect.

That respect would come across as someone without a Holier Than Thou attitude. The counselor would be aware that the patient has an illness, and, therefore, “There but for the grace of God…” That’s a sobering thought. I could be on the other side of the table. I could be the patient. How would I hear best. I would I like to be spoken to? Is there any evidence at all that I could run this guys life better than he has if I had the same disease? No one will listen to you when your message is, “You just don’t know how to handle life. Do what I do. Be like me,” even if you are a recovering person. If you hold the patient in unconditional positive regard, it won’t matter what’s wrong with you; you’ll be heard.

And the culmination of all of this? It is that the counselor will feel such humility in the face of the illness that they are filled with no motivation other than a sincere desire to be of help. “I have to get this person sober so I can feel good about myself,” will not work. “This one has to make it or my boss will think I’m no good,” will not work. No matter how good the cause or the outcome we have in mind, it won’t work. Our goal can’t be to get to a goal. The goal has to be the journey of helping. When we bring expectations to the treatment, not only won’t the patient hear us, we won’t even be in the room with our patient; we’ll be in our fantasy with our goal.

So do I think addiction counselors need to have addiction? I answer with a resounding, “NO.”

But what everyone needs who wants to do this work is the 5 qualifications above which I’ve found rare in counselors both with and without addiction.

copyright Howard C Wetsman MD 2012

Some recent headlines have brought back up the subject of athletes and drugs. Some have asked, “Why is it that some elite athletes with the world at their feet go out and use drugs risking everything they’ve achieved?”

Most articles I’ve read in the popular press chalk this up to stupidity or to immaturity. Others point to the culture of adoration for star athletes that results in their thinking that they are above the rules. But there’s a seldom mentioned reason as well. Do some of these athletes have addiction?

If addiction is defined merely by a pattern of use of substances, it seems unlikely that an elite athlete, enjoying the height of their profession would choose to start using, then abusing substances, and then become addicted. Stupidity and immaturity seems to be the only explanation. However, if addiction is a brain disease that exists whether the person is using drugs or not, then the formulation becomes different. I think, if you know me, you know which side of the coin I’d pick.

But why would addicted individuals, if in fact they are, be drawn to highly competitive sports and be driven to do well. Is there any way to explain a seeming higher prevalence of addiction in elite athletes over the general public? Well first, it’s not clear that there is a higher prevalence in that group. It may just be that they make the headlines more because they are elite athletes, and that people’s tendency to think it’s common is an example of the cognitive bias of availability. Regardless of whether athletes have a higher or not higher prevalence of addiction, how is it that someone with addiction might be drawn to athletics?

Addiction is, generally, a state of low dopamine in the midbrain where reward for normally rewarding activities is not felt as rewarding. There are many natural behaviors in addition to drugs that elicit a rise in midbrain dopamine. Novel visual stimuli raises dopamine release as does the completion of a hard task. Sustained physical activity increases dopamine release by releasing endorphin. Recognized personal achievement and the attention of others can increase dopamine tone by increasing availability of dopamine receptors. In short, sports, and success at sports, may be an early “drug” that raises midbrain dopamine tone. Rewarding things are motivating so that one can imagine an adolescent person with addiction who has a talent for athletics and gets a dopamine hit from athletics will be motivated to work for excellence there when not motivated in other important life areas.

Such a person may be drawn to practice when other are seeking normal reward from normally rewarding behavior. These individuals may, because of greater practice, rise to elite levels in their sport.

So if athletics is a good “drug” for this person, why would they then seek out external substances? People age and the illness progresses. In addition, there is the aspect of tolerance, meaning that one needs more and more of the “drug” to get the same effect over time. There will become limits to what can be achieved in any sport. A championship can only be won once a year for instance. What does one do in the off season? When you’ve achieved perfection, what do you do for an encore?

It seems to me that rather than ask why someone would be so stupid as to throw away a career, we might better ask, why would anyone in their right mind do that? The answer would be, because they need to. Then we could assess for the illness, find the specific need and address it.

I must add that treatment for addiction in athletes will raise many questions because some of the treatments are considered performance enhancing (the dopamine reuptake blocker buproprion, for example). Sports plays such a large role in our society that for us to shift our thinking to the way I’m looking at it would be nearly impossible. There are business owners with billions at stake in professional athletics, and to them, any shift in thinking would seem potentially dangerous. So for the foreseeable future, I think we’ll continue to assume that elite athletes are “normal,” sometimes do stupid things with drugs and alcohol, and continue to punish and kick them out when they embarrass the team or the sport rather than see that there is, in some, a biological brain illness requiring medical treatment.

copyright Howard C Wetsman MD 2012

No definition of addiction would be complete or valid unless it explained those core phenomena and epiphenomena that previous definitions and typology observed. Unless there is some new factor to the illness in nature, any new understanding of an existing illness must explain those valid observations made by earlier observers. Examples of such observers are William Silkworth writing in 1935 in “The Doctor’s Opinion” of Alcoholics Anonymous; the typology of Cloninger writing in the 1980’s; and multiple writers (Huss, Jellinek, etc) who’s observations of the natural history and course of the illness have been taken for a typology.

It should be noted that previous descriptions of addiction generally stuck to one “drug” of use and so, by their very nature, accepted as a first principle that “addictions” are not unitary but several. This may have originally been done out of necessity or out of convenience for the researcher, but the reinforcement of that principle has since been codified in the most authoritative current criteria for addiction, that of Substance Dependence found in the DSM. This first principle of the lack of unity in the illness of addiction has also been reinforced by the non-medical 12-step recovery community in their principle of “singleness of purpose,” where, for instance, in Alcoholics Anonymous, discussion of addiction related matters not pertaining to alcohol is discouraged.

It also should be noted that all of these previous typologies were derived before the first findings on the neurobiology of addiction, and these researchers should not be faulted for their conclusions. Indeed, their observations remain valuable, and give us a starting point to describe a unified view of the illness informed by later findings.

Those things observed within the various manifestations of addiction have included impaired control, craving, sudden relapse after long abstinence, chronicity and progression. Indeed, Silkworth suggested that craving, which he defined as the intense desire for another drink after the first drink is taken, is only seen in the alcoholic and referred to this phenomenon as an allergy (uncommon response in the contemporary usage of the term).Silkworth further stated that if only the allergy was present one could abstain from the first drink and not experience a problem, but that the alcoholic also had a continuing compulsion of the mind which he described as a set of symptoms (restless, irritable, and discontented) which were only alleviated by alcohol. Silkworth gave this “allergy of the body and compulsion of the mind” formulation suggesting that the alcoholic’s “body was just as disordered as his mind.” Of course this was before any significant information on the brains reward system was discovered, so Silkworth did not have the opportunity to create a physical formulation of the symptoms. Silkworth also noted that the illness was chronic and progressive in most cases and generally not responsive to the regular allopathic treatment of the day. He created his own informal typology limited to those with addiction using alcohol that seems to include elements of readiness to change, primary symptoms, and drug effects of alcohol. Silkworth originally published anonymously for fear of attracting scorn within the medical community but allowed his name to be used by Alcoholics Anonymous in the second edition published in 1955. Because he did not publish elsewhere, Silkworth’s understanding of addiction has been limited to the 12-step recovery community and those physicians practicing the specialty of addiction medicine.

Jellnek’s typology, funded in part by some early members of AA, seems to have more to do with the drug effects of alcohol than an underlying typology of addiction. Indeed, Jellnek later distanced himself from his original findings but his progression curve still bears his name and has been a major underpinning to the societal idea that substance abuse leads to and causes addiction.

Cloninger also limited his typology to alcoholism but went much further in identifying pre-existing symptoms. His Type I alcoholic (onset after age 25, low levels of sociopathy, frequently binge type, uncommon to have inability to abstain, high chance of comorbid depression, unlikely to have family history, less frequent use of stimulants) was seen as the most common, and that idea was certainly endorsed by the AA community. Type II alcoholic (opposite at each of those traits) was seen as less common. Some decade later a slightly different typology was proposed by Babor et al. Both of these typologies had the benefit of seeing that there were factors existing before the onset of drinking that were of importance, and certainly Cloninger’s ongoing work with genetics and temperament helps to flesh this out. However, both of these typologies suffered from their limitation to a single drug and their inability to answer broader questions such as use of more than one substance, serial substance switching, use of non-substance behaviors, and other factors. This led to a, perhaps, erroneous conclusion that Type I outnumbers Type II in addiction. There is also the factor of drug effect leading to brain changes causing a shift from one type to the other that was not originally addressed.

So for ASAM’s new definition to be useful in understanding and properly treating the illness it must explain what Silkworth, Cloninger, and others have reported. There must be an explanation for why some exhibit the illness earlier than others; how social factors may play a role; how to tell the difference between core phenomena, epiphenomena, and mere drug effect; and, most important, how the illness should be treated regardless of the patient’s manifesting substance or behavior. I think all these things can be explained as I’ve written in these posts and my book.

© Howard C Wetsman MD FASAM 2012

What if I told you that 106,000 people died each year because they took drugs? You’d probably be appalled and want the government to do something about it. Maybe make the drugs illegal, or block thier production or importation into the country, but do something right?

But what if it wasn’t what you think about when you think about drugs?

Well, as study done in the late 90′s stated that in 1994, 106,000 people died in American hospitals of adverse drug reactions. (Lazarou J, et al, Incidence of Adverse Drug Reactions in Hospitalized Patients, JAMA 1998 Apr 15; 279(15):1200-5.) Since we aren’t going to outlaw medicine and doctors, what else can we do?

Not all, but a good proportion of adverse medication reactions are due to factors that can be predicted by genetic testing. A good example is a rare (1 in 10,000) reaction to statins (cholesterol lowering medications) that cause myopathy (inflammation of the muscles and eventual loss of muscle mass). The reaction is temporary and reversible when the medication is stopped. Still it’s not something you’d like to go through especially if you didn’t know what was happening or what to do about it until your next doctor appt in two months. There is a SNP that has been shown to predict a 5X increased incidence of the reaction, so from 1 in 10,000 to 1 in 2,000. That takes it from the realm of “I never see that” to “we’ve seen that in our practice” for the average doctor.

I asked an internist friend of mine if he did any genetic testing on patients to whom he gave statins. He said no. I asked if he thought it would be helpful in order to see who was at greater risk and would need extra information and warnings. He said, “No. If it happens we’ll just stop it and then it reverses over six weeks or so.” At the time he was training for a marathon. So I asked him if he’d want his own doctor to be so cavalier with his muscle mass. Of course, he said no.

Now this may seem like a trivial example, because few (though some) people die of statin induced myopathy. Something more people die of is Stevens-Johnson Syndrome (an auto-immune reaction involving the skin also called scalded skin syndrome) which can occur with a variety of medications but is related to use of some anti-seizure medication. It turns out that a specific genetic marker (HLA B75) is associated with a SJS reaction to specific anti-seizure medication, but routine testing for it isn’t done.

I could go on and on with things, most of which are rare or trivial, and each would seem not a big enough problem to start doing genome wide testing on a routine basis. However when you put it all together, there are a whole lot of people dying of medication reactions. As genome wide testing becomes cheaper and cheaper, there doesn’t seem to be much reason not to go there anymore.

© Howard C Wetsman MD FASAM 2012

http://townsendla.com/wp-content/uploads/2012/08/NewOrleans_BestDoctors_Aug2012.pdf

I’m really hoping this will get some conversation started on the nature of the illness of addiction and the proper way to treat it.

This won’t be a long blog. I was reading the other day about parents who were prosecuted because they said their faith prevented them from getting their child medical treatment for leukemia. The same day I read an article about an organization getting a government grant to do faith based treatment for the disease of addiction. I don’t understand how the same government can see the faith based treatment of one disease as perfectly normal and worthy of tax payer support but not the other. The only conclusion I can come to is that the government doesn’t actually believe that addiction is an illness as biological as leukemia.

I don’t blame the government for that. I blame us, the people who treat addiction.

In spite of all the knowledge we have about the neurobiology of the illness, we continue to refer to it with the term substance abuse. Until we are clear that substance abuse and addiction are two different things, the lawmakers will continue to be perplexed as to what to do about this chronic, incurable, progressive illness. They will continue to allow educational and social programs, appropriate for people with normal brains who use substances, to be used to “treat” people who have a biological brain illness. And we have no one to blame but ourselves.

This post is a follow up to a previous post about Daniel Kahneman’s book Thinking, Fast and Slow. He makes a point in that book that tells us a lot about relapse in addiction.

Kahneman tells us of other researchers’ work about when we use the parts of our thinking that he calls System One and System Two. As a refresher, System One is intuitive and effortless. When we use System One we don’t even realize we’re thinking. System Two on the other hand requires real work. It takes attention and effort, and there’s not the least bit of doubt in our minds that we are thinking. This work, he says, gives us the Law of Least Effort.

What the Law of Least Effort says is, that, given a choice between effortless System One and effortful System Two, we will always pick the thinking method of least effort to solve the problem before us. This is one reason for the wide prevalence and persistence of cognitive biases that Kahneman is so fascinated with. Here’s an example he gives: “A bat and ball cost $1.10. The bat costs $1 more than the ball. How much is the ball?”

Got your answer?

Most people just subtract $1 from $1.10 and say, “ten cents.” In fact for the bat to be $1 more than the ball, the ball must be $.05 and the bat $1.05.

He also points out that under stress or even non-stressful use of mental resources, we are more likely to default to the simple (and wrong) answer. Rather than engage in effortful use of System Two and go through a calculation, we chose to answer a different question that is easier to answer.

Let’s be clear; by we I mean humans, not people with addiction. All humans will resort to the easiest method, the one we’ve practiced the most, the one that takes the least effort. So what does this have to do with recovery and relapse?

When people are new to recovery, they haven’t practiced the techniques of recovery much at all. They have practiced the techniques of active addiction. The techniques of active addiction, having been learned well and practiced much, reside in System One where they are intuitive and effortless. The new techniques of recovery reside in System Two and take a lot more effort.

So we should expect in early recovery for relapse to old behaviors to be more common until the new recovery techniques have been practiced enough to become second nature. And even then, when under stress or even non-stressful exertion, it will be harder not to default to the older, more deeply learned techniques of active addiction.

So, the important thing for me, and anyone treating addiction, is that our goal is not to teach people to use System Two or to convince them that System One is bad, but rather to help practice the techniques of recovery until they naturally move from System Two to System One. There they can be taken up intuitively and effortlessly. Unless recovery is as easy as using, the human brain will not default to recovery. The goal of treatment is to teach recovery and make it easy enough to keep.

© Howard C Wetsman MD FASAM 2012

I was reading an article online from the New York Times (http://www.nytimes.com/2012/05/18/science/many-rare-mutations-may-underpin-diseases.html?_r=1&ref=health) and it brings up a problem with most genetic views of chronic illness. There was a sort of unspoken doctrine in those looking for genetic precursors of illness; that is, that if the illness is common, the genetic difference will be common. It was a good idea, a hopeful idea, but very naive. Unfortunately most genetic literature I read today still shares this idea.

As full genetic sequencing (still too expensive to use in routine medical practice) has become more and more available, it has become clear that there are many more changes in each of us than we had previously thought. Let me point out a good example of that.

I’ve written before about MTHFR, a gene that produces an enzyme responsible for the production of L-methylfolate, which is, in its turn, required for good dopamine synthesis. Almost everyone who studies MTHFR looks at a single SNP, rs18001133, and occasionally at another, rs18001131. If a physician orders the test from a regular lab, they only get the answer for those two SNPs and bases the decision on whether or not to prescribe L-methylfolate on the answer to those two SNPs alone.

However, I’ve had the chance to look at over 100 SNPs in MTHFR for quite a few people who have responded to L-methylfolate as part of a treatment for addiction. There are other polymorphisms that can increase a person’s likelihood to respond to L-methylfolate and some that seem to make it unnecessary. This calls into question the conclusions of almost all modern genetic research in common illnesses.

Taking addiction for example, so many people look at one SNP and then report that they have found a significant difference in the prevalence of that SNP in a population with addiction using a certain substance. It’s easy to get these papers published. The problem is that they will not impact effective treatment much at all.

First we will require a good definition of addiction, which ASAM has provided us with just recently. ( http://www.asam.org/for-the-public/definition-of-addiction ). Then we will require whole genome sequencing of large numbers of people. The work of 23andme and other GWAS providers is just a beginning. I know that the public has a great amount of hope for genetic testing in disease, and it has already proven valuable to some with addiction, but this is still in its infancy and much, much more is yet to come.

© Howard C Wetsman MD FASAM 2012