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Rants, Raves, and other Thoughts About Addiction and It's Treatment
October 29, 2007
What an amazingly frustrating weekend.
After meeting with the treatment staff and the board members of Glenbeigh Treatment Center in Rock Creek, Ohio, I was feeling pretty darn good about addiction treatment and the progress that has been made over the 17 years since I entered treatment for the first time. But then that good feeling quickly dissolved over the past 24 hours.
I have a friend in treatment at the present time and she is doing well from the information I have received from her family. Unfortunately, the safety net that used to be in place for recovering nurses in the state of Ohio has disappeared. The group that had been following a nurse's progress through treatment and charged with monitoring the nurse's after care activities no longer provides that service. And as yet, I haven't been able to find anyone who has replaced the original organization or even knows of an entity in Ohio that I can contact about considering taking on this important service.
Chemical dependency in health care professionals is no surprise. After all, these dedicated professionals develop cancer, diabetes, hypertension, cardiovascular disease, and all of the other chronic diseases everyone else is subject to in their lifetime. Having an alternative to discipline program available for health care professionals with substance abuse issues and the DISEASE of chemical dependency is essential in discovering those individuals early and getting them into treatment before they can harm others or themselves. A punitive system assures prolonged periods while the practitioner is being investigated but is still practicing. When the loss of licensure is threatened, it prevents the impaired individual from seeking help early, if at all. It also makes it less likely a colleague or family member will report the individual because of fear of reprisal (i.e. lawsuits) or being held responsible for the loss of an individual's career and ability to provide an income for themselves and their family.
With today's "drug war" mentality, individuals who need treatment for this chronic, progressive, ultimately fatal disease will not seek that treatment until a major disaster occurs. Arresting the user and incarcerating them assures they most likely will NOT receive the medical treatment they deserve and need. Hopefully, that disaster isn't the death of a patient or of the practitioner.
Until society changes their view that addiction is a character flaw or moral weakness, the substance abuse/addiction epidemic will continue to grow, and society will continue to lose some of the best and brightest people in our communities.
September 7, 2007
Why do Addicts Choose to Take Drugs?
(Or, Don’t Addicts Do This to Themselves?)
Rev. Jack Stem
Pastor
New Life in Recovery Ministries
http://jackstem.com/new-life-in-recovery.htm
Peer Assistance Advisor
Ohio State Association of Nurse Anesthetists.
The number of reasons we addicts (yes, I'm a recovering addict) "use" the first time are as varied as the number of people out there. It's not about having excuses or rationalizations. Addiction is a disease process occurring in a susceptible individual under the right circumstances. Those circumstances vary from person to person. This is the case with many chronic diseases.
Let’s look at cancer as an example. Many people enjoy sunbathing, but not everyone will develop skin cancer. Some will, but many won't develop Melanoma, an aggressive form of skin cancer. Or the person who smokes 3 packs per day for 50 years and yet doesn't develop lung cancer. Adult onset (Type II) diabetes is linked to diets high in carbohydrates, obesity, and lack of exercise. But look at the folks who do all the wrong things and yet don't become diabetic. High fat diets and no exercise can lead to cardiovascular and cerebrovascular disease, but not everyone who follows this regimen develops disease. Genetics play a large role in the development of many chronic diseases.
Is the susceptibility to the disease of addiction genetic (nature)? In many individuals that is most likely true since research has shown familial tendencies.
Is the susceptibility environment (nurture)? Likewise, a likely scenario for some as well.
Is it a combination of both? A good chance that this can be said for many of us.
So what does that have to do with addicts and addiction? No one makes the person start using mood altering chemicals. They do it to themselves, right? This isn’t a disease! Addicts are just looking for an excuse so they don’t have to be responsible for their actions.
How many times in the past have people thought the same thing about other diseases or questions that science has answered? Leprosy, also known as Hansen’s disease, was thought to signify a state of defilement resulting from leading a sinful life. These poor souls would be sent into isolation so no one else would become “unclean”. In the mid 1800’s, A Norwegian physician named Hansen discovered the disease of Leprosy was caused by an infectious organism, that would eventually be treated with antibiotics. Until that time, and most likely for a time after Hansen’s discovery, there were still many people who still believed Leprosy was outward sign of inner sin. Today we know how ridiculous those claims as a result of the advancement of medical science.
Likewise, astronomy changed the belief that the earth was flat and the sun and moon circled around the earth. Today, anyone who claims the earth is flat and the center of the universe is ignored.
Research over the past 2 decades has provided a wealth of information on the biology (physiology and pathophysiology) of addiction. This research has shown that the brains of addicts are significantly affected by the chronic use of mood altering substances. These changes are much more dramatic in addicts than in people who have used mood altering substances for long periods but have not become addicts! This flies in the face of our cultural view of addiction and addicts. A majority of our society believe addiction is a choice made by the addict. If it’s not a choice, then it’s a result of stupidity, weak willpower, or a lack of morals. Until the scientific evidence that is piling up is spread through our culture by medical science, the out of control epidemic that is addiction will continue to grow each year.
Does this mean addiction can be prevented? In many, cases it could be. How? By avoiding the recreational use of mood altering substances. I say "recreational" based on studies that show people on long term opioid therapy for chronic, severe pain have an extremely low incidence of addiction once the pain is resolved. Margo McCaffery, one of the leading authorities on pain management, refers to a couple of studies in which over 20,000 chronic pain patients on long term opioid therapy had an addiction rate of around 0.03%. Leading pain management experts attribute this to a "protective" quality of pain to the addictive properties of opioids. Many of the pain patients I cared for in my homecare days after leaving anesthesia practice said they rarely experienced euphoria when receiving their opioids. In contrast, individuals who take an opioid for reasons other than pain describe the warm, euphoric feeling enveloping them, or feeling energized (as many here have described), or just feeling "normal" for the first time in their lives. In someone who is susceptible to addiction by way of nature or nurture, the snowball begins rolling down the hill. Slowly at first but gaining speed at varying rates depending on the potency of the drug of choice, route of administration (inhaled and IV providing a powerful "blast" to the pleasure centers in the brain), environmental factors (divorce, financial, legal, etc.), and the individuals genetic susceptibility. A vast majority of addicts have made the comment that the first time they tried a mood altering substance (alcohol, opioids, tranquilizers, etc.) there was a very intense sense of pleasure or euphoria that they simply had to do it again. In a majority of the population, that first use has significant negative effects! Most people know a person, or can say in their own experience that the first time they drank alcohol they didn't like the way it made them feel. Or perhaps they liked the feeling, but became violently ill and had a terrible hangover the next day. This significant difference in the reaction may be an early clue as to who might develop the disease of addiction.
While the initial decision to use the first time is 100% voluntary in the overwhelming majority of addicts, there will be those individuals who have such a strong genetic susceptibility to the addictive properties of opioids or other mood altering substances, that their disease is triggered even when the use of the medication is appropriate and medically indicated. Does that mean we withhold medications to someone who has a legitimate medical need for fear of triggering addiction? Absolutely not! Based on the studies quoted by McCaffery, that would mean withholding appropriate medications from 99.97% of those who need the medication for fear of triggering addiction in the 0.03% who will become addicted.
Again, the initial choice to try a mood altering substance is most likely 100% voluntary (someone might be exposed the first time from someone spiking a drink
as a joke or a way to commit "date rape"), but no one can predict the 12 - 20% who will become the addict. To list someone's search for the reason they used as being an excuse is perpetuating the myth that addiction is a moral failure or lack of willpower or a form of denial. In some individuals that is most likely true. But trying to understand the disease process in others and ourselves can only improve the way addiction is treated once it does manifest itself, and give us a better possibility of discovering effective ways of preventing the disease in a majority of the population. Granted, this could be decades in the future, but to simply ignore the epidemiology and pathology is unscientific.
Having said all of that, I DO agree that once we have been diagnosed with the disease and heave been through current evidence based treatment and given the best possible evidence based tools to keep our disease in remission, AND SUFFICIENT TIME WITHOUT MOOD ALTERING SUBSTANCES, THEN we have very few excuses as to why we picked up at the present time. In early recovery the brain is still too "pickled" and the ability to make rational choices in situations where there are strong triggers present is extremely difficult based on the fact the pre-frontal cortex (the area of the brain responsible for controlling impulsive actions) still doesn't function adequately. I recall reading somewhere that it takes the brain around 18 - 24 months to return to a state that enables the pre-frontal cortex to function well enough to allow better control over impulsive thoughts and actions.
Conclusion: First time use(s) are voluntary in a majority of individuals...first beer or wine, trying Dad's pain medication just to see what it feels like, first time injecting fentanyl because the patients all seem to REALLY enjoy it's effects, or any other scenarios. 80 - 88% of the population will NOT become addicts, but 12 - 20% WILL! Implications? Increased education to help the medical community understand andrecognize the early signs of addiction so that intervention and treatment can happens ASAP which MIGHT arrest the disease before significant pathological changes in the brain take place, which MIGHT improve the chance for significant long term recovery. Also improve the community at large in order to reduce the stigma of a disease that is treatable, especially when recognized early and appropriate, evidence based treatment is started.
Jack Stem
Pastor
New Life in Recovery Ministries
http://jackstem.com/new-life-in-recovery.htm
CEO
Addiction Prevention Education Consulting Services
www.jackstem.com
August 28, 2007
Why do we continue to try to STOP the production and sale of drugs by funding interdiction policies instead of decreasing the demand by funding TREATMENT policies? Studies and statistics PROVE treatment is a more efficacious method of decreasing the drug problem than interdiction. And yet we continue to spend an inordinate amount of money on interdiction and very little on treatment. If you ask me, it's a microcosm of our society. We'd rather LOOK tough than do something effective but unpopular. Check out this information which can be read in it's entirety here:
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Compiled by Anonymous, Drug Policy Alliance. 2002. (Isn't it a shame people have to be anonymous to discuss this topic?)
Are interdiction and eradication efforts a success?
No.
U.S. taxpayers have spent tens of billions of dollars on intense eradication and interdiction efforts, yet the prices of cocaine and heroin are the lowest they have been in 20 years and their street-level purity is at all time highs.(1)
- Eradication and interdiction efforts have not reduced youth access to illegal drugs. The proportion of 12th graders reporting that it would be "fairly easy" or "very easy" for them to get cocaine if they wanted some rose from 33 percent in 1975 to about 50 percent in 1999. The percentage of 12th graders reporting heroin "fairly" or "very" easy to obtain rose from 20 percent to about 35 percent. Every year from 1975 to 1999, over 80% of high school seniors reported that marijuana was "fairly easy" or "very easy" to obtain.(2) More than 54% of high school seniors have tried illicit drugs - up from 44% a decade earlier.(3)
- Eradication and interdiction efforts have not stopped the drug trade from expanding. The global illegal drug trade is now a $400 billion a year industry.(4) At eight percent of the global economy, the illegal drug trade is larger than the international trade in iron, steel, and motor vehicles.(5) In contrast, the entire U.S. defense budget was only $276 billion in 1999.(6)
- While coca production in Bolivia and Peru fell by more than 50 percent from 1987 to 1999, production in Colombia increased over 1,140 percent.(7) Despite our best efforts, the combined cocaine production capacity for Bolivia, Peru, and Colombia grew from 355 metric tons in 1987 to 765 metric tons in 1999.(8) Today, as the U.S. spends hundreds of millions of dollars on attempts to reduce drug production in Colombia, traffickers are shifting their operations back into Bolivia and Peru, as well as into Ecuador and other countries in the region.(9)
Why do supply side efforts fail?
Supply side efforts fail because they ignore the laws of supply and demand. As long as a demand exists for illegal drugs, a supply will exist to meet it. The enormous profits that can be reaped through drug trafficking, the ability for drugs to be produced almost anywhere in the world, and the fact that three billion people in the world live on less than $2 a day, all make interdiction and eradication a Sisyphean effort.
- Supply reduction efforts fail to reduce drug abuse because "suppliers simply produce for the market what they would have produced anyway, plus enough extra to cover anticipated government seizures."(11) Interdiction efforts are estimated to only intercept 10-15% of heroin(12) and 30% of cocaine.(13) The U.N. estimates that at least 75% of international drug shipments would have to be intercepted to substantially reduce the profitability of drug trafficking.(14)
- Supply reduction efforts also fail to reduce drug abuse because of what experts call the "balloon effect" - squeeze drug production in one area of the world, and price incentives cause it to pop up somewhere else. Secretary of Defense Donald Rumsfeld recently told Members of Congress that the United States would be better off reducing demand at home rather than chasing drug production around the globe. "If demand persists, it's going to find ways to get what it wants," Rumsfeld told members, "And if it isn't from Colombia, it's going to be from someplace else."(15)
- Stopping drugs from entering the country is like trying to find a needle in a haystack. Thirteen truckloads of cocaine are enough to satisfy U.S. demand for one year.(16) All the heroin the U.S. consumes each year can be fit in one cargo plane.(17) The United States has 19,924 kilometers of shoreline, 300 points of entry and more than 7,500 miles of border with Mexico and Canada.(18)
What is the best way to reduce drug abuse?
By providing treatment to all Americans that are trying to end their drug habits, the U.S. can simultaneously reduce domestic demand for illegal drugs and the foreign supply that exists to meet it. The Drug Czar's office reports that, "studies and statistics indicate that the fastest and most cost effective way to reduce the demand for illicit drugs is to treat chronic hard core drug users."(19)
- A landmark study of cocaine markets by the RAND Corporation for the U.S. Army and the Drug Czar's office found that, dollar for dollar, providing treatment to cocaine users is 10 times more effective at reducing drug abuse than drug interdiction schemes and 23 times more effective than trying to eradicate coca at its source. To achieve a one percent reduction in U.S. cocaine consumption, the United States could spend an additional $34 million on drug treatment programs, or 20 times more, $783 million, on efforts to eradicate the supply at the source.
- Every dollar invested in drug treatment saves taxpayers $7.46 in societal costs. In contrast, taxpayers lose 85 cents for every dollar spent on source-country control and 68 cents for every dollar spent on interdiction.(20)
- California's CALDATA study found that among previous criminal offenders, 72 percent stopped committing crimes after receiving treatment.(21) Hospitalization also fell by one-third after treatment. California's treatment expenditures of $209 million between October 1991 and September 1992 saved taxpayers an estimated $1.5 billion.(22)
NOTES:
1. System to Retrieve Information From Drug Evidence (STRIDE), Drug Enforcement Administration, 1981-97.
2. Ibid.
3. Monitoring the Future, National Results on Adolescent Drug Abuse, Overview of key Findings 1999, U.S. Department of Health and Human Services, Page 6.
4. United Nations, World Drug Report, (New York: Oxford University Press. 1997)
5. United Nations, World Drug Report, (New York: Oxford University Press. 1997)
6. CIA Fact Book: 2000
7. United Nations Office for Drug Control and Crime Prevention, Global Illicit Drug Trends 1999 (New York, NY: UNODCCP, 1999)
8. Ibid.
9. "Cocaine Cultivation Increasing in Colombia," Philadelphia Daily News, March 3, 2001; "State Department Calls for More Military Assistance in South America", Inside the Army, March 19, 2001; "With no other livelihood, South American peasants defy U.S. anti-drug effort", Associated Press, March 15, 2001; "In the War on Coca, Colombian Growers Simply Move Along", The New York Times, March 17, 2001.
10. G8 Kyushu-Okinawa Summit Meeting 2000, Global Poverty Report
11. Rydell & Evering, Controlling Cocaine, Prepared for the Office of National Drug Control Policy and the United States Army (Santa Monica, CA: The RAND Corporation, 1994.)
12. Ibid., World Drug Report,
13. Associated Press, "U.N. Estimates Drug Business Equal to 8 percent of World Trade," (1997, June 26.)
14. Ibid., "U.N. Estimates Drug Business Equal to 8 percent of World Trade,"
15. Rumsfeld Tells Senators His Views on Drug War," The Los Angeles Times, January 12, 2001.
16. Frankel, G., "Federal Agencies Duplicate Efforts, Wage Costly Turf Battles," The Washington Post (June 8, 1997), p.A1.
17. Walter Cronkite, The Cronkite Report - The Drug Dilemma: War or Peace (1995).
18. Central Intelligence Agency, World Factbook 1998, 1998.
19. National Drug Control Policy Strategy Report 1995, Office of National Drug Control Policy
20. Ibid., RAND
21. Ibid.
22. Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment. Chicago, IL: University of Chicago's National Opinion Research Center. |
July 20, 2007
Did you happen to watch the ABC News Primetime feature on Daniel Baldwin? It was a prime example of how wrong the media gets it when it comes to this disease.
This show did everything it could to show one side of the story and perpetuate the myth that treatment and recovery rarely happen successfully. They took a high profile celebrity and highlighted his story of failure after 9 times in treatment. This is ignoring the advances made in research on the disease of addiction and the successes of the millions of people who have long term recovery. The story never mentioned or explained the physiologic changes in the brain that perpetuate the disease and make relapse a very real possibility in all addicts. They casually referred to the genetic component and then moved on to the more sensational aspects of Mr. Baldwin's story. The questions asked by Cynthia McFadden revealed 2 things. First, she certainly didn't research the subject well. Second, myth, mibelief and misinformation continues to reign in our society when it comes to the disease of addiction.
The only way these myths will be eliminated is for those with long term recovery to stop hiding. Yes, it's difficult to be open and honest when the community has prejudice ingrained into them. Recovery is a difficult, heroic struggle waged everyday around the world. It's about time the HEROES of recovery remove their disguise and lead the battle against this disease that destroys the addict, their families, friends, and community.
May 29, 2007
There is a discussion in the recovering anesthesia community of how long treatment should last for the anesthetist/anesthesiologist addict (this includes alcohol as well). They also want to know what form of treatment should they receive, intensive outpatient treatment (IOP) or inpatient residential treatment (IP).
There is much to consider when trying to determine which type of treatment will provide the best chance of long term recovery. But one of the most important, if not THE most important consideration is, does this professional intend to return to the clinical practice of anesthesia? Will this person be returning to the profession that requires many to handle their "drug of choice." There are no perfect answers to this question. I'll give you my thoughts and opinion at this time and place. My opinion will no doubt change as more research is conducted into the pathophysiology of this brain disease.
As I read Dr. Roche's book, the pathology of this disease makes it perfectly clear (at least to this pickled bozo) why it is so important to spend as much time in a controlled environment, meaning long term residential treatment. This is important in early recovery because it keeps us away from as many cues associated with use , than any other approach, especially for those who intend to handle their drug of choice every day as a clinical practitioner. Any other approach simply defies scientific reasoning. We can argue the finer points of how the individual gets and remains clean all we want. The bottom line (for me anyway) is what plan of action, based on science, provides the best chance of long term recovery for the CRNA who intends to return to clinical practice?
Yes, there are reports of people getting clean and sober that don't go to inpatient, who don't attend IOP, who don't receive formal treatment of any kind. But that is trying to meet the "needs of the many based on the the "success of the few" (or as Spock said in Star Trek II: The Wrath of Kahn... the needs of the many outway the needs of the few...or the one).
When I spoke in New Hampshire last year, someone stayed to chat after the presentation. He told me how he was drinking excessively for several years until one day it dawned on him that most of his problems in life were a direct result of too much alcohol. He said, "As soon as I realized that, I stopped drinking. So I'm not sure all this treatment stuff is really necessary to get clean and sober."
My response (which Dr. Roche states so well in her book) was anyone who is abusing chemicals to the point of significant negative consequences in their life, but is able to recognize that the abuse is the cause and decides to quit...and SUCCEEDS, is NOT an addict!
Dr. Roche states: "Normally, the pre-frontal cortex acts as a brake on the other areas of the limbic system when a rewarding experience has a negative consequence. With substance ABUSE, the prefrontal cortex remains unchanged and control over the use of the drug is maintained. With ADDICTION, pre-frontal cortical function changes, resulting in decreased impulse control, denial of adverse consequences, and COMPULSIVE drug use."
Those physical changes can take weeks and months to begin to return to normal, and never really do return to the pre-addictive state. The cues associated with using can stimulate these altered brain pathways triggering the craving, and increasing the risk of relapse.
I know, I know, we all know this (don't we?). But, at least for me, hearing it again and again finally "turns on the light" of understanding, creates that "epiphany" where I move from intellectually knowing something to spiritually knowing something. Every fiber of my being now knows it. It clicks. It's at that point the "craving" (or, the obsession, if you will) is lifted. But that
takes time and repetition to be achieved. AND, just like with exercise, if we don't keep "working it", we CAN lose that spiritual knowing. No athlete will work their ass off to achieve a certain level of skill and then expect to remain at that level without continuing to train.
Recovery is no different. It takes time and effort to achieve it, and it takes time and effort to maintain it. And just like an athlete (or a warrior, or astronaut, or MD, or CRNA, or pilot, etc.), when we choose to become "something" (like a CRNA), we must initially immerse ourselves in intensive, prolonged training. We seperate ourselves from those things that can and will distract us, until we have a level of "knowing" that enables us to return to the rest of the world. But those of us who have chosen this profession know we will never return to the rest of the world at the same level we were at before entering this community. We must continually "keep up" to maintain our level of expertise. This means attending workshops, seminars, and teleconferences. It means reading several journals every month. Having discussions with our peers, sharing what we have discovered in the daily practice of our chosen profession, seeking input when failures and tradgedy occur.
What am I babbling about? Just as we would never expect a nurse to transition into a nurse anesthetist by taking weekend classes and chit chats with other nurses following the same path. So should we never expect a CRNA/SRNA to "get recovery" in the same fashion. We enter "intensive, "residential" training (hmmmm...could that be where the term "resident anesthetist comes from?) to become safe, competent CRNA's. Shouldn't we do the same when trying to become safe, competent, RECOVERED CRNA's?
Jack
May 26, 2007
This is the first of what will be many of my thoughts about this disease called addiction. I guess you could say these will be my "editorials" about the subject. The views I post here will be just that, my views. The things I post here will not be "official views" of the recovering community or the treatment community. Sometimes what I post here might seem irrational or the rantings of a lunatic. When that happens, it's most likely because I am trying to deal with something difficult in my recovery. Most likely, it will be a result of something totally ridiculous society believes about this disease.
Most of what society and the medical community "believe" about addiction, and therefore affects the way this disease is assessed and treated, is based on myths, misunderstanding, and misbeliefs. It is rarely based on a solid understanding of what research has discovered and shown to be scientifically accurate.
This is the overwhelming basis for the formation of my corporation/organization. Cintinuing education is the ONYL way our medical community will be able to accurately diagnose and treat the disease of addiction, a disease that is at critical levels in our modern society. The 21st century reasearch capabilities has not successfuly brought the medical treatment of addiction into the 21st century. In fact, in an overwhelming number of instances, diagnosis and treatment of this disease progress is still in the 19th century.
This is my attempt to assist, in some small way, in bringing scientific understanding of addiction to the medical and non-medical communities.
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