The Anatomy of Addiction (11 page)

When I suggested she think about cutting back on her wine because of the grave dangers it was posing to her health, she matter-of-factly stated, “Oh, no. I can't do that. I love my wine.” It's as if she were talking about her pet dog. At that moment she could not make the connection between the enormous amounts of alcohol
she was consuming and its deleterious effects on her health. Still, I went ahead and prescribed her an antidepressant that would not be dangerous to take with alcohol, nevertheless knowing that the alcohol would negate most of its effect.

Two weeks later when I saw her again, she began the conversation by saying that she had thought about what I had told her about how her large consumption of wine would eventually destroy her health. She said that she was thinking about cutting back. I reinforced her first baby step toward controlling what was obviously a full-blown alcohol addiction by saying that I wanted her to consider decreasing her daily wine consumption by two glasses. I asked if she thought she could manage that, and she affirmed that she could. She also agreed to take a pill called Topamax that helped decrease her cravings for alcohol.

When I saw her next, her depression had begun to ebb (because the medication was at last being given a real chance to work), and she had succeeded in reducing her habit to only six glasses of wine instead of the eight to twelve she had been consuming when she first saw me. I told her that she was doing a great job and that she was ready to take the next step to cut her wine back to only one bottle a day. “You think I can do that?” she asked hesitantly. “Oh, absolutely. As your doctor, I can see you're ready,” I told her confidently.

Six months after she first saw me, she achieved complete abstinence from alcohol. Five years later, she is still clean and sober.

Here's what we know in the twenty-first century about the disease of alcohol and drug addiction: Willpower or the lack
thereof isn't the cause of the disease. It's the symptom. Successful psychotherapy doesn't shame the patient into abstaining from alcohol or drugs, but rather cultivates that seed of ambivalence within every addict that what she is doing to herself could be very bad for her health. Together, the therapist and patient focus on creating an internally motived change rather than a step-by-step process.

SOCIOCULTURAL THERAPY

According to current brain research and developmental psychology, the risk of addictive disease is heightened by, and directly related to, life experience as much as genetics.

Human are the only species in which the majority of the brain develops after we are born, and what we experience at pivotal points in our life determines a vast amount of our neurological development. For the sake of simplicity, I'll put it this way: You are an individual, and what you experience in your life has just as much impact on your brain functioning as does heredity and genetics.

However, perhaps the most disturbing discovery, repeatedly verified by extensive international research, regarding the disease of addiction is that emotional pain and stress—especially alienation, social exclusion, and emotional distancing—create actual neurological damage that increases the risk of alcoholism and addiction and the risk of never recovering.

Stress has long been known to increase vulnerability to addiction. Research over the last decade has led to a dramatic
increase in understanding the underlying mechanisms for this association. Behavioral and neurobiological correlates are being studied and evidence of molecular and cellular changes associated with chronic stress and addiction have been identified.

Effective therapy, then, must identify chronic stress factors in the patient's life and create strategies for resolving them.

Nutrition and exercise also can play important roles in treatment by mitigating the symptoms of detoxification and promoting overall treatment outcomes. Many addicts have unhealthy diets that enhance anxiety. They often turn to sugar and carb-laden junk foods to satisfy their craving because these foods increase serotonin levels. Good nutrition provides a baseline foundation for physical well-being in which all other aspects of treatment from medications to counseling are facilitated.

Exercise can also have a direct effect on maintaining proper neurotransmitter levels in the brain. Because exercise stimulates the dopamine pathways, it can mimic the reward produced by the addict's substance of choice. It also generally helps mitigate the symptoms of depression, from which many addicts suffer. Finally, patients who exercise in groups increase their social skills and create social networks in settings not related directly to their substance abuse.

A New Generation of Addiction Medications

As I mentioned earlier in the text, addiction is a chronic disease characterized by the inability to consistently abstain, by impairment in behavioral control, by cravings, by diminished recognition
of significant problems with one's behaviors and interpersonal relationships, and by a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

The new generation of addiction medications, which are easy for the patient to take and easy for the physician to administer, are important for two reasons. First, recovery from addiction is hard, and patients need every tool that medicine can offer them. But there is another potential benefit: The growing availability of medical treatments will encourage doctors to treat their patients' addiction problems just as they would a patient's out-of-control blood sugar or high cholesterol.

Second, the emergence of long-acting drugs goes beyond diminishing the pain of detox and actually reduces cravings that persist, even in people who are highly committed to abstinence. Addicts no longer have to summon their willpower alone to take their medications each day. As an added benefit, long-acting drugs reduce the temptation to sell drugs on the street, easing their burden in the challenging first months of recovery.

New, even longer-lasting versions of these drugs will soon be coming to market. For example, Titan Pharmaceuticals is in the process of seeking Food and Drug Administration (FDA) approval of an implant that would provide continuous delivery of the drug buprenorphine—sold as Suboxone in its pill form—for six months to people attempting recovery from dependence on heroin or prescription painkillers. Studies at the University of California, Los
Angeles found that nearly 66 percent of patients who had the implant inserted under the skin in the upper arm stuck with treatment—compared with only 31 percent of those who received a placebo implant. They had higher rates of clean urine tests and lower rates of withdrawal symptoms and cravings.

The National Institute on Drug Abuse is also putting considerable effort into developing vaccines to fight addiction to cocaine, heroin, and methamphetamine. The aim is to trigger an immune response to a drug of abuse so it can't reach the brain and elicit a high, causing cravings for the drug to erode over time.

Treating the Unique Addict or Alcoholic

All addicts and alcoholics think they are unique. In a very true medical sense, they are absolutely correct. No two are the same, and each must receive a thorough medical evaluation to receive the appropriate medical care in a compressive program incorporating all the therapeutic and/or curative methodologies available.

It is interesting that people with a history of drug misuse can take prescription medications that have great potential for abuse and not misuse them. I usually avoid prescribing mood-altering medications, because they may trigger relapse. For selected patients, however, it is both prudent and necessary to use benzodiazepines, such as for patients who are severely bipolar. I also treat patients who have uncontrolled anxiety with other psychiatric medications.

We usually avoid giving patients stimulants unless it turns out that they have undiagnosed attention deficit disorder (ADD). In the majority of those cases, once they are prescribed the most
effective stimulant, their life is changed, and their drug misuse ends. For some diagnosed ADD patients who have a nonmedical stimulant dependence, even prescription stimulants trigger a relapse.

Physicians need to keep open minds and provide individualized treatment. The old belief that all addicts are the same is completely wrong. No two are exactly alike, and there is no one treatment that is appropriate for all patients.

To overlook the individuality of the patient is, quite frankly, a gross violation of both ethics and professional responsibility.

Variations in Intoxicated Behavior

ANGER

It is a fact that different people act differently when intoxicated. People often ask me why some people become rude and abusive, even violent, under the influence of alcohol.

The reasons for emotional rage, especially when under the influence, are complex. Comprehensive research regarding anger found that there are medical underpinnings to compulsive, repetitive outbursts of anger, even when not accompanied by ingestion of alcohol, and when the brain imagery of those afflicted indicates the physical disease of addiction along with other medical illnesses.

Researchers at Ohio State University found that men and women with higher levels of hostility also showed higher levels of homocysteine—a blood chemical strongly associated with coronary heart disease. It is medically correct to say that extreme and repetitive anger can cause heart attacks and strokes. There is an ongoing discussion and considerable research concerning hostility
and anger because they may be three things at once: a symptom of disease, the cause of disease, or in cases of compulsive rage, a medical condition of an addictive nature.

Jill Bolte Taylor, a trained and published neuroanatomist, garnered acclaim for her specialized postmortem investigation of the human brain as it relates to schizophrenia and severe mental illnesses. According to Taylor, all emotions, including anger, have a chemical component. Once triggered, the brain releases the neurotransmitter dimethyltryptamine (DMT), and you experience the corresponding emotion. Taylor insists that the chemical associated with anger is completely dissipated from the bloodstream in ninety seconds. She asserts that if your anger lasts longer than ninety seconds, it may be that you are self-perpetuating or self-triggering the chemical for much the same reason as a heavy drinker keeps ingesting alcohol.

As a specialist in addiction medicine, I see individuals come to me with highly complex problems involving more than one diagnosis. They may have heart and liver problems, brain dysfunction, addiction, or ulcers plus psychiatric and psychological problems. They may also have any manner of ailments engendered by, aggravated by, or marginally correlated to their compulsive use of alcohol and/or drugs.

Because of both complexity and individuality, there is no simple answer to the question regarding why we have “the angry drunk.” There are, however, some interesting recent insights into the phenomenon.

In an experiment at the University of Waterloo in Ontario, Canada, volunteers pressed a particular button when prompted by
a computer. These same volunteers were also instructed not to press the button if there was a bright red light. Some participants, when given alcohol, would become defiant. Despite the bright red light, they would smack the button with outright aggression. This is similar to the drunk who does something despite being repeatedly told not to do it.

Furthermore, many studies in the United States have found that a percentage of people who are told they are drinking alcohol behave as if they were under the influence, even becoming aggressive, hostile, and easily sexually aroused—despite not having any alcohol whatsoever.

The reason I introduced those two studies back to back is to raise the obvious question: Is the aggressive and defiant behavior the result of alcohol (or the result of what people believe about the effects of alcohol) or does it indicate another, more subtle medical condition? There is no absolutely correct answer under all circumstances, but we do know that in cultures where alcohol consumption is not associated in any way with aggressive or hostile behavior, the behavior of those who drink is not hostile and aggressive.

The Bad Drunk

The appearance of hostility when drinking is a manifestation of a physical disorder other than alcoholism, even if alcohol addiction is also present. A person who becomes insulting, aggressive, hostile, and/or abusive when drinking, even if he or she rarely touches alcohol, is exhibiting a known symptom of one or more medical conditions other than alcoholism, all of which require
comprehensive care by a trained physician. In popular culture, we know this kind of person as a “bad drunk.”

The implication for successful treatment of the angry alcoholic is clear: More than the physical illness of addiction must be addressed. There will be more than one diagnosis, and personalized treatment is of paramount importance. As with the alcoholic, solemn oaths to use willpower, the use of support groups, counseling, and the best intentions are, for the most part, useless. Yet, without fail and despite repeated failure, addicts continue to do more of what doesn't work.

Symptoms indicate illness, but symptoms don't diagnose the illness any more than the existence of clues is the answer to a mystery. One symptom or characteristic of addiction is self-stimulation. If an alcoholic has one drink, it stimulates a biochemical and emotional chain reaction triggering the compulsion to keep drinking, despite any unpleasant outcomes. As alcoholism is a medical problem with a biological component of approximately 50 percent, to ignore the physical illness would be irresponsible. Hence simply not drinking is not a medical treatment, although it certainly is a beneficial change in behavior.

If someone is going to assert that anger itself is an addiction or that there are adrenaline addicts, then the people so afflicted should certainly seek the help of a specialist in addiction medicine. Much to my personal shock and dismay, I have seen so-called anger addiction treatments that encourage the “patient” to become angry, express anger, and “get it all out.”