The Anatomy of Addiction (15 page)

I
n previous chapters we discussed the biological nature of addiction, the social and political currents that have shaped the disease in the public eye, and the changing demographics of those who suffer from it. But would you know an addict if you met one?

Let's take a typical social gathering of a hundred adults, say, at a wedding or a holiday office party. About nine of those there will regularly buy drugs illegally—opioids (heroin or prescription painkillers like Vicodin and OxyContin), stimulants (cocaine, meth, or bath salts), sedatives (Sizzurp, barbiturates), hallucinogens (ecstasy, LSD), tranquilizers (Valium, Xanax), or marijuana (legal in some states).

About ten will either be at high risk of becoming or already be an alcoholic, consuming an average of seventy-four drinks per week or the equivalent of eighteen bottles of wine—by themselves—per week. These heavy drinkers make up only 10
percent of the U.S. adult population, but are responsible for 60 percent of all alcohol sales (spirits, wine, and beer).

About half those at high risk for an alcohol or drug dependency actually suffer from an addiction, probably beginning early in their lives (more on that in the next chapter), although increasingly, beginning in late middle age (as we discussed in the last chapter). And a little over half of that subset will have a substance addiction
and
a diagnosable mental disorder (likely depression, but also possibly bipolar disease, schizophrenia, attention deficit hyperactivity disorder, autism, or psychosis).

So, if one in ten people have a substance addiction—the equivalent of the entire population of Texas—and a little more than half also have a mental disorder, could you pick those six people out among a hundred people in a room? Likely not. And that's a problem because as bad as treatment is in the United States for substance addiction in general, it's even worse for those addicted and mentally ill, a condition known as
dual diagnosis
.

Dual Diagnosis

I regularly see individuals with highly complex problems involving more than one diagnosis. They may have heart and liver problems, brain dysfunction, ulcers, plus psychological disorders, all in addition to an addiction to alcohol or drugs.

Most worrisome, however, is the correlation between mental illness and drug use that has been clearly established with about half of those with an alcohol or drug abuse problem showing signs of psychiatric disorder.

Dual diagnosis, also known as co-occurring disorder, is when a person is suffering from both the consequences of substance misuse and a simultaneous mood disorder, such as depression, bipolar disorder, panic disorder, or a more severe mental condition, such as schizophrenia.

There is a difference between induced psychosis from drugs or alcohol and psychosis as a result of mental illness. Induced psychosis is not uncommon, even with perfectly legal medications that affect brain chemistry. In that situation, the psychosis goes away as the drug's effects diminish over time. When the psychosis is the result of a mental illness, it does not diminish over time. It needs specific medical treatment.

When a patient has both drug-induced psychosis and mental illness, there are unique challenges to effective treatment. Even identifying both conditions presents problems. Drugs and alcohol can worsen the severity of mental disorders and present symptoms that look like those of mental disorders or, conversely, cover them up. Both severe intoxication and detoxification can give the appearance of mental illness, and vice versa.

It is so difficult to tell the difference that only 2 percent of mentally ill patients with substance abuse problems were detected in a university hospital emergency room. A state hospital did slightly better, detecting 15 percent.

Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse, and 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent also have problems with either alcohol or drugs. In those
people diagnosed with bipolar disease, substance use problems are seven times more likely than for the nonbipolar population.

One recent study revealed that 33.7 percent of schizophrenics also meet the criteria for a diagnosis of alcohol use disorder, and 47 percent of individuals with schizophrenia are more than four times as likely as the general population to have a substance abuse disorder.

The Need for Specialized Care

A person with dual diagnosis needs specialized professional care, and most mental health services are not prepared for patients who also have severe drug and alcohol problems. As a result, the individual may be bounced back and forth between services for mental illness and those for substance abuse, or they may be refused treatment altogether. Many treatment centers will not take a person with dual diagnosis because they don't have qualified medical personnel on staff to deal with mental health issues.

A “traditional” or religious-centric nonmedical rehab is definitely not a good place for someone with a mental illness because these patients are very emotionally fragile and sensitive. Being placed in a confrontational, accusatory, and coercive environment can be the worst thing for them and for those around them.

Many patients who need medication for mental disorders have self-medicated with street drugs. They go to 12-step recovery support groups, where they are told they are not “clean and sober” if they are taking medically prescribed medication. This is not only absurd and cruel but a direct contradiction of the original
12-step philosophy, which allowed for psychiatric or psychological treatment whenever appropriate. There is even a brochure published by AA General Services, titled “A.A. Member—Medications and Other Drugs” that says members can take medications under a qualified physician's monitoring and that “no A.A. member should ‘play doctor'” and offer unqualified medical advice to other members.

Unfortunately, there are few consequences for local AA groups that ignore that directive and impose a complete ban on medications, even pharmaceutical drugs prescribed by a physician for a mental disorder. This is all the more ironic since Bill W. (as he was known until after his death) conceived of AA after being treated at one of the first specialized addiction treatment hospitals in the country with a natural pain reliever that had known hallucinogenic effects, belladonna. In addition, he was exploring the use of a synthetic hallucinogen, LSD, as a possible treatment for alcohol addiction shortly before his death.

The dual-diagnosis patient is often discriminated against by nonmedical treatment professionals and emotionally abused by other recovering addicts and alcoholics who insist that all drugs are bad—often said while consuming massive amounts of caffeinated coffee and smoking cigarettes (which contain nicotine, a highly addictive stimulant drug). These unfortunate individuals find themselves as outcasts from both the drug and alcohol recovery community and from the mental health recovery community, and they are almost twice as likely to stop participating in outpatient mental health treatment than those who don't have issues with drugs and/or alcohol.

Integrating Treatment

Until recently, many mental health professionals believed that a patient with a dual disorder should be treated sequentially and that the substance addiction had to be cured before the mental disorder could be treated. There was a subtext to this approach that the addiction could be responsible for the mental disorder. To a degree, that was correct as it applied to drug- or alcohol-induced psychosis.

Today, we know that a nondrug or nonalcohol psychosis in a dual disorder is rare and that clinical depression is the most prevalent mental disorder. What, then, is the best approach to treating a dual diagnosis?

It is my opinion that the answer lies in integrating mental health and addiction treatment in a single, comprehensive program designed to meet the individual needs of the specific patient.

This approach is of proven value and is endorsed by Kathleen Sciacca, the founding executive director of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction, and Alcoholism in New York City. “There is a need for education that demonstrates that addictive disorders are illnesses,” says Sciacca. “Understanding mental illness as a disease that is not caused by families was necessary to successful advocacy for the mentally ill. The same advocacy must happen for those who are dually diagnosed, through a clear understanding of the addictive disorders.”

Distinguishing between Disorders

Even to the trained eye, the difference between dual pathology—addiction and mental disorder—and a mental disorder that has been substance induced can be elusive. Yet knowing the difference can have important implications for treatment. Because symptoms are similar, it's tempting to question whether all mental disorders suffered by addicts are induced by substance abuse. Yet, causative studies don't support the notion.

For example, public health surveys do not reflect a spike in the prevalence of dual disorder diagnoses when various drugs fall in and out fashion. That is, the recent rise in heroin addiction is not reflected in an increased incidence of pathological disorders among users. Simply put, exposure to addictive drugs does not increase mental illness, even though both can affect the brain similarly.

Identifying which is which remains a vexing problem for clinicians. There are diagnostic tools—tests to evaluate and assess the patient's mental health—that have been developed to help distinguish dual disorders from substance-induced disorders. These include Global Appraisal of Individual Needs—Short Screener (GAIN-SS) and Psychiatric Research Interview for Substance and Mental Disorders (PRISM) for the
Diagnostic and Statistical Manual for Mental Disorders
. However, by far the best diagnostic instrument is the
clinician's experience in treating addiction
, which speaks to the need for more doctors and healthcare professionals trained in addiction medicine.

Substance-induced psychiatric symptoms can occur both in
the intoxicated state and during the withdrawal state. For instance, severe anxiety and depression are common symptoms among alcoholics. Even binge drinking can increase anxiety and depression levels in some individuals. And, more often than not, psychiatric disorders induced by prolonged alcohol or drug abuse will eventually disappear with proper treatment and a sustained period of abstinence.

It's worth noting that abuse of hallucinogens can trigger flashbacks, delusional and other psychotic phenomena that occur months or even years after stopping the use of the drug. The condition is most associated with an acid flashback, meaning LSD induced, but there have been anecdotal reports of former ecstasy users experiencing flashbacks as well.

When Drugs Meet Mental Illness

I met my patient Samantha forty-eight hours after she had passed out from overdosing on ecstasy at an all-night rave. After an initial exam, I observed that her condition was more than substance abuse and that she likely suffered from a mental disorder.

Samantha, twenty-four years old, was a production assistant in the wardrobe department for a prime-time TV show. Pretty and fashionable, she looked the part of young professional in Hollywood. She described her work as an “investment in her future,” exciting at times, but mostly stressful.

“When we're in production, I have to be on call virtually any hour. There's no down time, and my days can last eighteen hours,” she said.

She used electronic dance parties as her pressure valve. “They really are a great way to escape for a while. And Molly [ecstasy] just enhances the whole experience,” she said.

Lately, however, she became aware that she might be using ecstasy too much. Over the preceding eight weeks there had been times when she attended raves and used the drug that she forgot what she had been doing for several hours. Her blackout incident two days before our first visit had scared her. “If I had not been with friends—really good friends—I don't know what would have happened. Fortunately, they were there and got me to an ER,” she said.

While Samantha was abusing a drug, and an illegal one at that, she was not an addict. She limited her use of the drug to weekends. While there was no way of knowing for sure, one reason she passed out the last time she used ecstasy was likely because it had been mixed with another drug, perhaps a sedative. She admitted that she bought the ecstasy tablets the evening in question from a new dealer because she couldn't find her regular pill man.

In her case, she didn't have so much a drug dependency as a behavioral problem. Psychology counseling and lifestyle medication were the best therapies for her (besides, medication was not an option because there are no known pharmacological treatments for ecstasy addiction).

However, beyond her drugging, Samantha exhibited several signs that indicated she had clinical depression. Physically, she had a flat, emotionless tone to her voice and had a difficult time holding eye contact. She also reported having recurring insomnia. While she worked long hours during the week, she said that she
was tired “all the time,” even on weekends. Finally, she disclosed that her family had a history of bipolar disease.

I introduced her to cognitive behavioral therapy, a short-term counseling program that helps patients see how self-destructive behaviors can play a role in depression and comes up with strategies for avoiding those problems. Her treatment also included a regimen of meditation to deal with anxiety, a healthier diet, and techniques for avoiding insomnia.

Finally, I prescribed a medication known as a selective serotonin reuptake inhibitor (SSRI). The SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). Side effects are generally mild and, if taken under the close monitoring of a trained health professional, are both safe and effective.