Author: Marc

Hi everyone. I haven’t been writing on the blog much lately. My book was released in the UK on July 14th, and that meant shooting off articles for various publications and giving talks and interviews. So I went to London two weeks ago. It’s still there, as colourful and overwhelming as ever. Despite Englands’ majority vote to leave the European union, London is the most multiethnic city imaginable. On ever street you hear a bubbling cauldron of accents and see faces of every colour and shape. What a city!

My trip was fabulous. The first day I was interviewed by The Times, and that night I gave a talk with Johann Hari as my host and interviewer. An interesting man…complex, smart, fun, and a bit darker than expected. The next day, an interview with BBC and another with The Guardian podcast. That night I talked to nearly 400 people — the most positive audience I’ve ever had. Waves of applause and even cheers. Felt like a rock star.

But the most interesting event of my trip was meeting a man named Colin Brewer. If you google him you’ll see that he’s a wild child in British psychiatry circles. Most recently he was villainized by the media for providing supportive assessments for people seeking assisted suicide in a Swiss clinic. The trouble was that they didn’t have terminal diseases, and that’s a no-no. Was this man a monster? He’d gotten in touch with me by email and came to one of my talks. When he showed up at the foot of the stage, I recognized his face from the internet, and he certainly looked…unusual.

That night at my hotel I googled him more thoroughly and found that the people he’d helped obtain assisted suicide were actually in big trouble. One was 90 years old and in severe, untreatable pain. Another was in his seventies, going blind, another had motor neuron disease, and yet another had Alzheimer’s. It turned out that Colin was motivated by empathy and a firm belief in people’s right to die with dignity. He was no monster.

So I accepted his invitation to come for a visit and arrived at his home a few days later. He lives in a beautiful house in the heart of London. He showed me around the antique-laden interior with evident pride, swelling a bit when I complimented the taste and beauty of his home. And then, equipped with home-made elderberry cordials, we sat and talked.

Colin’s trouble started when he used his own instincts and methods to treat addicts, beginning in the 80s. He prescribed methadone, as did other doctors — no problem. But he would also provide a couple of months’ supply of methadone to people who travelled a great deal and could not renew their prescription daily or weekly. He also prescribed heroin for those who needed it (while this was still legal in Britain) as well as generous supplies of benzos and other drugs for those withdrawing from opiates or alcohol. He even supplied do-it-yourself detox kits to people who could not afford residential care. Another well-intentioned though dissident policy. The press branded his practice a drug supermarket and he was struck off the medical register in 2006.

Colin was indeed a renegade who made up his own rules for dealing with addicts. In fact, like Percy Menzies, who wrote a guest post for this blog several months ago, Colin enthusiastically prescribed naltrexone for opiate addicts as well as disulfiram (Antabuse) for alcoholics. He firmly believed in giving addicts a time-out, a substance-free period for resetting their circuitry — and he brought their families into the act, so that they could help encourage their addicted loved one to stick with the program until they were in safer waters. Far from someone who took his patients’ plights too lightly, he seems to have functioned as a deeply concerned caregiver, who wanted above all to give addicts the freedom to transform their own lives.

We wasted no time discussing whether addiction was a disease or not. We both saw the classic disease model as a dead-end. Rather, we talked about the power of placebos, the extent to which addiction includes placebo-like effects — namely the belief that taking something has particular benefits, when the belief creates the benefits. Colin introduced me to a study showing that even physical withdrawal symptoms can follow sudden termination of a placebo believed to be an addictive drug. Fascinating!

But the most important idea I left with was Colin’s belief that overcoming addiction is like learning a second language: reframing, retraining, and thus rewiring synaptic networks. I guess I already knew that, but here’s the new punchline. The best way to learn a second language is through total immersion: avoiding going back to your native tongue for some period of time. The reason my Dutch is still so shitty is because I speak English most of the time. That’s sometimes called “controlled use” in addiction parlance.

I’ll end with a quote from an article written by Colin and a colleague. It makes it pretty clear why total abstinence — at least for a time — is so very helpful.

Relapse-prevention is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behaviour and establishing new, adaptive ones. This process resembles foreign language learning…. ‘Immersion’, the most effective foreign language teaching method, discourages students from using their first language…requiring them to use the foreign language instead, however inexpertly.

Colin Brewer & Emmanuel Streel. Substance Abuse, 2003, 24(3) 157-173.

 

Hi again. It’s me this time. No guests. I want to tell you about the debate I just had with a high priest of the Disease Church. Not the bishop, Nora Volkow. But her second in command, George Koob.

Those of us who oppose the disease label have been trying to organize a real debate for a long time. Nora Volkow has consistently ignored these requests or else replied No through her staff. But Koob made an excellent second choice. Judging by his picture and digital presence, I expected a slightly stodgy, soft-spoken academic/scientist type who saw addiction as a disease.

In fact Dr. Koob is the second author of the paper first-authored by Volkow in the January issue of the New England Journal of Medicine, the paper that made a lot of us anti-disease people more irate than usual. Here’s the title: Neurobiologic Advances from the Brain Disease Model of Addiction. And here’s a passage from the first paragraph:

In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…

I used this quote to launch a counterattack that was published last week in the Guardian. I was pleased to see my little fusillade appear on page 1 of the US edition last Tuesday. And it’s snagged over 600 comments and 2,700 shares in the first week. So a lot of people seemed to agree with my criticisms of the disease model (specifically the claim that the disease label led to an “effective” response to addiction and reduced stigma). But, if you happen to browse the comments, you’ll see that many others thought I was out to lunch.

I actually wondered whether Koob had already read my article. Because he seemed hopping mad from the first words of the debate.

Here’s how it went.

I was sitting in a flashy looking studio in Arnhem. Yes, even in my town we have studios with lots of computers and screens and expensive looking microphones. So I was sitting there in a sound-proof room in front of a state-of-the-art mic, and George Koob was in Washington. The debate was set up by CBC (Canadian Broadcasting Corp — Canada’s national radio) and will be broadcast a few weeks from now. I’ll let you know.

I was nervous. More nervous than I’ve been in any kind of talk or interview for a long time. My voice came out raspy at first. Yet I’d done my homework. I’d reread lots of stuff on changes to the dopamine system, Berridge’s review of his incentive sensitization model, findings on the desensitization of the striatum and the resultant loss of connectivity with the prefrontal cortex. I’d also scanned articles showing that these brain changes are common to drug addiction, porn addiction, obesity, “internet addiction,” and even compulsive shopping — so I had a few arguments ready.

I’d also read a few Koob papers (which I forgot I’d already read thoroughly until I found my yellow highlighting throughout) and felt completely caught up on his theory of the “dark side” of addiction, viz withdrawal, viz the rebound invoked by the “antireward” system. I was ready to talk brain science, because I had no doubt (and I still have no doubt) that George Koob is a top neuroscientist, highly respected and rightfully so. Not to mention the director of the National Institute on Alcohol Abuse and Alcoholism.

But within minutes of the word Go, I realized that I’d done all that cramming for nothing. This debate wasn’t going to be about the neuroscience of addiction. It wasn’t going to be smart, sophisticated, strategic, or fun. It was going to be a slug fest.

The moderator/host (a seasoned radio/TV person in Toronto) started things off by asking Koob: Why do you say addiction is a disease?

He replied something like: What else could it be? And when she asked for a bit more substance: Because it changes the brain. It’s as simple as that. That’s what he said, almost verbatim. And I thought: that’s the most vacuous argument he could possibly make. Everybody knows that the brain is always changing, it changes whenever we learn something, it changes massively throughout development, and there’s this thing called neuroplasticity which is basically the brain’s job description. But that’s what he said: addiction is a disease because it changes the brain. So I had to retort with…well, some version of what I just said.

It didn’t get any better. He sounded angry throughout. He was belligerent at times. He talked about how four people he was very close to had died from alcoholism, because they could not stop drinking. Absolutely could not stop. And he specifically accused me (and us anti-disease folk) of trivializing addiction by not recognizing that it’s a disease. I told him I’d lost a friend to addiction too, but I wasn’t pleased with myself for stooping to such arguments. He even said that I wanted addicts to be stigmatized and that’s why I opposed the disease label. Which was exactly the opposite of what I’d just said: that I felt the disease label merely entrenched the stigma of addiction, and there were much better ways to overcome stigma, like connection, compassion…all the things Johann Hari writes about….and understanding what it really is without giving it a simplistic label.

I’d better stop. I don’t remember everything, and maybe my memories are blurred by the adrenalin I was surfing through most of the debate….which lasted about 45 minutes.

But here’s the point I want to make. I’m pretty sure I “won” the debate because I said smarter things and backed them up better than my opponent. And I’m pretty sure I came off smelling sweeter because my tone wasn’t as antagonistic as his.

BUT IT DOESN’T MATTER.

The problem is that we weren’t talking. We were just fighting. We weren’t listening to each other. We weren’t getting to know each other’s views any better. We certainly weren’t arriving at some kind of middle ground that might benefit from both our perspectives.

And that is so sad!

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for addicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

The judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

……………………………………

I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

Any individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

 

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.

 

The heroin “epidemic” is a major concern all over the world right now. What are the various philosophies for dealing with it? In today’s post I’ll share some impressions from my recent visit to a harm reduction/methadone clinic in Belgium. Then I’ll post a piece by Percy Menzes who is dedicated to the use of naltrexone and policies that minimize access. Then we’ll see what Sally Satel has to say about programs that use punishments and rewards to get people to quit — so called incentives. That should keep us busy.

Last Thursday I took a train to a town in Belgium called Diest. It was two or three days after the attack on Brussels…so there were quite a few military guys standing around in the train stations with machine guns in their hands, ready for action. Not exactly reassuring.

But with all the chaos and pain that seem to infest the world right now, I felt a warm, cocoon-like embrace when I entered the Wit Huis  (The White House), a harm reduction clinic that provides prescriptions for methadone, counselling, and a place to hang out for a little while.

The waiting room was a pleasant lounge where people (mostly addicts) could relax with tea and cookies (and baked goods such as Easter cakes) and chat with their fellow travellers. It was clean, bright, and there was an air of positive energy: care, concern, and understanding. There were leaflets everywhere, outlining the dangers associated with different drugs. And there was always a staff person present, just being friendly, chatting, offering snacks. The staff consists of two social workers, two MA level psychologists, a criminologist (to help with charges, probation, as so forth), and the doctor, Carl, who wrote the methadone prescriptions. Carl was my host.

After being shown around — rooms for counselling, a play area for people with kids, a laundry room, showers, a medical area where wounds and infections were treated and clean needles and accessories were handed out (in exchange for used needles) — I mostly sat in a chair next to Carl in an office/interview room, while one client after another came for their methadone script. It was sort of fascinating.

Most were heroin addicts of course, but many also used meth and/or coke. Many of the heroin users balanced their methadone dose with heroin obtained on the street. And this was no secret. There wasn’t much lying or sneaking going on, according to Carl and the others. It was a tacit assumption that opioid addicts would fluctuate in when, whether, and how much heroin they used to spice up their diet. And there was no confrontation. There was no scolding, no pep talks, no condescension, no sense of a parent figure keeping tabs on the naughty children. Yet Carl was careful to balance the dosage of methadone against simultaneous heroin use: less methadone with more heroin, naturally, to minimize the odds of overdose. And overdose was rare with this population. So how did they manage that?

The clients seemed content to report honestly on what drugs they were taking, mostly because there was no censure or disapproval, either explicit or implicit, in the attitudes and behaviour of the staff — including Carl. But just to make sure, unanticipated urine tests were requested when people said they’d stopped using heroin and wanted to increase their dose of methadone to compensate. Again, it was the warmth and camaraderie that flowed between staff and clients that neutralized the temptation to lie. The smiles and hand-shakes, the invitations to chat about how things were going, the absence of demands. These people were leading lives that to some extent they were choosing and to some extent they were stuck in…and nobody was judging them. The purpose of the clinic was to keep users safe, healthy, and out of jail.

Nevertheless, despite all this sweetness and light, these folks were seriously addicted, both physically and psychologically, to a very powerful drug. They weren’t anywhere close to safe and stable in the big picture. About half were homeless, which generally meant they slept in different homes night by night, or in abandoned houses, or with relatives. They were not the happiest of campers.

And where I saw this most clearly wasn’t in the statistics — re homelessness, unemployment, co-occurring psychiatric disorders — but in the posture and facial expressions of the people sitting in the chair across from the doc. They often looked defeated and helpless. While some expressed enthusiasm, plans for the future, many looked dreamy or blank. Quite a few had the hunched over posture that expresses shame or remorse. Their eye contact might be sparse and fleeting, looking down a lot — the gaze pattern of people who live with a chronic level of shame or sense of inferiority. A sense of personal failure they’ve grown deeply accustomed to.

That part was sad. That aspect made me think that harm reduction and methadone provide a solution to the heroin epidemic, but it’s not a great solution. Something is still seriously wrong here, and this form of treatment, connection, and care can make it livable. But only just.

Clinics of this sort have sprung up in towns and cities throughout Belgium and other European countries. As always, I’d love to hear your opinions.

Here’s an article I wrote for The Guardian a few weeks ago. This link will take you right there. And while you’re there, check out some of its neighbours in The Guardian’s Autocomplete series. These articles try to provide quick, neat answers to the deep questions we often pose to Google. Or, in their words:

Every day, millions of internet users ask Google some of life’s most difficult questions, big and small. Our writers answer some of the most common queries.

I  especially like David Shariatmadari’s piece on depression. And another that might be of interest is David Nutt’s attempt to answer the question Why are drugs illegal?

This reposting is an easy way out of sitting at my desk and pounding out something original. Instead of being productive, I’m supposed to lie on my back on the sofa, which sounds very appealing, because…

I just went to Geneva to attend a conference on Behavioral Addictions. But something very painful happened to my hip soon after I arrived. No, it’s not serious…according to the X-rays and CT scan, but to find that out I spent roughly 15 hours in a hospital in Geneva, moaning, squirming, with a bit of writhing thrown in. The best part of the story has something to do with the irony of lying on a cot, pleading for more morphine, while skipping these cutting-edge talks on addiction. More on that next week.

Sofa, here I come.