Category: Connect

…by Shaun Shelly…

I just pulled into a lodge in Banff, Canada at 2 AM (roughly noon for me) after a flight delay and missed shuttle. I’m way too tired to introduce this intelligently. All I can say is that I have huge respect for Shaun’s understanding of what goes on in opiate addiction, both above and below the surface we call treatment. See for yourself:

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Firstly, I think that the most important thing to remember is that OST (either agonists such as methadone or partial-agonists such as Buprenorphine, with or without naloxone) saves lives. There is up to 75% reduction in mortality for those in these programmes as opposed to those who do not have access. That alone should sweep away almost any argument against the utility/ethics/need for OST programmes. OST is well researched and has been shown to work and save lives over many years. (*1 for examples -there are many)

Secondly, low threshold programmes, such as the one you describe [see last post], that do not insist on abstinence or accessing other services, are a vital part of the continuum of care. The data tells us that psychosocial interventions such as CBT add nothing to the outcomes of these programmes in terms of drug use, retention, other health issues etc. Personally I have some issues with the design of some of these studies, and as with most “addiction” research they are too limited to draw absolute conclusions from, but certainly the lack of availability or the lack of willingness to engage in psychosocial services should NEVER prevent the supply of OST.

Thirdly; there is plenty of evidence that these programmes improve access to health services; improve compliance on ARVs and TB meds; reduce criminal activity; improve quality of life in some people; can help people become employed; lead to people choosing to engage in other “addiction” treatment programmes, including abstinence based programmes (but this increases risk of mortality in the short-term!) etc etc

So, it is clear, in my opinion, that we should be offering low-threshold OST programmes. I think it is also very important to note that this type of programme, along with needle and syringe programmes, offers a unique opportunity for drug users who are highly stigmatised to engage with health and other services, and, perhaps vitally, to engage with people who are part of a wider community without stigma or judgement. This interaction can, and sometime does, provide the “scaffolding to construct a vision of future self” (to paraphrase one of my favourite quotes from Marc).

For some people the simple move from a street opioid to a pharmaceutical opioid with a longer half-life is all that is needed to find some stability and start “living” again. If they have the correct support structures, mental faculties, education, family or alternative family structure, the right lucky break or a guardian angel individually or in any combination, they will be able to build a productive life. I know many such people. They are still dependent on an opioid, but are not addicted – so what! Just the structure of attending the clinic and not having heroin be their all-consuming vocation, can give them the space and the belief  to start making changes, and these are often self-accelerating. Some of these people will eventually down-titrate to zero or close to zero dose, some may not. Their choice. Some may have, as Dr Mark Willenbring has suggested to me, a hypoactive endogenous opioid system that requires a life-long agonist to function optimally.  Either way, they, and many of the rest of the world, except the abstinence Nazis, are happy.

However, there are many exceptions. While many of the people you saw “weren’t anywhere close to safe and stable in the big picture” I would argue that this has little to do with their drug use. I certainly do not want to paint all street dwelling dependent heroin users as victims – they are often the most resourceful and resilient people I have ever met – but many of them (but not all as Gabor Mate would have us believe) are sufferers of serial trauma and most have been highly stigmatised, ciminalised and ostracised. In this case, they may not have the resources, intrinsic and extrinsic, to build on the new-found structure of methadone or buprenorphine and create a “new life” or find “recovery”. Indeed, for many that may not even be desirable.

For many of these people heroin is a form of vocation and indeed the thing that binds them to their street family (see the video I have linked at the end of this post). I have worked extensively with these populations, and I find that for many drug use is a supremely logical choice in the face of little chance of finding meaning in what others would call “normal” pursuits. As I stated earlier, this is not a problem of pharmacology, this is a problem that lies beyond the individual and in the structural and systemic issues of modern society – the work of Alexander (his FULL BODY of work!) is very relevant. To expect methadone programs to address these issues is unrealistic!

This leads me to the one area where I do have a problem with methadone programmes and the reductionist approach that reduces harm reduction to a set of bio-medical interventions. Just because people are being kept alive does not mean we have solved the problem. The other issues that need attention are criminalisation, stigma, inability to address the needs of those with mental health and other issues. These are not (only) drug issues, but societal issues.

One of the steps towards addressing these wrongs lies in the fact that agonist therapies work – they are the only consistent therapies to work with “addiction” when it comes to health issues. The logical conclusion is that we should make pharmaceutical agonists easily available to all drug users – allow these street users the same benefits that many of us “functional due to privilege” users enjoy – access pharmaceutical quality drugs with the minimum of barriers. That is decriminalise, legalise and regulate all drugs. This will not solve all the problems, but will go a long way to prioritising who does and doesn’t need “treatment”!

Video on “street families”:
http://www.featureshoot.com/2015/11/photographer-chris-arnade-on-street-addiction-and-the-devastation-it-leaves-in-its-wake/

*1 EG :Caplehorn, J. R., Dalton, M. S., Haldar, F., Petrenas, A. M., & Nisbet, J. G. (1996). Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use & Misuse, 31(2), 177–196. http://doi.org/10.3109/10826089609045806
Connock, M., Juarez-Garcia, a., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., … Taylor, R. S. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment (Winchester, England), 11(9). http://doi.org/10.2165/11632820-000000000-00000

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.

Three posts ago, I discussed the personality traits that make us most vulnerable to addiction. And I promised to say more about them.

Most experts agree that the two biggees are….

(1) an impulsive or risk-taking personality style

(2) an anxious, oversensitive personality style

Note once again that there is nothing like a standard “addictive personality” — contrary to popular belief. In fact, these traits are almost perfect opposites. In her upcoming (excellent!) book, Maia Szalavitz emphasizes a third gateway: an insidious combination of the two. Maia says this was the recipe for her own addiction, and I think that was it for me as well. So let’s call this third personality pathway…

(3) an impulsive or risk-taking style combined with oversensitivity

How do each of these trait structures predispose us to addiction?

Most experts emphasize the link between impulsivity and addiction. That’s pretty straightforward, but it’s especially problematic in adolescence, when every kid gets somewhat impulsive (except for the real nerds) because evolution designed us that way. Now trait impulsivity becomes a risk factor for all sorts of things: shop-lifting, uprotected sex, preventable accidents, etc. But when you’re an impulsive person at an impulsive stage of life, you’re especially likely to hold out your hand when powders or pills get passed around. “Hey, I want to try that!” Drugs and booze are risky, and risk-takers are first in line.

But there’s another, subtler, causal connection. Research links the impulsive/risk-taking trait package with inborn differences in the dopamine system, and this path to addiction was touted by Kenneth Blum as the reward deficiency syndrome. Due to normal genetic variability, some people have fewer or less sensitive dopamine receptors of a particular type (e.g., the D2 receptor in the nucleus accumbens, the brain region underlying reward seeking). According to Blum, these people need more dopamine to feel excited or engaged. I’ve written about this in detail elsewhere, but the idea is simple. If you need more dopamine to satisfy your underpopulated D2 receptor system, the easiest way to get it is to take drugs.

Now, if you know (maybe unconsciously) that you need more of a charge than others to feel good, then it makes sense to train yourself to seek and find risky situations. So, you may end up “hypersensitive” to high-impact rewards because that’s really what you live for. People who are extreme in their impulsivity also lack normal levels of social anxiety. So they don’t care much about how others react to their excesses. Then we are verging on the antisocial/psychopathic personality style. And those people can be bad news in all kinds of ways.

What about the anxious, oversensitive person? We become anxious about how others react to us, sensitive to rejection, and perhaps obsessively concerned about how we are acting, not only based on genetic patterns (e.g., not enough serotonin) but also based on our family environment. If you are raised by parents who are unpredictable, touchy, volatile, or anxious themselves, then you have every reason to become anxious in social situations — and a genetic blueprint that favours anxiety will help you get there. Why would such people be more likely to find drugs appealing and, eventually, addictive?

I can speak to that personally. My mom was volatile and somewhat of a perfectionist. There was a lot of love between us, but I learned to worry about how I was behaving — and my behaviour was far from perfect. What looks like social anxiety from the outside can feel like self-criticism and self-doubt on the inside. That was me, and like many others who feel this way, it led me to depression even before I got to boarding school — where I learned just how nasty life could get. Depression and anxiety are highly correlated with addiction for good reason: drugs make you feel different, either calmer or more uplifted, they give you the sense that you can control your mood by ingesting something, and you become less reliant on social approval because you’re standing right next to the feel-good tap. Particular drugs help (“self-medicate”) in particular ways. For me, it was the soothing caress of opiates; for others it can be the bright reassurance of meth or coke. For some, it’s both.

What about #3, the combo? Maia Szalavitz speculates that being a risk-taker and an anxious perfectionist was the recipe for her addiction. Same with me. From the age of 3 or 4, I was the kid who would climb up the rose trellis and stand on the roof, crowing. I was constantly cajoling my cousin, Nancy, to explore the ravine with me, though it was strictly off limits. To present my mom with the nicest possible bouquet, I picked every flower in our neighbour’s backyard. I slid down the ice slide right in front of my teacher, because I’d literally forgotten that she’d just told me never to do it again. That sent me on my first visit to the principal’s office — in Grade One! Then, as a teen, I wanted to try booze, and weed, as soon as they were offered. And I spent my last year of boarding school dreaming about our upcoming move to San Francisco, where the streets were said to be awash in LSD and other exciting chemicals.

But I think this is the most interesting part: my penchant for anxiety, depression, and self-criticism joined forces with a deeply rooted attraction to risk-taking. Take the pill, try the needle, why not? And then, wham! I suddenly feel like I’m the conductor of the symphony of my moods. Depression, be gone! With the help of my allies in the chemical kingdom, I’m the one in charge.

What this shows is that personality development brings divergent traits and proclivities to a point. Development takes the parts and welds them into a whole. And if that whole starts to coalesce around the attractions of substance use, there’s going to be a rough road ahead.

Will a developmental-learning model of addiction (e.g., Maia Szalavitz, Gabor Maté , Stanton Peele, and me) ever make peace with the disease model? That would be a happy ending! Nora Volkow and I could eat muffins together…or maybe have a glass of wine. We could establish a space for sharing data and ideas, working together toward an explanation that incorporates the best of both worlds.

Yet I don’t think it’s in the cards. Not because the disease model is so far off base scientifically. In fact, where the brain in concerned, the distinction between learning and pathology isn’t always obvious, as epitomized by ADHD, autism, bipolar disorder, even schizophrenia. There’s got to be some allowance for overlap — doesn’t there?

It’s not that the disease model is so wrong, it’s that the baggage it carries may never fit in the same home as the learning model. Here’s what I mean:

Society’s understanding of addiction can be seen as advancing through three stages.

First, beginning in the Victorian era, addicts were considered morally flawed and indulgent. We could call that the “sin” model. Consequently, the appropriate response to addiction was to punish the addict through scorn, isolation, and maybe even jail time. Through shame and retribution, the addict might, with luck, go back to being good.

The second stage was the era of the disease model, beginning in the middle of the 20th century. The change was driven by the emphasis on helplessness in Alcoholics Anonymous, beginning in the 30s, and the evolution of residential treatment centers that stressed obedience to therapeutic regimes, beginning in the 50s. Finally, the proliferation of neuroscience in the 80s and 90s put a seal on the package by pointing to a diseased organ, namely the brain. Now specific neural changes could be pinpointed as the source of addiction, and the disease model ruled the roost.

According to the disease model, the appropriate solution to addiction was medicine. Specifically, addicts were to be urged to follow the advice handed down by medical practitioners. Rather than confess to being immoral, addicts were advised to confess to being incapable. The only hope to control addiction was to accept a regime imposed by an authority. In other words, to subdue a problem located on the inside, you needed to take orders from the outside. It is this baggage that seems destined to clash with the mindset of a third, more progressive view of addiction.

The third stage in our understanding of addiction is the learning model: a developmental sequence of events that gives rise to habitual patterns of thinking and feeling. This view of addiction admits the potency of social factors, like isolation and dislocation, as catalogued by Bruce Alexander. It makes sense of the impact of adversity in early development, as emphasized by Gabor Maté and Maia Szalavitz. And it allows for the influence of societal and cultural issues, as portrayed by Carl Hart and Johann Hari.

According to a developmental-learning definition, the appropriate response to addiction is neither shame and isolation nor submission to a therapeutic regime. Rather, it is further growth. The solution to addiction can’t be a medical regime that returns the addict to some previous level of normality. Nor can it be disempowerment, intended to counter built-in character flaws. Rather, people emerge from addiction through ongoing development. In this light, addiction can be viewed as a stage of individual development, and it must therefore be addressed through individual efforts based on individual perspectives, goals, and capacities. A developmental-learning model of addiction suggests that positive change must be pursued from within.

The final two stages in our understanding of addiction, the disease model and the learning model, have both achieved some of their plausibility on the basis of brain research. But the role of neuroscience in these two stages of conceptualization could not be more different. Neuroscience helped shore up the disease model by identifying deviations from what is considered standard neural architecture, a project we could call “neuronormativity.” Remember: the target was a cure. In contrast, the developmental-learning model of addiction embodies an emerging understanding of neuroplasticity. This replaces the search for normality with an emphasis on the brain’s capacity to change.

Thus, both models borrow something from the brain—a detailed breakdown of measurable biological events. But they are fundamentally different in orientation, and they perceive the brain in such very different ways that it’s hard to imagine how they might be reconciled. It’s the same problem that’s appeared in the tension between developmental psychology and mainstream psychiatry over many decades. The brain is either a normative thing that can go wrong and then be repaired, or it is an open system that can develop along diverse trajectories, integrating the meaning of experience according to its own expertise.

Addiction is one of those trajectories, but then so is progress beyond addiction.

NOTE TO READERS: I do try to respond to most of the comments in the comment section following each post, unless there is already a dialogue going and/or I have little or nothing to add.  But I can’t always keep up with the volume of comments (volume = GOOD!) I’ll have an easier time responding, and so will others, if you keep your comments relatively succinct. Try for two or three paragraphs, max. Longer “essays” can be very thoughtful and informative, but they take time to consider and respond to intelligently. That’s the trade-off.