The Addiction Solution

Treating Our Dependence on Opioids and Other Drugs

Lloyd Sederer

• Publisher: Scribner
• Year: 2018
• ISBN:
  9781501179464
• Topic: Psychologie
• Subtopic: Sucht in der Psychologie

A groundbreaking, "timely and well-written" ( Booklist, starred review) guide to addiction from a psychiatrist and public health doctor, offering practical, proven solutions for individuals, families, and communities dealing with substance use and abuse. Written with warmth, accessibility, and vast authority, The Addiction Solution is a practical guide through the world of drug use and abuse and addiction treatment. Here, Lloyd I. Sederer, MD, brings together scientific and clinical knowledge, policy suggestions, and case studies to describe our current drug crisis and establish a clear path forward to recovery and health. In a time when so many people are affected by the addiction epidemic, when 142 people die of overdoses every day in the United States, principally from opioids, Sederer's decades of wisdom and clinical experience are needed more than ever before.With a timely focus on opioids, Sederer takes us through the proven essentials of addiction treatment and explains why so many of our current policies, like the lingering remnants of the War on Drugs, fail to help drug users, their families, and their wider communities. He identifies a key insight, often overlooked in popular and professional writing about addiction and its treatment: namely, that people who use drugs do so to meet specific needs, and that drugs may be the best solution those people currently have.Writing with generosity and empathy about the many Americans who use illicit and prescribed substances, Sederer lays out specific, evidence-based, researched solutions to the prevention and problems of drug use, including exercise, medications, therapy, recovery programs, and community services. "Comprehensive…well-informed and accessible" ( Kirkus Reviews ), The Addiction Solution provides invaluable help, comfort, and hope.

PART ONE

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WHAT COUNTS

1

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TEN THINGS THAT MATTER

That humanity at large will ever be able to dispense with Artificial Paradises seems very unlikely. Most men and women lead lives at the worst so painful, at the best so monotonous, poor and limited that the urge to escape, the longing to transcend themselves if only for a few moments, is and has always been one of the principal appetites of the soul. Art and religion, carnivals and saturnalia, dancing and listening to oratory—all these have served, in H. G. Wells’s phrase, as Doors in the Wall.

—ALDOUS HUXLEY, THE DOORS OF PERCEPTION

. . . to understand how and why certain users had lost control I would have to tackle the all-important question of how and why so many others had managed to achieve control and maintain it.

—NORMAN ZINBERG, DRUG, SET, AND SETTING

One unpleasant consideration for those whose drug views and policies call for total abstinence is the substantial number of individuals who use but do not abuse psychoactive substances. These include people who drink alcohol in modest amounts as well as those who periodically use opioids.

Over time, as more people who take drugs own up to their use, we have reliable information about “chippers,” occasional users of opioids, as well as those who use other drugs periodically without damaging their bodies, their relationships, their work, and their lives. This finding extends to occasional users of psychedelic drugs such as psilocybin, ayahuasca, peyote, and LSD. We are still learning about marijuana as it has become legalized for recreational use by adults in eight US states and the District of Columbia, and decriminalized extensively. But the same cannot be said for tobacco or for persistent, heavy drinking, both of which cause damage to vital organs.

General statements belie the nuances and variation of response to psychoactive agents within a population of individuals. We are still left to try to understand adequately the critical dimensions of a person’s biology, psychology, and community that shape any given individual’s actual drug experience and use over time.

One remarkable story comes to mind. William Stewart Halsted, MD (1852–1922), was an American surgeon who was one of the four founders of Johns Hopkins Hospital. He became its first chief of surgery when it opened in 1889. Born of privilege and Ivy League educated, he was an early champion of proper aseptic techniques and the use of anesthesia for surgical procedures. He pioneered the introduction of radical mastectomies for breast cancer. Halsted performed one of the first successful gallbladder operations in the United States—in the middle of the night on his mother on her kitchen table—and delivered one of the first blood transfusions. (He transfused his own blood to his sister whom he then operated on, saving her life.) He initiated surgical training internships and residencies, which fortunately continue to this day. These are only a handful of his contributions to modern medicine. Yet throughout his distinguished medical career, Dr. Halsted was a daily drug user. First it was cocaine, an available legal local anesthetic; his “addiction” to it was treated at a Rhode Island asylum. There he was given morphine, also legal in his time, as an alternative drug, which then became his lifelong chemical partner. He injected morphine daily, all the while performing surgery and leading an exceptionally gifted and energetic life. He had some problems—would, for instance, apparently go missing from time to time—but evidently did not appreciably suffer the ravages of an opioid addiction nor a serious, deleterious effect on his health, family, or achievements.

I clearly am not advocating a morphine habit as the path to a famed life. Instead, Halsted’s example, along with many others, compels us to look beyond the pharmacology of any given drug to understand how it may or may not affect the life of the person who uses it.

Below I identify ten factors that influence how an individual will interact with a psychoactive substance. My purpose is to try to fill in the information gaps and correct some of the misinformation that clouds our thinking about substances. My goal is to more intelligently inform how we feel about, respond to, and set social policy for those who use drugs as well as their families, friends, and communities.

I address these ten, which are not of equal valence, in a limited fashion and not in order of importance. While there are other factors, these are salient.

1. AGE

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The human brain does not complete its maturation until well into the third decade of life, later for males than for females. Appreciating the protracted development of the human brain can help parents understand the emotional volatility, impulsivity, and potential for poor judgment that drives youth, especially adolescents. It also is a caution about the use of substances while the brain is developing, laying down the myelin that braces our nerve fibers and helps us make better decisions.

The regular use of marijuana in teenage years may indeed impair intellectual, academic, and athletic performance. In addition, in youth with a biological predisposition to psychotic illness, its use can unleash an underlying mental disorder. The use of drugs, alcohol, and cigarettes in adolescence can also signal a greater propensity for their use in later years. Teens who smoke cigarettes by the time they are eighteen are far more likely to use tobacco when they’re older. (Smoking remains the greatest preventable cause of morbidity and mortality in developed countries.)

There are similar considerations for alcohol use, which is pervasive among American teenagers despite being illegal. Its limited use, without bingeing or overdose, usually turns into the social-drinking patterns that characterize most adults. Genetic traits and experiences of alcohol, positive and negative in a family, can tip the balance and foster dependence on this substance—or not—as a youth matures. Early drinking is a marker of biological vulnerability to alcohol as well as to individual and family social malaise. Preventing use in vulnerable teens as well as early detection of and intervention for problem drinking and drug taking are age-specific actions that can make a lifetime of difference.

2. SET

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Billie Holiday (1915–59) was arguably one of the greatest blues singers. I happen to think so. Johann Hari, in his remarkable and bestselling book Chasing the Scream, eloquently tells her story, which I summarize here. When Billie was born, her mother was nineteen and her father seventeen, but he was nowhere to be found. Billie’s mother was a prostitute, and the streets of Baltimore became Billie’s home from an early age. When ten, she was raped. Her screams brought the police, who concluded she was also a prostitute. (Imagine alleging a ten-year-old to be prostituting herself?) She was briefly jailed and soon mandated to a year in a reform school. While there, as punishment for her lack of obedience, she was locked in an empty room overnight with a dead body; no one answered her screams. She escaped and fled to Harlem, in New York City, where she thought her mother might have gone. Indeed, her mother was working in a brothel, would not keep her, and threw her out. Billie’s “solution,” as a fourteen-year-old, was to prostitute herself, first in a brothel and then for a violent pimp whom her mother urged her to marry.

It gets worse. She was arrested for prostitution and sent to prison on Welfare Island, now Roosevelt Island, the predecessor institution to Rikers Island. When she was released, her first objective was to ingest the most powerful substances she could find, first high-proof, cheap alcohol, and soon heroin. Her habit would transport her away from a mind filled with rape, imprisonment, physical violence, and maternal neglect. She looked for work, failed as a dancer, but, boy, could she carry a tune. Billie the singer was born.

But she continued under the “management” of her abusive pimp (and husband), who stole her money and reportedly punched her in the face after one of her storied performances at Carnegie Hall. She continued to drink heavily and shoot heroin. She became the special target of one Harry Anslinger—whose story is bracingly told by Alexandra Chasin in Assassin of Youth—the first director of the Federal Bureau of Narcotics, the successor agency to the former Department of Prohibition, which had no Prohibition left to enforce.

Billie was set up to be busted by her pimp-husband, who wanted her punished. She was sent to prison again, this time in West Virginia, for a year. As a consequence of her crime she lost her cabaret license and became homeless—though her legend continued. She found gigs outside of standard clubs until she once again was pursued by the Feds and arrested in San Francisco in what appears to have been a drug plant by federal agents, who entered her room without a search warrant. She was acquitted at trial, but her life spiraled further down. She had cirrhosis of the liver from the alcoholism and remained addicted to heroin. She died in a hospital at the age of forty-four, afraid that the Feds would send her to prison again, to make her an example of the perils of drug addiction.

Imagine the first moments that this heavenly songstress—raped, beaten, abandoned, neglected, imprisoned, and without prospects—knocked down her first strong drink or felt the warmth and comfort of heroin coursing through her veins. It is a bit of a miracle that some escape a life like hers without alcohol or drug dependence—but too many, like Billie, don’t. Her psychic pain became the driver of her addiction, the ingredient that made her encounter with psychoactive drugs necessary and irresistible.

Set means a personal vulnerability to drugs, which has two components: first, personality, the preexisting character of a person, fashioned by their life story and including any tendency to externalize or hold circumstances and other people responsible for any problems; and second, an individual’s unique biological responsiveness to any given drug.

In work supported by the National Institute on Drug Abuse (NIDA) in the 1970s, when this concept was postulated and popularized, set was more specifically defined for research purposes. Five personality dimensions were studied: passive vs. active; intimacy vs. isolation; rebelliousness vs. conformity; awareness of affect vs. distance from affect (feelings); and distortion of reality vs. its acceptance. Moreover, attention focused on the indicia of early personality problems such as delinquent and criminal behavior as well as troubled family backgrounds. This research revealed the qualities of people that can shape the set of their use and their experience when taking drugs. The person who takes the drug is an active “ingredient” in his or her response, for immediate as well as longer-term effects.

In the late sixties and in the seventies, inspired by a culture of “turn on and tune out,” the ingestion of LSD (as well as other drugs) became popular. For a number of years urban emergency departments (EDs) were populated by young people in the throes of a “bad trip.” A scare spread about the danger of LSD, and its potential to destroy the minds of its users. But then, a few years later, EDs would rarely see a bad trip. What happened? It was not the drug, it was the psychological state that people using had been in upon ingesting the LSD. Their fear and misinformation, their psychological set, produced the panic that infused their drug experience. Over time, LSD subcultures educated users about how to use it, how not to panic, and to take the drug in environments conducive to calm and security, with guides to help smooth out the bumps. The set had been altered—and the drug experience went from what had been a nightmare to a pleasant reverie.

I do not mean to suggest that anyone who is well prepared for the use of a psychedelic drug and takes LSD in a sweet setting with good and experienced drug-using friends can ingest it with impunity. Some people with latent or preexisting serious mental disorders, including schizophrenia and bipolar disorder, are at high risk of unleashing a psychotic state that may persist well after LSD has left their body. This exemplifies a biological set or disposition, different from a psychological set, where the mental state of the user will powerfully influence what happens when a drug is ingested.

3. SETTING

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In 1971, Dr. Norman Zinberg, of Cambridge Hospital and Harvard Medical School, was asked by the Department of Defense and the Ford Foundation to go to Vietnam, where a deeply unpopular and deadly war was raging. He was an expert on drugs, whose work I greatly admired when I worked in the same psychiatry department, and his mission was to assess the degree to which combat soldiers were using heroin and advise on what might be done. A worry was that when the soldiers came home, they would bring their habits with them, outnumbering the estimated total of those already addicted to heroin in the United States.

From reports by Zinberg and his collaborator Lee Robins, about 20 percent of the enlisted men in Vietnam were using heroin frequently, from daily to many times a week. They had access to potent, uncontaminated, cheap heroin, which they principally smoked or snorted. This psychiatrist and psychiatric epidemiologist, working together, forecast that the soldiers’ drug use would be largely left behind in the jungles of Southeast Asia after they came back to the United States. And they were right. Eighty-eight percent of the returning soldiers who used did not continue to do so. Though 12 percent did, in excess of the rates of the general population, these men had battled in a guerrilla, tropical war that lacked support at home and from the people they were ostensibly trying to “save.” Many were seeking a means to “make time go away.” Moreover, we know today that up to 30 percent of battle-exposed veterans develop PTSD, clinical depression, traumatic brain injury (TBI), or all three—coupled with high rates of alcohol and drug use related to these conditions.

All this is what is meant by setting, in which the context, the environment, and the circumstances are fundamental to a person’s use, abuse, and dependence on a drug. We are in the dark unless we shine a light on the setting in which a psychoactive drug is employed.

4. ROUTE OF ADMINISTRATION

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The faster a substance gets into our brain, the more likely it is to become habit-forming.

The tobacco in cigarettes has perhaps the most rapid form of administration of any substance, which helps make cigarettes among the most addictive of substances and the hardest to quit. Much the same can be said of crystal meth and cocaine when they are smoked, the latter as crack cocaine. Some experts and drug users remark that it is easier to quit heroin than cigarettes, and a 2010 scientific report to the EU declared tobacco to have a substantially greater risk of causing addiction than heroin, alcohol, cocaine, or cannabis. Yet Alcoholics and Narcotics Anonymous (AA and NA) seem to accept addiction to tobacco as an exception to their prominent aim of achieving abstinence.

Cocaine snorted is less addictive than cocaine rolled into a cigarette and smoked. When cocaine is crystallized and smoked as crack, potent amounts even more rapidly reach the brain, where they have a short but intense effect that fosters repeated use and dependence. Methamphetamine is a common, available stimulant that has been used recreationally and to improve academic performance, and to a lesser extent as a treatment for attention deficit/hyperactivity disorder. But its illegal crystallized form, crystal methamphetamine (meth), evokes incredible energy and euphoria that is so rewarding, especially when the drug is inhaled, that the user often repeatedly chases the (initial) high. But that first-time nirvana is seldom reachieved, while the repetitive use of the drug can be destructive, toxic to our brain cells. This drug was popularized in the hugely successful TV show Breaking Bad.

Our brains seem to become more habituated to substances that arrive immediately, powerfully, and that don’t last long. The route of administration counts when it comes to how we humans respond to substances.

5. PURITY

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