Friday, August 27, 2004

Swiftvets Interlude

Fox Island SunsetIt would be hard to add anything - pro or con - to the firestorm of comments regarding John Kerry's service or the Swift vets attack on his character and post-Vietnam testimony about ubiquitous war crimes in Vietnam. This is presidential campaign season, and tempers and hyperbole are on overdrive. Vietnam, even so many years later, is a festering wound which refuses to heal, and the scab's been picked off again.

One thing that has moved me considerably has been the quiet testimony of so many soldiers from Vietnam, now coming out to tell their stories. So long in hiding, having been scorned by their countrymen on their return after honorable and courageous service, a few now come forward to share ther experience and bravery - not seeking kudos or political gain, but simply that the truth as they have seen and know it be heard. Granted that in the fog of war truth can be an elusive thing to define. But I am glad that these honorable men have their brief moment of acknowledgement, and I salute their service which was performed by the vast majority out of good motives and by the high standards of military service.

I was in college and medical school during Vietnam, in D.C., so I had a lot of personal experience with the massive protests against the war. Myself, I was softly opposed - far more out of fear than principle, with a draft lottery number of 31. Mixed with that was the naive idealism of youth.

It was always clear to me that the radicalism that energized the antiwar movement was wildly out of touch with reality. The Jane Fondas, SDS, Chicago 7, Black Panthers, and their ilk, with their demonization of America and glorification of Ho Chi Min as a populist hero and liberator, always struck me as both foolish and frightening. I conceived of Vietnam as an initially well-intentioned conflict which bogged down in irresolution, handcuffed as we were by the Cold War nuclear threat from the Soviet Union and Red China.

Vietnam was a misguided and frustrating episode in an otherwise noble and morally justified conflict against the tyranny and imperialism of global Communism. The soldiers who fought there, with few exceptions, were men of honor and courage, who were horribly treated for their service by an angry, confused and frankly misguided country. Perhaps we can hope - after the dust of an election year has settles - that they receive the honor due them and the peace they were never allowed to experience.

Saturday, August 21, 2004

There Is a Solution

Pink Rose"There is a solution." So starts a chapter of the
Big Book of Alcoholics Anonymous - the virtual Bible of recovery from alcoholism and the basis of all 12-step recovery programs. And it works - according to the testimony of millions of recovering alcoholics and addicts in the nearly 70 years since the inception of AA by its two founders, Bill Wilson and Dr. Robert Smith.

In our age of science, secularism, and skepticism, such simplistic answers seem almost mythical, perhaps purely psychological in origin. And the basis of the success of 12 step recovery programs remains incompletely studied and poorly understood. To those in recovery, this comes as no surprise, for they attribute their success to a fundamentally spiritual process of transformation, one therefore not likely to reveal its secrets through the rigors of scientific study. But the overwhelming power of addiction in the lives of those affected - seemingly immune to force of will, ravages of disasterous consequences, or the intervention of psychology, counseling, or pharmacotherapy - succumbs only to the apparent impotence of humility, honesty, and submission to others.

Despite our culture's formidible expertise in psychology, neurophysiology, pharmacology, and social science, despite billions spent on the war on drugs, we have failed miserably at solving the addiction problem. Yet the very fact that anyone can recover from the hopelessness and destructiveness of this disease is remarkable. That millions have done so - unaided by medical science, psychiatry, or neuropharmacology - is truly a phenomenom.

In some regards, recovery programs like AA are rather simple: if you don't drink, or take the drugs, you don't start the physiological process which creates an intense craving for more of the same. Furthermore, the adverse consequences of substance use also disappear: if you don't drink, you don't get a DUI, or end up in jail for vehicular homicide. If you stop shooting up, your chances of acquiring hepatitis, AIDS, or endocarditis go away. Most alcoholics and addicts who stop drinking or using find their lives get better relatively quickly: their health improves, many social conflicts resolve, they keep their jobs and become more stable financially. Reason would dictate that this is the only sane way to live. But reason evades the addict even when dry, and such logical and will-based attempts at sobriety are surprisingly short-lived as a rule.

It is not clear whether the thought disorder of addiction - the obsessive desire to pursue a substance despite diminishing euphoric returns and increasingly dire consequences - is acquired as a result of the intake of the large quantities of drugs over time, or is rather inherent in the underlying physiology and genetics of addictive disease. It is likely, however, that the secondary psychological compensation mechanisms - denial, rationalization, minimalization, etc. - are a result of the need to accomodate the cognitive dissonance resulting from obsessive-compulsive drug pursuit and the spiraling negatives resulting from such abuse. Herein lies the trap for willpower-driven abstinence: it does not remove the obsessive component and is therefore undermined by the mind's incredible capability to use denial to achieve what it so desperately desires. And here is where the true wonder of recovery lives: successful recovery provides the tools to overcome the obsession and the profound denial which enables it.

So how do 12-step programs like AA accomplish this feat? Recovering addicts and alcoholics are quick to reply that they don't understand it, it just works. But it is not hard to postulate some mechanisms by which it succeeds.

Cessation of drinking or drug use, after a period of physical withdrawal (a high-risk period both physically and for relapse), ultimately removes the physiological craving induced by the drugs themselves. But the psychological obsession remains and is typically intense, often for many days or months. It is during this period that the continual support of peers who have endured and survived this extraordinarily difficult passage is critical. Group meetings, frequent phone contact, and close association with recovering individuals is critical at this juncture.

This is the main value of treatment programs, especially those with inpatient confinement. The addict is separated from their drug, isolated from high-risk enviroments and associations which can trigger the potent denial mechanisms to their detriment. The alcoholic or addict is also thrown into forced association with others in the same dire straits, as well as those in recovery who understand the problem clearly and objectively. This provides an excellent opportunity to begin breaking down the self-deception and dense denial which propogates the problem. It is easier to see a problem in others than in ourselves - particularly when their experience parallels your own, and others' weaknesses and shortcomings are openly shared. The alcoholic or addict may not believe in the principles or program of recovery, but it is hard to deny the proof of its effectiveness in the lives of those who have traveled the same journey, successfully overcomimg their liability.

There is a certain amount of magical thinking among public policy makers and pundits about the value of drug and alcohol treatment, however. Treatment facilities do not have some magic mojo they can whip out to convince the addict of the errors of his ways, forever setting him on the path to a sober life. What must occur is that the alcoholic must be willing to change, and trust the guidance of others to succeed at something far too difficult to master by oneself. Trust of others also runs counter to the endemic paranoia of addicts. These are no small hurdles for those who enter treatment, even willingly - and for those involuntarily confined without sufficient desire to change, they can be insurmountable.

This is what alcoholics call "hitting bottom": pain intense enough, and willingness sufficient enough, to become determined to change and follow the direction of others to overcome the hopelessness of addiction, no matter how foolish or implausible the process seems. Self-denial - not self-confidence or self-control - is the key ingredient. Some, through impenetrable denial and determination to resist change no matter what the cost, never reach this point. "Their chances" - as the Big Book says with classic understatement - "are less than average", with relapse, disaster, and often death the ultimate fruit of their recalcitrance.

The surprising benefit of pursuing recovery successfully lies not only in deliverance from the obsessive destructiveness of alcohol and drug abuse, but in the almost inevitable acquisition of life skills and peace of mind which are enormously positive and enriching. Those successfully recovering from addiction - particularly those who maintain relationships with others in recovery, pursuing honesty, self-sacrifice, and regular efforts to enhance their spiritual lives - are often far better adjusted than even emotionally healthy individuals who have never abused drugs or alcohol. What is evident here are the fruits of brokenness: a deep humilty from reaching the end of our own resources, the gift of grace manifest in selfless giving by others so humbled, and the power of God to transform lives, overcoming evil with good.

Wednesday, August 11, 2004

The Downward Spiral

Japanese Woodblock PrintIf you take the opportunity to speak with those who have survived the ordeal of addiction and alcoholism and who are in recovery, you will find a wide range of stories and experiences. When we think about those who are alcoholics and addicts, they are typically viewed through the lens of late-stage affliction: homeless, disheveled, living on the street or under bridges, hanging out in seedy bars or shooting galleries, exhibiting anti-social and criminal behavior. What is less apparent until we take a closer look is that addiction is an equal-opportunity destroyer. I have spoken with men and women in recovery from many walks of life, from high-rolling investment bankers to common laborers; physicians, attorneys and accountants; contractors and convicts, housewives and hookers. Each person has his or her own story, but there is an eerie commonality shared among them.

Early patterns and progression of drug or alcohol use in addicts vary widely among individuals and their preferred drugs. Some drink to blackout from the first; others pursue what appears to be normal consumption for years before accelerated use. At times, surprisingly, early experience with alcohol or drugs is decidely adverse, yet repeated use still follows. The substance used can also have a large impact on abuse and behavior: drugs which cause large and rapid swings in neurotransmitters, such as crack cocaine, tend to produce more rapid behavioral change and addiction. At some point, early or late in the user's history, the most significant change occurs: the addict begins to crave the drug in an obsessive manner, regardless of negative consequences or experiences. The drug is no longer merely wanted for its effects; it must be used, no matter what its effects. The fatal attraction has begun.

Repeated use of drugs or alcohol produces certain physical and physiological changes. The substances stimulate enzymes and metabolic pathways which enhance their metabolism by the body. This phenomenon is known as tolerance. Tolerance occurs not only for the euphoric or mood-altering effects, but for other effects as well. For example, opiates in high doses in non-tolerant individuals produce sedation, severe constipation and impaired respiratory drive, and can result in cessation of breathing altogether. Yet opiate-tolerant individuals (addicts and those taking such meds medically, such as cancer patients) can tolerate doses which would be lethal in others, with little adverse effects.

The other major physical effect of prolonged drug use is dependence, wherein sudden cessation of the drug results in a withdrawal syndrome which is highly unpleasant or even fatal. Exact symptoms vary by drug, but often include irritability, mood changes, agitation, abdominal pain, sweating, hallucinations, and seizures.

A common misunderstanding - even among medical professionals - is that addiction and physical tolerance and dependence are one and the same. They are not. Place the addict and the non-addict side-by-side, and administer potent narcotics such as morphine on a regular basis over time, and both will develop tolerance and physical dependence, requiring more drug to achieve the same effects. Both will exhibit physical withdrawal symptoms if the drug is suddenly stopped. The difference is seen in what happens next: the non-addict will be glad to be off the drugs with their unpleasant side effects; the addict will obsessively seek them again, even if their euphoric effects are no longer experienced - a dilemna which is increasingly likely as length of use and dose increases.

It is this obsessiveness, and the resulting compensatory mental responses to its demands, which lies at the heart of addiction and alcoholism. The drugs themseleves in susceptible individuals produce intense physical craving for more - far exceeding such instinctual demands as hunger and sex - but it is the mental obsession which is ultimately so destructive. Were the adverse physical and social effects of addictive drugs - and their rapidly diminishing euphoric benefits - the only problems addicts and alcoholics faced, most would endure the suffering of withdrawal to restore their physical, emotional, and social well-being. But the obsession persists even when sober, ultimately laying the trap for recurrent use, progressive physical, personal, and social adversity, even to the point of insanity, incarceration, illness or death. And this process occurs while the addict or alcoholic remains blissfully and stunningly unaware of profound negative consequences.

As drug or alcohol use accelerate, and physical and social problems multiply, the obsession does not relent, but rather intensifies, resulting in a host of
psychological defense mechanisms, including denial, minimalization, and rationalization. Deceitfulness is a cardinal manifestation as well, lying both to oneself and to others until the line between truth and untruth is no longer discernable. Indeed, the ability to use free will at all becomes severely impaired, as pursuit of the obsession becomes equated with survival itself. As Dr. Jeffrey Smith states in his discussion of alcoholism and free will:
Alcoholics and addicts not yet in recovery behave as if they were fighting to preserve life itself. They act as if they are citizens in a malevolent society where operatives are using every technique including authoritarian force, manipulation and seduction to attack their existence. They valiantly resist all efforts to effect change. They may not like to lie, but they will if necessary. They use specialized psychological defenses including denial, minimization, rationalization, blaming, intimidation and proclaiming the right to make their own decisions in life. Like victims of oppression, they go underground in their attempts to protect their freedom. Their defenses become habitual and function smoothly even when cognitive faculties begin to fail.

Such a perversion of thought and action is extraordinarily destructive, not only to the individual, but to immediate acquaintances, family, co-workers, and society as a whole. It is unsettling and mystifying to see an end-stage alcoholic, days from death, denying his problem and demanding a drink, but this is the end result of a process of compulsive self-deception driven by forces far larger than the ability of mere human will - no matter how determined - to resist.

It is the failure to understand the physical power and mental distortions of addiction which results in so many simplistic societal solutions, doomed to failure however coercive or well-intentioned. By understanding these forces, however, although simple solutions to this pervasive problem do not immediately spring forth, nevertheless the journey to freedom can begin. This is the testimony of many who have recovered and repurchased their lives from its destructive slavery.

Saturday, August 07, 2004

Addiction & Judgement

Persian Cat with CigarretteI was listening to Bill O'Reilly on the radio a few days ago, discussing a sports figure whose career was ended by drug use. He was using it as a segue into his philosophy about drug laws, enforcement, legalization and addiction. Now, I like O'Reilly, and agree with him maybe 60-70% of the time, but he - and almost all conservatives I've heard - are way off base about this issue. His conclusion, in essence, was that all this discussion about "diseases" such as addiction was an excuse to avoid personal responsibility and create victims - addiction was, pure and simple, a personal choice made by individuals, who could just as easily choose to give it up and live responsible, upright lives.

It's a sentiment I understand fully. And it's wrong.

First of all, why talk about addiction here? As a physician, I've been interested in the problem of addiction and alcoholism for many years, even though it's not my main area of specialty. Like most physicians, I have had to sort out patients with legitimate need for potentially addictive medications, such as opiates, from those seeking the same drugs for different, abusive reasons. This might seem easy at first glance, but those with drug addiction are masters at deception - it's a survival skill, learned through repeated practice. Why does one patient get a prescription for pain pills, take a few, hate the way they it makes them feel, and flush them down the toilet, while the next fellow gets the same prescription, triples the dose, tells you he "lost the prescription", and demand more in a few days? It's easy to blame this on irresponsible hedonism, but it's nowhere near that simple.

Secondly, I have many friends who are in recovery from drug and alcohol addiction, and have spent quite a few hours discussing and understanding their histories, behavior, and the recovery process. There is no better way to shatter misconceptions about alcoholism and addiction than to go to the source - those who've walked through hell and survived to reclaim their lives and tell their stories.

Lastly, the solution to the problem of addiction is, somewhat surprisingly, far more spiritual than medical or sociological in nature. Hence, it is a natural for a blog on medicine, religion, and politics (not so sure about the pet connection, although the photo above is not a Photoshop montage, so maybe I'm on to something...)

I anticipate blogging a series of articles on aspects of this topic, since there is a lot of ground to cover. Libertarians and liberals should not feel too smug just yet - they've pretty much got it wrong as well. More on that later.

First let's address the issue of the "disease" of alcoholism and addiction. I use scare quotes because that is the way most conservatives view this problem - a pseudo-disease fabricated from thin air by psychologists and social workers, to create another class of victims in need of a big-government fix. Conservatives, who pride themselves on their reliance on logic, reason and tough love over emotion, feelings, and faux compassion, have abandoned science and objective truth on this subject, however.

The simple fact is that medical science is rock-solid in conclusion that alcoholism and addiction are well-established disease processes, comprised of genetic, physiologic, and mental illness components. As a quick MEDLINE search will demonstrate, there is a vast amount of medical literature addressing this disease in its many medical, psychological, behavioral and social aspects. One of the better recent summaries of this body of research appeared last year in the New England Journal of Medicine ( NEJM 2003;349:975-986 [subscription required]) entitled Mechanisms of Disease: Drug Addiction. To summarize some of the evidence:

  • Family History: Children of alcoholics are much more likely to become alcoholics. This is true even when adopted at birth by non-alcoholic parents.

  • Genetics:Specific genes have been identified which influence the metabolism and psychological effects of drugs and alcohol. Alcoholics and non-alcoholics metabolize the drug differently because of differences in the enzyme aldehyde dehydrogenase; a neuropeptide Y gene mutation is associated with higher incidence of alcoholism; a gene expressing the gamma opiate receptor, when mutated, is associated with a higher risk of heroin addiction. Many other such genes have been identified related to cannabis, codeine, nicotine, and other addictive substances

  • Animal Research: Specific genetic modifications in mice can reproduce or block addictive behavior.

  • Neurophysiology: Addictive drugs have profound effects on critical neurotransmitters, such as dopamine and GABA, which are long-lasting and have profound impact on affect, behavior, and thought processes.

The point here is not to bore with excessive medical details, but to emphasize that the addict is different: physically, genetically, biochemically, mentally. They are not simply wanton hedonists who wake up one day and decide to live a life of pleasure-seeking and irresponsibility, and can just as easily wake up and decide to stop. No doubt some - perhaps even many - enter the world of alcoholism and addiction by means of such ignoble motives. But once ensnared, their journey back to sanity and wholeness without drugs, even if pursued with passionate willfulness and desperation due to a destroyed life, faces enormous challenges inherent in their genetic, biochemical, and mental liabilities. And many enter the slavery of addiction through otherwise legitimate portals, such as social drinking or legitimate prescription use. The addict is in many ways a hidden time bomb waiting to detonate.

Yet conservatives, and society in general, are entirely justified in seeking and demanding solutions to the problem of addiction. Addiction plays a major role in virtually every social disruption we face: divorce, homelessness, inner city crime and gangs, child and spousal abuse and neglect, unemployment, poverty. It has engendered an enormous illegal industry which corrupts entire countries and funnels vast amounts of money to crime and terrorism.

But to find a solution to such daunting challenges it is imperative that our understanding of the problem be one of clarity and truth, not prejudice and false premises. Solving the addiction crisis by demanding personal responsibility may feel good, but does not begin to solve the problem. Personal responsibility is a result of recovery from addiction and alcoholism, but an ineffective means to accomplish it. Surprisingly, the real answer comes from the spiritual rather than the will.