The Anatomy of Addiction (5 page)

Just as the vast majority of drinkers are not alcoholics, the majority of stimulant users (like meth heads) are not addicts. They stop on their own or with help from family and friends. There is that small minority of those who actually have the disease of addiction and require true medical treatment. These are the people with whom I am concerned.

“Meth is a real problem for some people, but it is an over-hyped problem. All you have to do is look at the use rates and look at sentencing,” said Jason Ziedenderg, executive director of the Justice Policy Institute. “When 100,000 people a year die from alcohol, I'm still saying that's the most dangerous drug in America.”

5. People Addicted to One Drug Are Addicted to All of Them

It is not true that a person who is addicted to one drug is addicted to all drugs. The drug to which someone becomes addicted corresponds to that individual's particular brain chemistry. Most alcoholics are not meth heads, most heroin junkies don't regularly use meth, and so on. Now, when the preferred drug of choice is scarce (meaning, expensive) or not available at all, addicts will turn to another drug. Read on.

6. Prescription Pills Are Safer Than Illegal Street Drugs Because They've Been Prescribed by a Doctor

The Centers for Disease Control and Prevention (CDC) recently released some startling facts about drug use and deaths in the United States.

• In 2013, of the 43,982 drug overdose deaths in the United States, 22,767 (51.8 percent) were related to pharmaceuticals, notably opioid analgesics (also called prescription painkillers), stimulants, and tranquilizers.

• In 2011, about 1.4 million emergency room (ER) visits involved the nonmedical use of pharmaceuticals. Among those ER visits, 501,207 were related to antianxiety and insomnia medications, and 420,040 were related to opioid analgesics.

• The drug overdose death rate has more than doubled
from 1999—about the same time that doctors dramatically increased the prescribing of painkillers—through 2013.

• In 2013, more than 17,000 people died from prescription painkiller overdoses, with more than 400,000 going to an emergency room.

The CDC called the prescription painkiller epidemic that took hold in the late 1990s the worst of its kind in U.S. history. “The bottom line is that this is one of the few health problems in this country that's getting worse,” CDC director Tom Frieden told the
Huffington Post
in 2014.

Echoing those sentiments, the editorial board of
USA Today
wrote in November 2013, “The deadliest drug problem in America is not heroin or cocaine or even crack cocaine. It's the abuse of perfectly legal prescription pain medications—familiar names such as Vicodin and Lortab and generic hydrocodone.”

The extent of the prescription pill problem is reflected in this startling statistic: The painkiller hydrocodone is the most prescribed medication in America—136.7 million prescriptions a year at last count. To frame the problem another way, in 2010, enough prescription painkillers were prescribed to medicate every American adult every four hours for one month.

In 2014 the Food and Drug Administration (FDA) and the Drug Enforcement Agency (DEA) began a joint effort to crack down on the prescription pill epidemic by reclassifying hydrocodone, Vicodin, and other leading painkillers in the category reserved for medical substances with the highest potential for
harm. The initiative also required patients to present to a pharmacist in person with a written prescription from a qualified health provider—a move to stem the practice of faxing or calling in the prescription multiple times to multiple pharmacies.

The good news is that all of that worked. The tidal wave of prescription pills available on the legal and illegal markets began to recede. The bad news is that pill addicts switched their drug of choice to an equally dangerous drug—heroin.

7. Today's Marijuana Is Extremely Powerful and a Leading Cause of Drug Overdose, thus Possession in Small Amounts Shouldn't Be Decriminalized or Legalized

I could write a book about marijuana myths alone, but I'll confine myself to two points. First, even today with some states legalizing marijuana for personal recreational use, there has not been one recorded death from marijuana overdose. While tens of thousands of people die each year from alcohol or prescription painkillers, no one has ever died or overdosed on marijuana. Why? Let me quote the National Cancer Institute: “Because cannabinoid receptors, unlike opioid receptors, are not located in the brainstem areas controlling respiration, lethal overdoses from Cannabis and cannabinoids [marijuana] do not occur.”

Although painkillers can cause a person to stop breathing, you could smoke or ingest marijuana all day and all night and your respiration would still not be affected because marijuana does not affect the body's brain pathway that controls it.

Second, there is no evidence that decriminalizing, legalizing,
or otherwise making marijuana more available to the public in any way increases its use. In fact, according to a recent national school-based survey among teens in grades eight through twelve, the increased availability of marijuana in the twenty-one states that legalized medical marijuana did not significantly change its use. The study was conducted by researchers at Columbia University Mailman School of Public Health and supports a growing body of evidence that making legalized marijuana more available to the public does not increase its use.

All this said, I still support the regulation of marijuana. At the moment, there are no federal standards regarding dosages. The problem of nonstandardized packaging—including the lack of clear warning labels—is particularly egregious with marijuana-infused edibles as well as drinks and pills. Unlike smoking a joint, the user can consume a relatively large quantity of THC, the high-inducing compound in marijuana, by eating a cookie, for example. This can impair the user's cognitive and motor skills, a potentially fatal scenario if it involves driving a car.

Ingesting too much THC can also increase the risk of mental illness. Too many people are ending up in the ER for THC-induced intoxication and panic attacks. Unregulated THC-infused products pose an even bigger danger for those at risk of serious mental disorders. A recent study published in the British journal
Psychiatry
showed that large doses of THC can trigger schizophrenia in predisposed patients. 

Finally, isn't it obvious to all concerned that edibles such as brownies, cookies, and candy infused with mega doses of THC pose still another danger to children? We regulate alcohol and
cigarettes, which like marijuana are legalized recreational drugs intended for adult use, with standardized dosages and packaging. Why not, then, marijuana? 

8. Heroin Is Mainly a Ghetto Drug

A comprehensive study called, appropriately, “The Changing Face of Heroin Use in the United States,” published in 2014 by the journal
JAMA Psychiatry,
reported that contrary to popular belief, most heroin addicts today did not start on their “silk road” to perdition with another illicit drug, such as marijuana. Instead, most first started getting high with prescription painkillers, likely obtained at home, from a friend, or illegally on the street.

As mentioned earlier, the campaign to restrict prescription painkillers simply switched the addiction problem in the United States to heroin, which, unfortunately, at the same time was becoming cheap and plentiful on the black market due to overproduction in the narcotic countries, notably Afghanistan but also Mexico and countries in South America and southeast and southwest Asia.

Quite suddenly, the new prescription painkiller epidemic transformed into the new heroin epidemic. As
The Atlantic
magazine noted in an October 2014 article, “ten years after prescription painkiller dependence” swept America and “the government cracked down on doctors and drug companies, people went searching for a cheaper, more accessible high. Now, many areas are struggling with an unprecedented heroin crisis.”

Heroin, the drug that was once exclusively associated with
urban America and particularly black ghettos, was now becoming a fixture in white suburbia and in rural states. The problem became so alarming that in Vermont, everyone's ideal of pastoral beauty in America (not to mention the headquarters of Ben & Jerry's ice cream), the governor devoted his entire annual speech in 2014 to what he called “a full-blown heroin crisis” gripping his state.

In a 2014 article headlined “Heroin Overdose Deaths Quadruple over Last Decade, As Painkillers Open Fatal Gateway,” the website Medical Daily reported that the death rate jumped from 0.7 deaths per 100,000 people in the year 2000 to 2.7 deaths per 100,000 in 2013. More troubling, between 2010 and 2013, the death rate made even greater leaps: from a 6 percent increase over the previous decade to 37 percent. “Beneath this trend lurks a more fundamental change in how heroin is used, and, importantly, who is using it. The demographics of fatal overdose have changed considerably in the last decade. In 2000, black adults between forty-five and sixty-four years old showed the highest rate, at two deaths per 100,000. In 2013, white adults between eighteen and forty-four earned that distinction, at seven deaths per 100,000. Some suggest heroin's vanishing stigma can explain the change,” according to the report.

Fueling the epidemic was a new, more pure and potent form of heroin that could be snorted or smoked to achieve the high previously possible only through injections. So, while we're at it, let's destroy the other myth about opioids as largely a drug of choice of young people. As it turns out, prescription pill addiction skews much older than other drug epidemics. In 2012, those between the ages of forty-five and sixty-four accounted for the
highest rate of inpatient hospital stays for opioid overuse. Two decades earlier, according to the federal Agency for Healthcare Research and Quality, the highest rate was for those between twenty-five and forty-four.

When the supply of prescription pills tightened because of new federal restrictions, baby boomers turned to, yes, marijuana (did they ever leave it?), but right behind it as the most common illegal drug of choice was, according to the National Institutes of Health, heroin (in its new, noninjectable form).

9. Alcoholics and Addicts Have to Hit Rock Bottom before They Can Be Treated Effectively

The need to hit rock bottom is another pseudo-science precept of AA, which, however, welcomes alcoholics to join at any stage of their addiction. Yet, if you're around anyone who is a member of AA, the idea of hitting rock bottom is thrown around like a badge of honor.

There is no medical science that supports the idea that addiction can be treated only once you've blacked out on Skid Row, driven a car into a tree, ended up in a hospital or jail cell, or any other calamities associated with hitting rock bottom. That's tantamount to saying a diabetic can be treated effectively only once he or she goes into insulin shock. It's always better with any chronic disease—be it asthma, heart disease, bipolar diseases, or substance addiction—to get help early. In short, the whole idea of rock bottom is utter nonsense.

How did we reach the point where the treatment of a chronic
disease includes the notion of rock bottom? Part of the reason lies in the origins of AA. Its founder, Bill Wilson, indeed had lost everything of value to him and was hospitalized because of medical conditions related to his illness when he says that he received his epiphany to begin AA. His plight became the model for all AA followers.

Another reason is the double-speak world of AA dogma.
Rock bottom
provides cover for when AA members fall off the wagon. AA can say that its prescribed abstinence-only treatment did not work on those who left because those quitters hadn't yet—and here it comes—hit rock bottom. In the world of AA, the program is never the problem; relapse is always the member's fault.

10. Treating Addiction with Medications Won't Work Because You're Just Substituting One Drug for Another, and Besides, Addicts Will Figure Out a Way to Abuse the New Drug

Recent scientific research shows that the process of addiction is related to overstimulation of the brain's reward pathway. A study published in
Science Daily
states that what happens in addiction to drugs is lethally simple: “The reward pathways in the brain have been so over-stimulated that the system basically turns on itself, adapting to the new reality of addiction, whether it's cocaine or cupcakes.”

From a medical perspective, then, the key to treating addiction is crystal clear: Stop the overstimulation of the brain's reward pathway. This is where AA and 12-step programs confuse
correlation with cause. Abstinence can be achieved when proper medical treatment is provided, which halts the addict's craving for his favored substance. But simply talking about stopping the craving and listening to stories of other people's addiction will not achieve abstinence for most people.

Modern medical science has given us an array of pharmaceutical medications that have proven effective in stopping the craving that characterizes addiction. We'll get into that deeper in the next chapter, but suffice to say that among the most effective treatments for addiction to opioids (prescription pills, heroin, morphine) is buprenorphine, an FDA-approved, opioid-derived medication. When a patient switches from his opioid of choice to buprenorphine, the addictive behavior usually stops. That's because buprenorphine's ability to cause a high has a ceiling. Patients can snort, smoke, or inject buprenorphine all they want, but extra doses will not make them feel any differently.

Some addicts stay on buprenorphine for weeks or months, others for years. There is no one-size-fits-all cure for addiction. It's a complex disease requiring individualized treatment. Buprenorphine has allowed addicts to live a normal life by helping them regain control of their brain's reward pathways.

I'll close this chapter by acknowledging that buprenorphine is now one of the most sought-after drugs on the streets . . . but not for the reason you might think.