Archive for the ‘Addiction’ Category

Is Benadryl addictive? How can you wean off of it? Can it cause gastrointestinal problems?

Addiction means continued use in spite of negative consequences.  In this sense Benadryl addiction is not known to be a common problem.  Since it can cause weird reactions at high doses I guess that is possible.  People who abuse downers are usually trying to be somewhat emotionally “numb” – so that’s a possibility.

Many people confuse physical dependence with addiction.  This results from taking something long enough or in high enough doses that  you become physiologically adapted to it – then if you just stop it you can have withdrawal symptoms.  In the latter case you just need to taper it slowly – it could take a few weeks, depending on how long you have taken it regularly.

The other issue would be what were you taking it for?  Is there a condition that needs to be treated?

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Pictures of Addiction

These scans looking down on the brain are measuring dopamine activity in the nucleus accumbens and reflect levels of interest, drive and motivation.

A recent research finding is that people who are born with below average receptors (D2) in this area are more likely to develop behavioral and/or substance addictions.

Conversely, people born with above average numbers of these receptors are relatively protected from developing addictions.

The function of this area of the brain is to learn what is pleasurable and then fire to activate our systems of pursuit.  Mother nature wants us to be motivated to eat and have sex.  These are natural activators of the nucleus accumbens.

In addictions this part of the brain is “hijacked” by some behavior, like gambling or alcohol/drugs.

Tolerance frequently develops to addictive substances and results in a depletion of dopamine.  Low dopamine causes craving for substances that have powerful effects on the dopamine system – like speed, cocaine, or alcohol.

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Are You Prone To Addiction?

One of the major themes of this year’s APA was the neurobiological basis of addictions. 

First it was schizophrenia, then manic and depressive disorders, then the anxiety disorders, then attention deficit disorders – These all became much better understood not just as abnormal behavior or feelings but as complex medical disorders with genetics and physiology. 

Science of mind is making possible much more effective treatments – not to replace psychological and social dimensions but to enhance them. 

Most recently, advances in understanding the science of addiction is beginning to help us treat these disorders more effectively.  How many D2 receptors were you born with?  It makes a difference. (see pictures of addiction)

One of the personalities that stood out at this years APA was Dr. Nora Volkow, Director of the National Institute of Mental Health Division for Addictions.  Dr. Volkow is a wiry, hyper, opinionated woman with a strong Germanic accent which seems to add force to her dynamic personality.  Her favorite thing to say is, "I like to be provocative."  She occasionally apologizes for dominating the stage and microphone but is not able to stay silent very long. 

One of her lectures was titled "Addictions and Free Will."  Free will is one of the things between stimulus and response.  Is this response a good idea?  What happened last time?  What are the possible consequences, options…etc.?

Unfortunately, the addictive brain may not access these thoughts.  Control is reduced or absent.  Fortunately we’re starting to understand why, and we’re starting to find treatments that give addicts new controls and options.

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New Help For Smokers

Smoking is the prototype addiction, i.e. compulsive behavior, in spite of negative consequences.  Only the most extreme denial can rationalize smoking as something that is not harmful and allright to continue.  There is no question that smoking significantly increases two of the most common causes of premature death both cardiovascular disease and cancer, but in addition quality of life significantly decreases by illnesses such as Chronic Obstructive Pulmonary Disease.  Smoking is socially a nuisance and is increasingly expensive, and it accelerates aging especially of the skin.  Despite these facts, smokers argue "it relaxes me and I enjoy it."  For some individuals the increased risk and fear of gaining weight, especially among women, keeps them from quitting.    However, there are much better alternatives to these arguments.  

Addictions are not easily given up and smoking proves one of the most difficult.  In fact, inhaled addictive chemicals reach the brain faster than drugs given IV.  Since every puff reinforces smoking addiction, one pack per day provides 200 reinforcers per day.  The good news is that there are new treatment options that work through novel mechanisms to help smokers overcome the addiction.

"But I have to be ready to quit."  Not necessarily true.  With one new treatment, you can take the medication while you continue to smoke.  The medication interferes with the addictive power of the cigarettes.  Now with multiple medical options and cognitive behavioral techniques, you can give up your worst habit- or at least significantly reduce the number of cigarettes you smoke per day.  In addition, lifestyle modification and sometimes medication can prevent weight gain, and lifestyle coaching is useful and often necessary.

When researchers look at smokers who successfully quit, one thing stands out.  Most say they just decided one day to quit on their own.  Those that quit, however, were more likely to have been advised by their physicians.  That just reinforces my responsibility as a physician to educate and discuss the risks of smoking and the various treatment options available.   

One important consideration that should be taken into account when quitting is whether you have a history of depression or are currently depressed.  Quitting smoking can make your depression worse, and taking Bupropion (Wellbutrin, Zyban) or other antidepressants can be protective.

For more information or to schedule coaching to help you quit, contact Melissa King during regular office hours at 972-234-0489. 

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What's up with these guys?

The power of addiction is almost constantly in the news – Ted Haggard, Mark Foley, To Catch a Predator, catholic priests …

Haggard, Foley, and Cardinal Law

What do you think is the main problem?

  • Pre-Extraction Disorder – they have their heads up their **** – clueless as to what their problem is
  • Milk of Magnesia Deficiency – they are full of @#$% – rationalize their behavior
  • Total selfishness and hedonism – like the excitement too much
  • No self-control – they are weak
  • Need medical treatment – they have a serious deficiency of dopamine in their nucleus accumbens

As I’ve written before, addiction is not only incredibly powerful, but it’s also one of the most difficult illnesses to treat.  I’ll be writing more about this soon.  In the meantime, cast your vote in our poll and let me know what you think by posting a comment here.

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Putting the Pieces Together: An Epilogue

Last week, RandomHouse.com posted “a note to the reader,” written by James Frey. It will be added to future printings of A Million Little Pieces.

When we put the pieces together he’s given us, what picture do we see?

 

Take One: Give the Guy a Break!

Taken as a whole, Frey’s note expresses a sincere sounding apology, an explanation of the embellishments and a re-affirmation that the book represents the “subjective truth” of his fight against alcohol and drug addiction. His purpose was to write a book to encourage other addicts to fight against their demons. He also hopes to help the families of addicts to be more understanding and empathetic. He closes with “I am deeply sorry to any readers …” This is the picture Frey says we should see. But …

Take Two: Get Honest!

The very 1st sentence reads,

“Pieces” is about my memories of my time in a drug and alcohol treatment center.

It should have read “was inspired by …”

In the second sentence, he says, “… I embellished many details …”

When 6 hours in a police station becomes 3 months in prison, somehow the word “embellish” doesn’t quite capture the spirit. What if Lance Armstrong hadn’t really had metastatic cancer but an abscess leading to septicemia requiring 3-4 days in the hospital?

The third paragraph begins,

“I didn’t initially think of what I was writing as nonfiction or fiction, memoir or autobiography. I wanted to use my experiences to tell my story … I wanted to write, in the best-case scenario, a book that would change lives.”

Had he actually set out to write a memoir, he might have said instead, “I wanted to write in the most honest way I could.”

When he says, “I wanted to write a book that would detail the fight addicts and alcoholics experience …”, I translate that to, “I didn’t think my story was interesting enough or dramatic enough to have an impact.”

Later in the statement, he says,

“I made other alterations in the portrayal of myself … that made me tougher and more daring and aggressive than in reality I was, or I am. … My mistake, and it is one I deeply regret, is writing about the person I created in my mind to help me cope, and not the person who went through the experience.”

This admission to me contradicts what he says later, “It is a subjective truth.”

I certainly agree with his concluding comments “that drug addiction and alcoholism can be overcome, and there is always a path to redemption if you fight to find one.”

He ends with, “Thirteen years after I left treatment, I’m still on the path, and I hope, utimately, I’ll get there.”

What could possible be wrong with his final sentiment?

Drug and alcohol problems come in many different levels of severity. There are certain genetic variants that make addiction extremely hard to overcome. Addiction is about denial (deception of self and others) and dyscontrol (lack of control). Many people, maybe most, need AA or least the AA philosophy to fight their demons. Relapse is the rule not the exception in hard core addicts.

James Frey went into rehab at age 23. He had graduated from college. He spent 6 weeks in rehab and supposedly has had no relapses. Neither he nor his mother thought there was any risk in light of the current onslaught of criticism.

When I start putting the pieces together, the picture I get is – he used drugs and had a drinking problem but he wasn’t a hard drug addict or alcoholic.

If I’m right, then should his road to recovery be a model for others to follow? Should others expect to spend 6 weeks in rehab and then go on to be successful? When others fail to achieve this relatively rapid success, are they less adequate or less committed to fight the fight?

You can have cancer and it can be spread to your lungs and brain. This is not necessarily a death sentence. It’s even possible that you can completely recover and go on to great achievements and help change the world. We know this because we know Lance Armstrong’s story. Unfortunately, I don’t believe we really know James Frey’s story.

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How To Take Wellbutrin (Bupropion)

WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 

HOW TO TAKE FOR DEPRESSION

WELLBUTRIN XL

Do not break tablets.


Starting dose
150mg in the morning for one week
After one week Increase dose to 300 mg in morning.
Sometimes dose needs to be increased to 450mg, and rarely to 600mg.

WELLBUTRIN SR

Starting dose One 150 mg tablet in the morning. 

If any significant side effects, decrease dose by cutting the tablet in half or switch to 100mg tablet. (Only about 10% of the slow release action is lost when the tablet is cut.)


After 3 – 7 days
Add a 2nd tablet at lunch

After 1 week on 2 tablets per day
Take both tablets in the morning if tolerated
After 3 – 4 weeks of 2 tablets per day If dose is not strong enough, add a 3rd tablet per day and take in divided doses of 2 in the morning and 1 at lunch.
(A total of four tablets per day can be used in divided doses but this is rarely needed by most people.)

OTHER TREATMENTS

SMOKING

300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.

SEXUAL DYSFUNCTION

Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.

WEIGHT REDUCTION

Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.

ADD and BOREDOM

Often respond well to Wellbutrin.

ANTIDEPRESSANT AUGMENTATION

Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.

SIDE EFFECTS

Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

  • Insomnia
  • Dry Mouth
  • Nervousness
  • Irritability

For full information, see package insert or prescribing information.

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Teachers Having Sex With Students!

Two attractive young school teachers have come to national attention this year because they had sexual relationships with 13 and 14 year old boys in their classes. What is even crazier is that both of these women were married and neither would have any trouble finding sexual partners if they wanted to have sex outside their marriage. In both instances they knew that what they were doing constituted a felony offense and could easily result in prison time if caught. Neither of them was particularly careful. Both must have heard of the notorious case of Mary Kay Letourneau who served seven years in a Washington state prison (1998-2005) for having sex with an under aged male student.

The insanity defense

But were they insane? Unfortunately, no. Insanity is not a medical or even psychiatric term. It is a legal term meaning not sane or not rational. The concept of legal insanity was first introduced in England in 1843 when the courts decided that Daniel M’Naghten was not guilty of murder because he thought he was acting in self defense. He had paranoid delusions which if true would have put him in danger. More specifically insanity was defined as: because of a mental illness at the time of the criminal act the individual didn’t understand what they were doing or they didn’t understand that it was wrong.

Since Federal courts do not have jurisdiction over criminal behavior except in special instances, e.g., national defense or interstate commerce, almost all of these cases are handled according to the laws of their state. The age of consent for sex varies from 14 in Nevada to 18 in California. Many states also have age difference stipulations, in an attempt to prevent exploitation by adults.

In 1962 the American Law Institute expanded the definition of insanity. The first standard was basically the same – due to a mental defect the individual did not know that the act was wrong. They added that legal insanity could also be the inability to adhere to the right. This latter standard was interpreted as an “irresistible impulse” but was sometimes limited to acts that would have occurred even if a policeman was standing there. Now four states have completely eliminated the insanity defense. Most states don’t include “irresistible impulse” as a legal defense.

There has always been a public skepticism about the use of the insanity defense. It has been seen as a loophole for sociopaths to escape responsibility or a mechanism where psychiatrists could get people off because they had some mental problems or a difficult childhood.

In 1982 there was a national uproar when the insanity defense was used by John Hinckley after he attempted to assassinate President Reagan. He was found not guilty by reason of insanity. Since that time it has generally been more difficult to successfully use the insanity defense. There is a perception that the insanity defense is used frequently but the fact is that it is rarely used, maybe 1 in 2000 cases. When used it is usually not successful. When successful it is usually so obvious that the prosecutor agrees and it doesn’t even go to trial.

So, the legal question is easy to answer in the two prominent current cases involving teachers. They were both continuing to function in their teaching jobs. They undoubtedly knew that what they were doing was wrong. In fact Debra LaFave in Florida was quoted as saying that, “part of the arousal was because it was not allowed”. They couldn’t even use the defense of “irresistible impulse” since there were multiple separate instances. Both of these women may have bipolar symptoms with seriously impaired judgment and impulse control. Both may be genetically addiction prone and both may have Attention Deficit Hyperactivity Disorder with impulsivity. Is it possible that they both have an Adderall or Concerta deficiency? As Dennis the Menace said, “by the time I realized the consequences of my action I had already done it”. But these psychiatric/emotional factors would only apply as possible mitigating factors in the determination of punishment – not the establishment of guilt.

The cases of Debra LaFave (Florida) and Pamela Turner (Tennessee) are dramatic if not shocking but not unusual. According to the U.S. Department of Education, between 6-10% of public school children have been sexually abused or harassed by school employees and teachers.

It’s in our genes

We are still left with the question “why”?

Remember, to understand any behavior you have to look at the immediate causality (motivation, dynamics, brain chemistry, etc.) but also the ultimate causality. Why does this behavior exist in the world?

One of the main functions of the highest level of functioning of the human brain is to control deeper primitive instinctual behavior. In certain conditions such as Attention Deficit Hyperactivity Disorder and hypomania there is a deficit in higher level functions and behavior is more at the mercy of our emotions and instincts.

So, the first answer to why is that “it’s in our genes”. The single most important reason we exist is to reproduce. The more we reproduce the greater the chance that we will be able to adapt to the ever changing world.

Age of consent

What about the question of age. At what age is it appropriate to begin having sex? According to Mother Nature it is when we are capable of producing offspring. That means in many cases younger then 13. In four states the legal age of consent for sex is 14 and all but Nevada have an age difference specification. As a medical student in 1966 working in the obstetrics department of Parkland Hospital it was not unusual to deliver 12 year old girls having their second baby. They were usually from very poor families and because of the financial aid provided for dependent children program this was a way for children to help support for their families.

What makes people act crazy?

So if it’s so natural why is it crazy? It’s crazy when it’s against the law and in fact a felony. The potential consequences are so severe that there must be powerful forces at work other than basic instinct. Is it hormones or pheromones? Is it brain chemistry? Is it a society where we hear a lot about sex but especially in the case of married couples we?re not having a lot of sex? Is it cultural with a lot of emphasis on doing what feels good? Yes to all of the above.

Personality determines some behavior. Personality is character plus temperament. Character includes maturity, self-sufficiency, lack of self-centeredness, and respect for others. Perpetrators of inappropriate sexual behavior usually have some deficits of character.

Temperament is mainly genetics and includes persistence, harm avoidance, need for approval, and novelty seeking. Risk taking is one of the traits for which specific genetic polymorphism has been identified. Risk takers have been found to have lower amounts of a particular enzyme in the brain (monoamine oxidase inhibitor, or MAO). Some risk takers are sky divers, some are pathological gamblers and some break rules or the law as a form of excitement. Personality traits tend to be fairly stable. To know the degree to which pathologic personality traits would explain the behavior of the two recent teachers in the news would require detailed personal history.

Is it a personality disorder?

Two particular personality disorders are commonly associated with sexually deviant behavior. They are borderline personality and narcissistic personality. (These do not include antisocial personality which is cool calculating manipulators without conscience that can be perpetrators.) The borderline personality lacks a clear sense of identity and is impulsive and engages in self-destructive behavior. They often but not always have a history of being abused. The borderline personality usually has elements of bipolar disorder and ADHD.

There are two types of narcissistic personality. One is a person who was treated as being better than other people and deep down truly believes it. They may be from wealthy families or be particularly attractive or gifted in sports, art, or music. Because they feel better than others they don’t believe the rules or laws should apply to them. They have a sense of entitlement – they should be able to have what they want. The more common type of narcissistic personality is a person who deep down feels inferior, inadequate, unlovable, but works hard to avoid these feelings by trying to convince themselves and others of their superiority. They may end up acting the same way as type one.

It is certainly possible that the two teachers recently in the news fit into one of these personality categories.

Could it be love?

Is it possible that a 13 or 14 year old boy could be “in love” with a 25-35 year old teacher? And if so, could it be morally wrong for them to engage in sexual intercourse? This is a harder question than the legal one. The fact that what’s legal depends on what state you live in reflects the subjectivity and arbitrariness of the issue. No matter how bizarre it may seem, Mary Kay Letourneau at age 35 began an intense emotional relationship with her 12 year old student. Their relationship became sexual shortly after he turned 13. Recently they were married. Their relationship survived unbelievable media scrutiny and her spending 7 years in prison. Along the way they have had 2 children. It certainly seems crazy but it’s hard to deny that their love for each other is real.

What is love?

A lot of times I’ll ask a patient, “are you in love with??” The answer I often get is “well I do love them”. I often push for a more definite commitment. I say something like, “you love your dog. You love chocolate”. What I’m asking is, “are you IN love with them, committed to them? Do you want to/like to have sex with them?” One of the most telling questions is “how would you feel if they had sex with someone else?” If you are in love with someone the idea of them having sex with someone else is devastating. But what is love? In the context of relationships there are 3 components, each with a unique biology and psychology.

They are:

  • Sex
  • Romance
  • Attachment

Sexual attraction and arousal is most highly correlated with the hormone testosterone in men and women. Men are more aroused visually. Youthfulness, beauty, and cleavage are thought to be arousing because they are associated with fitness to reproduce. Men are competitive and hierarchical. Mother Nature wants the men with the best genes to have the most offspring. A man can impregnate many women during the same time period. This is not something women like to hear, but they need to understand that a man’s biology and physiology is different than theirs. When a man makes an exclusive commitment to a woman he will still notice other attractive women, but that will not take away from his committed love relationship.

Women are less sexually aroused visually. A woman can only be pregnant by one man at any given time. She will be more physically vulnerable during her pregnancy and it will be hard for her to attend to an infant and also provide for all her own and the babies needs. Women are more attracted to men who can be providers/protectors. They are more impressed by maturity and stability.

Since the availability of birth control men and women have more freedom to have sex for fun, but the underlying biology and instincts still play a major role. But one of the risks of sex for “fun” is that you may fall in love or get “attached”. This is a warning that Helen Fisher, PhD gives her students in her college classes. She has done years of research into the “biology of love” that she describes in her recent book, Why We Love: The Nature and Chemistry of Romantic Love.

When Dr. Fisher did functional MRI’s to measure brain activity she found dramatic differences in those who were “in love”. Their brains looked similar to people with major addictions. The reward area of the brain and the brain transmitter dopamine increase with romantic love. Norepinephrine also goes up and serotonin goes down. Does this mean that raising our serotonin levels with some antidepressants could interfere with our romantic feelings? Maybe. Does this mean that “being in love” with someone is like being hooked on them or addicted to them? Yes. Sorry if that seems unromantic. When you read how Mary Kay Letourneau after spending time in jail, going through a humiliating trial, sentenced to seven years of prison probated still sought out her under age lover does that not sound like addictive behavior? She was clearly out of control.

Probably the most important part of a relationship is attachment. Sex is great but it’s only a small percent of the time a couple spends together. Romantic feelings can come and go depending on many factors especially stress but the attachment can grow steadily for a lifetime. The biology of attachment is most related to the hormones oxytocin in women and vasopressin in men. Women who don’t bond to their babies have been found to have low oxytocin. Estrogen increases oxytocin. Studies using voles (rodents) show the importance of oxytocin to attachment. Mountain voles have low oxytocin and are polygamous but prairie voles have higher oxytocin and are monogamous. Orgasm causes the release of oxytocin (women) and vasopressin (men) and dopamine. Sex can increase attachment and romantic feelings. This is great in a committed relationship. It may not be so great in a forbidden relationship such as is usually the case between a teacher and student.

Self-control

So are we mainly at the mercy of our genes, brain transmitters, and hormones? Obviously not. But we are certainly under their influence. No testosterone, no libido. No dopamine, no interest. In mature adults control is in the highest level in the front of the brain – the prefrontal cortex. There are numerous cases of individuals who were high functioning, moral, responsible adults who after suffering damage to the front of their brain began acting impulsively and more under the influence of their primitive instincts. We know that certain psychiatric disorders are associated with reduced functioning of the highest brain levels.

Where does this leave us with our two school teachers accused of sexually assaulting their young male students? To understand their behavior is not to excuse it. In each of their cases we need a lot more information. They will be held responsible and will be punished. Hopefully, the punishment will fit the crime but with so much media attention and so much emotion involved there is no telling how it will turn out. The real issue is that this is a complex, common problem that deserves a lot of study and hopefully new national standards and programs to protect kids from determining their life course before they are mature enough to fully understand their options.

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Part Five – Brain Transmitters and Food Craving – The Role of Addiction in Weight Control

“Keep things as simple as possible not simpler”     – Albert Einstein

This isn’t rocket science but it is a little complicated. To really understand craving and other issues regarding eating and weight control you have to have a sense of how the brain works. Serotonin is one of the neurotransmitters that enables brain cells to communicate with one another. Brain transmitters are mostly made from amino acids (building blocks of protein). Some of them the body can make but some have to come from the proteins that we eat – another reason that our diets need to include adequate healthy protein.  In response to stimulation nerve cells release various transmitters. These transmitter are like keys that cross the synapses, spaces between nerves and other cells, which plug into receptors, like locks on other brain cells. Sometimes transmitters activate other cells.  While other times they plug up plug up the receptors preventing other transmitters from activating them.  

Serotonin, the oldest and most primitive brain transmitter, is found in single cell organisms. If you recall Maslow’s Hierarchy of Needs and Motivation, you know that the first level is our basic biologic needs. Of these biologic needs, air is the most urgent need, but water and food come in second and thrid.  Produced in the brain stem, serotonin’s primary responsibilities include maintaining homeostasis, or balance, of temperature, blood sugar and many physiologic systems. Serotonin raises when blood sugar increases, and this increase in serotonin stimulates satiety receptors and decreases craving for carbohydrates. Conversely, low serotonin or low serotonin activity due to certain medications working certain receptors leads to carbohydrate, or sugar, craving.  Don’t get between someone with carb cravings and sweets.  It’s dangerous, because the next level up on Maslow’s hierarchy has to do with safety and interaction with our environment.

Another neurotransmitter, norepinephrine (Noradrenaline) releases when changes occur, especially dangers in the environment. Norepinephrine activates our Cortisol stress system muscles for “fight or flight” while releasing adrenaline in the body. This has to do with avoiding danger and basic survival.  Adrenaline causes us to dump sugar from the liver into our blood stream, because sugar provides emergency fuel for muscle activity and is the only fuel for brain cells.  Muscles burn fat and carbohydrate (sugar), but the brain can only burn carbohydrate (sugar).  Norepinephrine increases arousal while decreasing appetite and libido, so it is not surprising that some appetite suppressants work by increasing norpinephrine levels.

Once our basic biological needs are met, and we feel safe, the next level up on Maslow’s Hierarchy is well being.  The next brain transmitter, dopamine drives us to pursue well being.  Every addictive substance increases dopamine.  Dopamine should not be confused with endorphins, which make up the pleasure system, but dopamine activates us and enables us to pursue the things that provide the feelings of pleasure and well being.  Experiments with male dogs found that their first experience with female dogs in heat or their first T-bone steak didn’t release dopamine but did stimulate the endorphin system. The next time they were given a T-bone steak or a female in heat, their dopamine release was off the chart. In other words, Mother Nature provided a brain system that learns where fun and well being are driving us to pursue this pleasure when future opportunity arises.  In another experiment, male rats had all their brain dopamine depleted. They were then given female rats in heat and an All-the-Cheese-You-Can-Eat buffet.  The rats acted completely normal, though, making passes at the females and chowing down on cheese. This meant dopamine wasn’t necessary to enjoy something pleasurable that’s put in your lap.  However, when a barrier was put up separating the food and females on one side and the males on the other,  the rats without the dopamine said, "Screw it, I can’t do it," and the normal rats with dopamine went right over the wall.  

Addiction is a process where the brain is hijacked by some substance(s) or activity and the individual loses control (dyscontrol).

The other primary symptom of addiction is denial to self and/or others.  A book title on alcoholism tells you everything you need to know about addiction: I’ll Quit Tomorrow. Other books, The Selfish Brain and The Craving Brain also paint the picture. The need for well being and the pursuit of pleasure can drive us to love and creativity or lead us down a path of self destruction. Losing a patient to an addiction is a painful and sobering experience. Mother Nature wants us to do things that are pleasurable like eat and have sex.  Though, not necessarily in that order and the survival of the human race depends upon these activities.  

People with ADHD need more stimulation, because their dopamine systems are not as naturally reactive.  People with addictions are low in dopamine in the area of the brain that is activated during pleasurable pursuits, the Nucleus Accumbens. One of the technological advances in the past decade enables us to look at not just brain structure but brain activity. Functional MRI’s are being used more often now because they don’t require radioactive material to be injected. PET scans using radioactive glucose were previously the most useful. Compare the PET scans of a normal individual on a normal day. Notice the dramatic difference between the normal brain and a chronic cocaine user. The cocaine user’s brain is like the rats with their dopamine systems depleted. They are useless unless pleasurable things are put in their lap. They need cocaine or some other powerful stimulant to turn on their brain.

The alcoholic brain is not as bad but still reflects low motivation and drive. The surprising finding is the low brain activity in the Nucleus Accumbens in the individual with obesity. What turns on their brain? The answer is food and especially carbohydrates.  Many experts now show that sugar can be as addictive as alcohol, speed, and cocaine and that addictions overlap to some degree. Periods of abstinence from addictive substances increases cravings, and the longer the abstinence the greater the craving. Sugar addiction increases response to amphetamines and visa versa. Some food addicts eat when bored, others eat when stressed.  Addiction occurs when you lose control meaning: You don’t control it, It controls you.  That’s why the first step in AA is admitting powerlessness, but change starts with awareness. The next step occurs with the decision to change and finally the hard part comes on the day you decide to start the process of change.  Fortunately there are things to help. See Part Six

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We Can Put People on the Moon, Why Can't We Cure Addictions?

I felt sad when I read this week that Joan Kennedy, former wife of Senator Edward Kennedy, was found lying on a sidewalk in the rain. She had suffered a concussion, a laceration on her forehead, and a broken shoulder.

The story goes on to say that her son has been trying to get appointed as her legal guardian, so that he can ensure that she cooperates with treatment for chronic alcoholism. She has been through several rehab programs after a series of arrests for drunken driving. She obviously has unlimited financial resources and political connections and has undoubtedly had the best treatment available in the world, and yet here she is basically lying in the street like a homeless person.

Why can’t we help her? One reporter described Mrs. Kennedy as shy and reserved, unlike the other strong Kennedy women. Apparently her major problems with drinking started after her husband’s scandal.

Two general principles are demonstrated by Mrs. Kennedy – using alcohol to cope with stress and social anxiety. In one study 60% of alcoholics were using alcohol to help reduce social anxiety.

Understanding Addiction

The good news is that addiction is easy to understand. There are only two symptoms: “denial”, and “dyscontrol”. Addicts lie to themselves, “I’m not really an alcoholic, I just drink too much occasionally”, or “I just drink socially”.

One of my favorite all time books is titled, I’ll Quit Tomorrow by Vernon Johnson. That title tells you everything you need to know about how an addict thinks. Two other great book titles on addiction are: The Craving Brain by Ronald Ruden and The Selfish Brain by Robert Dupont.

Addicts also lie to others – “I only have one or 2 beers a day” – unfortunately they buy 2 cases per week, and there’s never any left and they always drink alone. The math doesn’t work.

Dyscontrol means it controls you, you don’t control it. The first step in AA admits to being powerless over ________ (fill in the blank). But of course, it’s not just alcohol.  It’s food, drugs, gambling, work, sex, etc.  Even people who pull out their hair or cut on themselves are addicted to the body’s response to bodily injury – it may be as simple as causing a release of endorphins. These are chemicals released by the body that act like morphine or heroin in low dose.

A great prototype for addiction is smoking. Addiction means compulsive behavior in spite of negative consequences. People who smoke die 13-15 years earlier than nonsmokers on average. How negative is that? Of course the smoker rationalizes “I didn’t want to be an old person anyway.”

Do you have to drink every day to be an alcoholic? No. The rule that I have used in diagnosing addictions over the years is, “does the behavior result in harm to health, jobs, grades, or relationships?”

What causes addictions?

The single strongest factor is genetics. The part of the brain that learns what substances or actions lead to pleasure or escape from pain is genetically less reactive to normal life pleasures or serves to help reduce pain.

There are two primary goals of addictiongetting high, especially when bored and getting numb when feeling overwhelmed.

Why would someone jeopardize their marriage or custody of children just to get drunk? They don’t actually make a conscious decision, “I’m going to get drunk and I don’t care what the consequences are.” It’s more like self-manipulation. They forget to take their medication or they set themselves up to desperately need a drink – of course just one, or maybe two larger ones. For some people, their judgment is soluble in the first drink.

There are actually 2 subtypes of alcoholics. The first type starts usually in the teens and the goal is to get high. People who inherit this form have a high tolerance even when they first start drinking. The second type starts later, 20’s or 30’s and is primarily to treat chronic anxiety. Some people are unfortunate and have both types.

What about treatment?

Addicts, especially alcoholics are masterful at alienating everybody and using alcohol as their primary or only relationship. They can make people so angry with them that they get no social support. But effective treatment requires an alliance with the person against the problem – you have to separate the person from their addiction. It has to be you and them against the addiction.

The worst form of “pseudo” support is enabling. This is basically making it easier for them to continue with their addiction. The opposite of enabling is “tough love”.

Treatment ideally needs to include the significant other(s). In the movie When a Man Loves a Woman, the potential benefits of AA and Alanon were well depicted. Early in the movie the characters, played by Meg Ryan and Andy Garcia, seem like a normal healthy family. In retrospect we could see that the husband encouraged his wife’s drinking because she was more fun when she was drunk. I thought the treatment program in the movie was seriously flawed. Instead of involving the husband and children in couples and family therapy the treatment was mainly with her peers in the program. When she got out she continued to rely on her peers for all her social support and it almost destroyed her marriage.

Any couple dealing with an alcohol problem or other serious addiction should see this movie. It shows the secrecy, deception, and subtle way alcohol takes over one’s life. It shows how alcoholism is a family illness and everyone is effected. It ends by instilling hope – it’s possible to take back your life.

Since addiction is denial and dyscontrol, recovery is getting honest (with self and others) and getting control.

AA provides many tools like “one day at a time, sometimes one hour or one minute at a time”. Addicts should ask for help and may need medication.

What about medication?

Antabuse is often helpful. It’s not a medication that keeps you from drinking. It’s a medication that is taken in the morning and helps protect you from drinking impulsively later in the day. Antabuse interferes with the metabolism of alcohol and will cause you to get very sick – as in vomiting through your eye sockets. There has even been an occasional death resulting from drinking a lot of alcohol when on Antabuse.  Also, the longer you take it the longer you have to be off before you can safely drink – it means you have to premeditate your drinking up to a week in advance. Of course alcoholics don’t usually think, “I’m going to stop it so I can drink this weekend” – more like, “I don’t need it anymore”, and then oops!

One of the myths about recovering from addiction is that you have to want to do it and do it yourself.

Studies have shown that Antabuse works better when a loved one hands it to you every day. Treatment programs also work better when ordered by a judge.

One of the most annoying things about some programs is their negative attitude about medication. One alcoholic young man told me he liked taking Antabuse because he didn’t have to worry about drinking at night. But he was ordered by a judge to attend a program – the program wouldn’t let him attend if he was on any medication. Brilliant!

Just recently another medication has become available in the U.S. – Campral. It has been used in Europe with some success for 10 years. Early results here look promising. One disadvantage is that it has to be taken 3 times per day, two tablets each time. It apparently lowers craving by having one of the actions of alcohol in one part of the brain without itself being habit forming or having any reinforcing properties. It is not clear how well it will work if started while drinking, but getting people to stop drinking first is a major challenge – as in good luck!

Another treatment for alcoholism that has been around for several years is Revia. It works by blocking receptors for endorphins. In studies, 1/2 of alcoholics didn’t drink and 1/4 of alcoholics markedly decreased their drinking. The main draw back has been cost and insurance companies refusing to pay for it. It has been helpful for a few patients.

Since many times addictions are a self treatment for an underlying disorder, being able to diagnose the underlying problem and provide adequate treatment is often helpful. This is especially true when ADHD is the problem. Putting patients on stimulants has often significantly reduced or eliminated addictive behavior.

The TImberlawn Foundation did a study once of former cocaine addicts. They asked why and how they quit. The responses were vague and not especially convincing. But when they asked when did you quit and what was going on at the time they almost always found that addicts had gotten involved with something outside themselves. They became less self centered. Some became actively involved with a church or in other cases fell in love. They found a substitute. They found something that could help them achieve a “natural high”.

In other cases effective treatment of post traumatic stress disorder resulted in the addict no longer needing to get “numb”.

So we are left with the image of a woman of status and wealth, loved by her family found in her exclusive Boston neighborhood lying on the sidewalk in the rain with a concussion and multiple injuries. This was presumably a consequence of alcoholism – a medical illness that does not discriminate against any gender, race or social status. But as we learn more and more about the science of addiction and as we get better treatments there is much cause for optimism. Sadly, for some it may be too late.

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