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 addiction – getting 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.
