The Addicted Brain (24 page)

³
Ibid.

⁴
Ibid.

⁵
For example, see Rosenberg D.R. and Lewis D.A. “Postnatal Maturation of the Dopaminergic Innervation of the Monkey Prefrontal and Motor Cortices.”
J Comp Neurol
, 358: 383–400, 1995. See also Sowell E.R. et al. “In Vivo Evidence for Post-Adolescent Brain Maturation in Frontal Regions.”
Nature Neuroscience
, 2: 859–861, 1999.

⁶
Ibid.

Suppose you have been doing drugs for several years, and your life has begun falling apart. Your boss is suspicious over your behavior and absences. Your spouse is fed up and threatening to leave. You owe plenty of money to the banks and your friends. Out of desperation, you talk to your family physician, who has been telling you for months that “It doesn’t have to be this way. Get into treatment! Get into treatment!”

Many people are in trouble because they are using drugs, but it
really
doesn’t have to be this way. Treatment is available. Some people are confused about what treatment means. It does
not
mean that they will be handcuffed, arrested, locked up, given a prison record, forcibly withdrawn from drugs, and then tossed back into the street! It is going to be much less traumatic and more helpful than they might think. The effectiveness of treatment is well documented. Many people’s lives have been saved by timely treatment. Does it always work for every person? Well, some people require several episodes of treatments and relapses before their addiction is successfully treated. Some might drop out of treatment or never get adequate treatment. We might not yet know how to reach these latter subjects, but treatment research goes on and advances are made all the time. There are some factors that predict better success in treatment, such as a lower level of dependence or drug use, a good support system, and a job/career. That is not to say that all of these are absolutely needed, but just that they seem to help. People with none of these characteristics have successfully recovered.

There are significant costs of drug use and addiction.
Chapter 1
, “What’s in This Book, and Why Should I Read It?” (see
Figure 1-2
) shows how the costs of drug use are distributed. If an individual is contemplating treatment, he or she might feel it is too expensive. But on the other hand, the person probably can’t afford not to go into treatment. Also, in many cities treatment can be free, at low cost, or on a sliding scale, so cost is not a valid excuse. Even if it was expensive, it is cheaper to treat than not to treat! That might be surprising but this is what has been found by several studies on different drugs such as alcohol and cocaine. We have a good idea what the costs are to drug users, their families, friends, and society. Assuming reasonable costs for treatment and reasonable recovery rates for drug users, it is clear that treatment is cheaper than allowing drug users to continue on as they are. Some studies say that the savings over a three-year period are multiples of what it costs to treat the individuals compared to leaving them untreated. Treatment is more of an investment than a cost.

When we say that treatment has been successful, does it mean that the patient never takes the drug again? Is it total and permanent abstinence? Well, that is certainly the ideal and would be best. The goal of many treatment groups such as Alcoholics Anonymous (AA) is total abstinence, but no one denies that it can be a difficult and lifelong process. Many doctors believe that a reduction in drug use has to be considered at least a partial success. By this book’s definition, drug abuse is causing distress and harm in your life, and a reduction of harm, even if not completely eliminated, is a good thing.

In earlier chapters we saw that drugs overwhelm the brain and produce long-lasting changes in powerful brain systems. From this perspective, it is no wonder that addiction is a serious, chronic, and relapsing disorder, and that recovery can be a difficult, long process
with setbacks. Perhaps progress doesn’t have to be complete abstinence, but any kind of progress, no matter how little or great, helps. Sometimes just a little progress has to be accepted for now with the hope and expectation of greater progress and abstinence later.

This is an important issue and has to do with society’s views and attitudes about addicts. Addicts and addiction carry a stigma. Many consider drug use a moral failing requiring something like an awakening, an epiphany or a spiritual rebirth for a cure. Many feel that addiction is something that the individuals do to themselves so therefore they should undo it by themselves. Why bother with addicts? Let them figure it out! There is a lot of self-righteousness and moralizing in some groups. But research in addiction over the last decades has shown that addiction is a brain-based disorder due to biological and environmental factors. From this perspective, drug abuse is similar to other diseases, such as cardiovascular disease, for example.

Cardiovascular disease usually refers to atherosclerosis, which is a disease of the arteries. Cardiovascular disease is costly to treat because of the expense of medicines and medical procedures, loss of productivity, and the worry of the patients. The cardiovascular patients can be at least partly to blame because they might choose, in many cases, to lead a sedentary lifestyle and continue to eat high fat foods. The patients have at least partial control over the disease in that they can visit their doctor, take medicine, exercise, and watch their diet. One can argue that they voluntarily initiate their disease by improper diet and lack of exercise and perhaps by lack of attention to health care. Treatment is both behavioral and medical. It is behavioral in that they must modify their behavior in accordance with the advice of doctors, counselors, dieticians, and personal trainers. It is medical in that they must take their medicine and regularly see their physician. The doctor might suggest that they need to change their lifestyle by breaking some ingrained, bad habits and by learning and
adopting some good ones. Sometimes, in spite of everyone’s best efforts, the patient dies. We just don’t know enough to cure every cardiovascular patient. But we can prevent or reduce cardiovascular disease in many people.

Drug addiction is similar to cardiovascular disease. The emotional and treatment cost is great. The patients have initiated their disease and are at least partly to blame. They have some control over their behavior, and a lifestyle change is needed. Treatment is both behavioral and medical. Sometimes treatment doesn’t improve things and the addicts continue drug use. Perhaps their habits, environmental pressures, inherited traits, and other factors are so strong that we haven’t yet found a way to beat them. In spite of the similarity, cardiovascular disease carries much less blame and stigma than addiction. Addicts deserve the same help and attention as anyone with any kind of brain disorder or disease.
¹
Unfortunately, many addicts don’t want their drug use known. The fear of being stigmatized prevents many from seeking and sticking with treatment. What can we do to help? We can develop a more compassionate and supportive attitude about addiction and treatment, and we
all
can try to combat the stigma of drug addiction. We can think of drug addiction in the same way we think of cardiovascular disease, asthma, or late onset diabetes—as a preventable disorder.

Drug abuse is complex and is the result of many interacting factors (refer to
Chapter 8
, “Could I Become an Addict?,”
Figure 8-1
, which describes these interacting and additive factors). Accordingly, treatment is geared to meet this complexity. If treatment has not worked for someone, then it might not have been done or understood properly. There are several important, general principles that characterize good treatment. Dr. Martin Adler and his colleagues have summarized principles of effective treatment.
²
Reading through these provides an idea of what to look for in a treatment plan, or why treatment might have failed in some cases.

The
first
principle is that no single treatment is good for all individuals. What a counselor would do for a college student who gets stoned on marijuana a lot, and whose grades are falling is different from what a doctor would do for a sixty-year-old alcoholic who has imbibed every day for years and years and is on the verge of liver failure. Importantly, if treatment does not seem to be working, consider another type or source of treatment. A life might be at stake!

A
second
principle is that adequate treatment must be found. It might be far away and expensive. However, much is at stake and the patient might have to make nearly heroic efforts to get proper care, but, as described, it is worth it.
Third
, effective treatment addresses multiple problems of the person. Because drug use can have multiple roots—including family history, availability, and anxiety or depression—and occurs in a social setting that includes family, a group of friends, a neighborhood, and so on, it is very complex. All of the various parts of this complexity must be addressed to give the drug user the best chance of staying drug free and rehabilitating.

Fourth
, treatment plans must be assessed and modified to meet the subject’s changing needs. As drug users improve, or even if they get worse, the best treatment might change. For example, after some improvement, the drug user might be ready for vocational training, if suitable. Flexibility in treatment is important and it can offer substantial, new opportunities that drug users haven’t had before.
Fifth
, subjects must remain in treatment for an adequate period of time to get benefit. Research suggests that it can take about three months of treatment for the patient to show significant improvement. Too many people give up and leave before they can derive enough benefit.
Sixth
, counseling and “behavioral therapies” should be part of treatment. Drug users often need to rebuild personal and social skills that include problem-solving and succeeding in relationships. Medications can’t do this, although they can facilitate them.
Seventh
, medications are important for some users and can be effective when combined with counseling.
Eighth
, drug users with mental problems,
such as anxiety or depression, should have access to mental health professionals who can effectively manage and treat mental problems. If a person is taking cocaine to curb his or her depression, getting treatment with counseling and medications such as antidepressants will hopefully eliminate that root need or cause of taking the drug. Again, addiction is a complex disorder.

Ninth
, detoxification, or getting the drug out of your system, and coping with withdrawal if necessary, is only the first stage of treatment. By itself, it is unlikely to prevent relapse, but it must be done before the user can move on in treatment.
Tenth
, treatment doesn’t have to be voluntary to work. It can be mandated by a judge and data shows that treatment works anyway. It is an urban myth that treatment must be voluntary to succeed.
Eleventh
, drug use must be checked during treatment to assess improvement or relapse. No one expects drug use to stop immediately in all cases, but the status of the patient regarding drugs must be known in order to address it effectively. Relapses or continued drug use are not the end of the world, but they might suggest a different direction of treatment.

The
twelfth
principle is that treatment programs should test for infectious diseases including hepatitis, HIV/AIDS, tuberculosis, and STDs. Instructions on how to avoid health problems can be critical for some users, and overall good health is needed to cope with the stresses of detoxification and treatment. The
last
principle is that recovery from drug use can take a long time and might require multiple episodes of and commitments to treatment. This seems important and the patients—their support groups must appreciate that treatment has to last a long time for many people. Addiction is a relapsing disease or disorder where changes in the brain last a long time.

If you know of a treatment failure, knowledge of these principles might give you some ideas about what went wrong. They might help answer the question “Is there anything else we could have done?”

“But I don’t have a problem!” This is something that is often heard from individuals who are letting drugs destroy their lives. “I can stop any time I want.” This is another thing that is unfortunately sometimes not true. We can easily be in
denial
about ourselves and our problems. Denial frustrates doctors—in itself it is a disease. Having to hit rock bottom and become desperate because of denial is risky and unnecessary. The earlier in life we address drug use and dependence, the more of a productive life we have.

Many drug users misjudge their position, and they don’t grasp the benefits of or the need for treatment. It is commonly said that users must hit “rock bottom” before they are shaken into action and seek treatment. Although a crisis can help, it isn’t necessary for things to be at an absolute worst before getting help. Many users see where things are headed and decide to get help before a crisis does happen. It can take months of thinking about it before one actually enters treatment. When they do, they are engaged by a professional who has much training and many ideas. The patient must be assessed, and this can involve, depending on the situation, testing—both physical and written, giving a drug history and a personal history. When the situation is understood, a treatment plan can be formulated and treatment begins. Treatment often involves both efforts to modify your behavior and medications that help patients tolerate drug abstinence. But, as has been said before, treatment is flexible and formulated differently to meet the needs of different patients. Therapists have a broad range of techniques and approaches to choose from.