It is Christmas Eve. Lacey and her three daughters eat dinner, finish the dishes, and tidy up before realizing that Jason is unresponsive. Jason has overdosed for the umpteenth time after downing a handful of Vicodin.
Like that of a highly decorated military hero, Jason’s chest is carpeted in patches—only his are plain white and contain fentanyl. Each medicated patch releases the drug for three days, but Jason amasses the patches on his chest over several weeks, in case there is a chance he can absorb more from them. Lacey has never seen him eat a patch, although she heard at an Al-Anon meeting that it has been done.
In the early nineties, Jason had begun using opioids to help with back pain. A doctor friend prescribed some painkillers to help take the edge off. Before the opioid prescription frenzy that started in the midnineties, Jason’s opioid use was manageable—even hidable. That’s when he met and married Lacey. They had a good marriage, raised three smart daughters, and enjoyed a healthy community of friends. Outwardly, they were a model family, ever cheerful and happy to help anyone in need. No one knew, not even Lacey, that the last two years of their marriage would be complete and utter hell.
Twenty years prior to Jason’s Christmas Eve binge, at the age of thirty, Jason suffered a snowboarding injury that left him disabled and no longer able to work. Jason became depressed and anxious. Before long, he was sitting in front of the TV 24/7, eating black market painkillers like popcorn and nodding off.
Now, on Christmas Eve, paramedics take Jason to the ER for overdose. From there, he is transferred to a hospital for detoxification, where he spends the first four days blacked out. Eight days later, Lacey comes to pick him up.
“You should be dead,” the physician says to Jason as he sits glumly. “Your beautiful wife here should be planning your funeral.” The doctor, who is no stranger to seeing opioid addicts, feels no need to mince words.
What Defines a Disorder?
From the outside looking in, it might seem as if addiction were a disorder of selfishness or even insanity. But if you compare addiction with other disorders, the concept is the same: Like any other medical condition, addiction has signs (drug taking, nodding off, cold sweats), symptoms (inability to stop thinking about the drug, anxiety), and a target organ (the brain). Drug use takes a direct hit against one of our most precious organs, and one that cannot be replaced. Over time, regular drug use alters brain chemistry, more dramatically in people with a genetic predisposition, creating conditions that promote more use—drugs activate parts of the brain responsible for memory and appetitive drive and suppress the part of the brain responsible for curbing urges and harmful behaviors.
Believing that addiction is a disorder rather than a voluntary choice sometimes requires a leap of faith. The families of affected individuals remain confused and angry for a long time about the inexplicable change in their loved ones’ behavior, the choices they are making, and their seeming unwillingness to return to the old way of behaving. Because people using opiates can remain rational in most other areas of their lives, it seems that their behavior around drugs is knowing and deliberate. With that, most families reject the reasoning that drug use has become involuntary and compulsory. They become angry rather than compassionate, accusatory rather than supportive. They initially reject the comparison to other medical disorders as well. Only over time do they begin to accept it.
But the evidence does not lie. Brain-imaging studies that evaluated the activity of areas of the brain involved in maintaining uncontrollable drug use show changes in function as compared to otherwise healthy brains, just as imaging studies show decreased function in the areas of the heart muscle where blood flow is blocked. In parallel, studies show reversal of these “abnormal” changes in the brains of patients who are able to remain drug free for more than six months as compared with the brains of patients with only days of abstinence. Other studies show that medications effective in treating drug addiction not only block specific receptor sites but also reverse deficits in the functioning of key brain centers. While it is difficult to identify brain areas that are only responsible for addictive behaviors, the fact that there is a predictable brain activity with the emergence and resolution of the disorder supports the fact that at the core of addiction is a disordered brain. It functions differently than the brain of an average person without the disorder.
The Best Way to Treat a Disorder
Viewing addiction as a chronic disorder not only helps dispel stigma but aids in understanding and treating the disorder. If addiction is proven to be a chronic brain disorder, our intervention should mirror the medical model for management of other chronic disorders, which allows for ongoing medical attention with a focus on long-term management, education, and support—the same model we use to treat hypertension and diabetes, for example.
Diabetics live with an impaired pancreas (the target organ) that is unable to fully control insulin levels. No matter how much diabetics try, they cannot fundamentally change how their pancreas works. And so, because we know diabetes is a chronic but treatable disease, we offer diabetics medication in the form of insulin, along with education about the best possible diet. If diabetics cannot control their craving for sugar, we adjust their insulin dosage until it stabilizes blood sugar levels. We don’t give up on these patients or send them to a residential program away from their home to give them a controlled diet and correct blood sugar levels. We intervene with evidence-based treatments before the onset of the possible consequences of the disease, including kidney failure, amputation, and blindness. And we keep treating diabetics for the rest of their lives, making sure they continue taking the medicine correctly and safely but also educating and supporting them to become personally responsible for the management of their disease.
You’re probably thinking that this explanation is all good and well, but none of it gets to the heart of the behavioral aspect of drug taking. Why, for instance, do people take drugs to begin with? Nor does it address why almost everyone uses substances recreationally at some point in their lives but only some become addicted, or why a once reliable person starts betraying loved ones for the sake of getting a fix. And why do addicted people, in particular, continue using despite some fairly severe negative consequences—such as getting fired or losing a toddler to child protective services? How is it possible that someone who willingly and habitually takes drugs, isolates, and not only neglects responsibilities but steals and lies in order to get high has a disorder? Lastly, why do nearly 25 percent of people using heroin develop OUD, when only 8 to 10 percent of alcohol drinkers develop alcohol use disorder?
The Power of Memory
The short answer to why people start drinking or taking other mood-altering drugs is simple: to feel good or feel better. Some do it to bring on an intense pleasure that is not otherwise available; others, to cope with daily stress, financial problems, the memory of traumatic experiences, or symptoms of a psychiatric disorder. Conversely, some, by the nature of their brains, cannot enjoy the positive effects of a given drug because the drug’s adverse effects are stronger. For example, groups of people living in China and Japan have a genetic mutation that causes them to have a very unpleasant reaction to alcohol. These people find little or no pleasure in drinking. As a result, very few of them become heavy drinkers or alcoholics.
Mood-altering drugs make most us feel good or better because they make a beeline for the “pleasure center” of the brain. Once there, they mimic the effects of natural brain chemicals to produce a sense of well-being and euphoria. The pleasure center is an ancient and forceful presence. It functions by rewarding us for behaviors essential for our survival as a species. The brain releases these same “feel-good” chemicals when we eat, socialize, have sex, or exercise. They’re the brain’s way of encouraging us to keep doing these life-promoting activities. The feel-good chemicals stimulate the brain centers so we remember the experience and how good it made us feel, as well as the environment where these important experiences took place. All of this is to make sure we will do it again.
With each such experience, the brain changes a bit, making it easier for us to want to repeat the experience. The desire or craving that precedes the activity is there to influence our choices. Addictive drugs, however, flood the brain with chemicals that act like impostors, taking hostage of functions that exist to ensure survival. We feel good and cannot differentiate whether this feeling plays any important role in survival. We just want to repeat the experience, which can be likened, at first, to the heady feeling of falling in love, an overpowering sensation that is often stronger than our ability to reason. If we get in the habit of turning to drugs regularly to feel good or better, we find that the drugs start to lose some of their wondrous and giddy effects. All potentially addictive drugs, whether made in a lab or found in nature, eventually stop working as well when overconsumed. More and more, positive effects are replaced with negative ones. This change in drug effects over time happens faster in some people than in others.
The Importance of Tolerance and Physical Dependence
The brain does much more than promote our desires to have a good time. It preserves important functions, such as breathing and alertness. It is about survival and will adapt to preserve its most essential functions if necessary. When overwhelmed by repeated and massive amounts of drugs, your brain adapts by going into protective mode. It shuts down neurochemical receptor sites to prevent an overflow of drugs from interfering with essential brain functions. To keep you alive, your brain has changed its function and structure. Two of the most clinically visible brain changes are tolerance and physical dependence.
Tolerance
Tolerance is a key term in addiction medicine. It is used to describe a threshold, or how much of a drug you must consume to get the desired effect. With continued use, the threshold rises. As it rises, you need to take more drugs. For example, if you increase the number of pills consumed from, say, one to two and then six but continue to feel the same way you did when taking one, you have increased your tolerance. Your brain function has changed in an effort to prevent overdose. You now need six pills to feel the same way you did when you were taking only one pill. Although it may sound counterintuitive, tolerance is the brain’s way of protecting the body against overdose. It is a defense mechanism.
The more powerful and faster the effects of the opioid, the faster tolerance develops, and the sooner you must escalate the daily dose. This is an experience known well to all drug users, whether using marijuana or painkillers.
Physical dependence
Physical dependence is another sign that the brain has adapted to the constant presence of opioids. When you are physically dependent on a drug, the brain expects the daily presence of the drug, whether prescription painkillers or heroin, to stay “in balance.” Physical dependence is not addiction (although it can be a symptom of addiction), which involves another set of changes in the brain center. The opioids block the release of noradrenaline, a brain chemical that mobilizes the body in dangerous or stressful situations for the “fight or flight” response. In response, the brain exposed to opioids produces more noradrenaline, but the constant flow of opioids keeps this extra noradrenaline in check. In this way, the brain remains “in balance” as long as opioids are regularly flowing into the body from the outside.
If you are physically dependent and stop taking opioids, your system quickly goes off-balance, and you start feeling symptoms of withdrawal—aches, pains, nausea, diarrhea, insomnia, hyperactivity, and anxiety. This is a result of an overactive noradrenaline system, whose effects are no longer suppressed by opioids. In some sense, symptoms of withdrawal serve a purpose. Without opioids, your digestive, cardiovascular, and nervous systems (also adapted by and now dependent on drug use) are stressed, and your brain is doing what it can to encourage you to take more opioids so your body can preserve “normal” function. You experience this encouragement as craving. Your brain is now focused entirely on self-preservation, and all other functions go by the wayside.
Some drugs affect you more severely than others, depending on their type, dose, and the speed with which the drug reaches your brain, but all addictive substances, even alcohol, marijuana, caffeine, and nicotine, are capable of altering your brain and producing withdrawal symptoms. Depending on the severity of the withdrawal symptoms, stopping can be easier said than done.
At this point, the only thing you can do is abstain and give your brain time to heal so that it starts opening up receptor sites and producing feel-good chemicals on its own again. But with opioids, the cravings are so pronounced, and withdrawal so miserable, that abstinence seems unfathomable. And so, as much as you might want to escape your addiction, you are compelled to seek an ever-higher dose to try to feel normal. Feeling good is a thing of the past.
It’s All in Your Head
Football as a Metaphor
Aaron Hernandez, the former New England Patriot football tight end who was convicted of murder and later committed suicide in his prison cell at the age of twenty-seven, was posthumously found to have chronic traumatic encephalopathy (CTE), a degenerative brain disease caused by repeated blows to the head. CTE is not uncommon among professional athletes who have suffered multiple concussions throughout their career. The brain disease can lead to aggressive and impulsive behavior as well as suicide. There is no test for CTE, although there are some signs and symptoms. Only an autopsy of the brain can confirm that the disease is present. Aaron’s CTE was severe. Doctors compared it to the progressive CTE of NFL football players who were more than thirty years his senior. So, why didn’t Aaron stop playing football when he felt himself changing?
Let’s rewind a little further. First, Aaron chose to play football. Probably, like most professional athletes, he loved the sport as a kid and was good at it. So, he kept playing. As a professional, he made good money and felt elevated by the cheers of a stadium full of fans for doing what he loved—in other words, his behavior was repeatedly rewarded. He would suffer a concussion or an injury but would recover and continue to play. In other words, the adverse consequences didn’t stop him because the reward was stronger. Aaron’s personality started to change, the result of changes to the structure and function of his brain from years of being hit in the head during practices and games, causing him to lose control over some of his behaviors. Only after being thrown in prison for murder did Aaron stop playing football. And it wasn’t by choice.
In Aaron’s case, football was the drug; head trauma, the needle; and CTE, the resulting brain disorder. The injuries inherent in the game had an effect on Aaron’s brain that gave him a disorder. It is true that if Aaron had chosen not to play sports, none of this would have happened. But playing football made him feel good, so he kept repeating the experience. An unfortunate combination of external events and his inability to recognize what was happening to him and stop before it was too late were what led to his demise and death.
How addiction develops is in many ways similar. As with CTE, there is no test for addiction; at first the opioid user is rewarded for repeating the experience; adverse consequences are often not enough to stop the desire to repeat the experience; and the structure of the brain changes so that the user loses the ability to stop at will, regardless of the consequences.
Opioid Use Disorder
We know far more about addiction now than we did a hundred years ago, when snake-oil cures were the rage. Guidelines for how to best understand and diagnose addiction continue to change and improve with research.
Current diagnostic criteria, established by the American Psychiatric Association, call addiction a substance use disorder (SUD). The association also calls out SUDs by the drug of choice: alcohol, cocaine, cannabis, tobacco, and opioids (opioid use disorder, or OUD). Before any individual develops SUD, they are using the substance without the signs or symptoms of addiction, sometimes for a long time, even months or years. SUD rarely develops after only a few episodes of use. More often, it develops in a step-wise progression, moving from mild to moderate and finally severe.
Determining whether someone uses opioids recreationally or has a full-blown addiction is not always easy, even for addiction experts following clear-cut guidelines. It is not as if we can draw a line in the sand and delineate that when it is crossed, addiction is present. OUD and other drug addictions follow a progression marked by twists and turns. The continuum jumps back and forth and can change month to month. To date, there is no physical test to determine whether addiction is present (although there are many physical consequences). We gather information from a clinical interview and the patient’s report. We diagnose OUD and other SUDs by a set of behaviors—behaviors indicative of someone whose brain functioning has changed and who has lost the ability to control their substance use. The more consistent the presence of behaviors, and the more numerous, the more serious the disorder.
Most diagnostic standards emphasize four core components of addiction:
The DSM-5 lists eleven symptoms: two to three symptoms during the prior twelve months are considered to have a mild use disorder; four to five symptoms over the same period is considered moderate use disorder; six or more symptoms equals severe. OUD may also be complicated by the presence of other psychiatric disorders, medical issues, and by many social problems. How we address each stage of OUD varies. We can work to prevent a mild opioid use disorder, for instance, by identifying individuals at risk and implementing psychoeducational interventions or initiating therapy that focuses on coping strategies. Initiating treatment early on in a disorder’s progression ensures the best outcomes, prevents progression to more severe forms, and minimizes risks of serious consequences, such as infection, liver disease, overdoses, psychiatric complications, and personal losses.
Nicole’s Story
It is Nicole’s twenty-fifth birthday. She spends the day moving into a new apartment with Jake, her boyfriend of seven years. Nicole has been sober for about five years, minus an occasional lapse or two. She went through multiple detoxes and treatment programs, two of them residential, to finally reach the point where she is comfortable in her own skin. Although she has a drink on occasion, she is abstinent from opioids.
Jake is just out of a sober house. He has been gone for nearly a year, including the time he spent in residential treatment. After being sober for three years with Nicole, Jake relapsed to painkillers and heroin for a punishing year. Watching him deteriorate was prevention enough for Nicole, who stayed clean. Now, they are going to try to live as a couple again.
After a long day of unloading and unpacking, they go to bed. Nicole senses something is off. Jake, she can tell, is high. Too tired to fight about it, Nicole falls asleep. In the morning, Jake is not breathing. She shakes him and tries to do CPR, but she cannot move his jaw.
The paramedics arrive and get Jake’s heart beating again. At the hospital, the intensive care physician tells Nicole that Jake went into cardiac arrest after taking cocaine and two bags of heroin. Before treatment, he was accustomed to taking much more. Because he had detoxed and no longer had any tolerance for the drugs, they were a complete assault on his system.
Jake is put on life support. Five days later, Nicole and Jake’s family make the grueling decision to end support. Having gone so long without oxygen, Jake’s body cannot be fixed.
Nicole holds it together until the funeral, but afterward turns to her old friends heroin and cocaine for comfort. Before long, she is consuming fifteen to twenty bags of heroin a day topped with a gram of cocaine. She loses thirty pounds in four months; the source of her weight loss is part grief and part drugs.
One day four months later, Nicole wakes to find her legs grossly swollen. She has no clue what is happening, and her mom shuttles her to the ER. The sonogram does not lie. Nicole is six months pregnant, carrying a healthy, three-pound fetus. Not having felt one symptom, and having lost rather than gained weight, Nicole is in shock.
Nicole has never liked using, but stopping on her own is not an option. The moment she tried cocaine at age sixteen, she was hooked and snorted at least a few lines every day. At seventeen, she tried OxyContin, and like a fickle lover, immediately dropped coke for the painkillers and used daily. By the time she was eighteen, she turned to heroin.
Nicole has never had a good day while using. She remembers only bad days. And now, again, she wakes up every morning thinking only about her next fix.
A Chronic Condition with Many Unknowns
For practical purposes, OUD can be defined as a disorder that follows a chronic course. If you have OUD, even if you undergo treatment and abstain, the risk of relapse persists. The more and longer you used, the more healing your brain must undergo. Cravings for the drug do not suddenly subside in the absence of opioids. It can take months or years—usually said to be at least five years—before you stop thinking about the drug completely. However, I see recovery as more of a continuum. Without medical support, each year of abstinence reduces the risk of relapse, yet the risk still exists. There is no way of knowing whether relapse is imminent. I tend to advise my patients that the best way to live with this unknown is to accept OUD as a chronic condition, just as you would accept diabetes.
OUD cannot be cured, but if you have it, you can return to living a “normal” life. Sustained recovery can and does happen, regardless of how many overdoses or relapses you have undergone. It is possible, even, to find a life in recovery far better than the one prior to opioid use. The key is intervention. Long-term treatment with medication, preferably in combination with psychological treatment, is without a doubt the most effective treatment available for OUD. Additional interventions, such as participation in self-help groups, is desirable and can be extremely helpful, but it cannot be suggested in lieu of medical treatment. Some people achieve and maintain long-term recovery without medication, but at this point we have no way of determining who they are. Medication-based treatment, on the other hand, is a proven approach that works for most people, which is why we should offer it as a first line of treatment to anyone in need of help.
Who Is a Candidate for Developing
Addiction and OUD?
The first use of drugs is almost always a choice: the teenager who wants to fit in and takes his first sip of beer or hit of marijuana, the mom who starts drinking wine every evening after all the kids have moved out of the house, and patients taking two Percocet as needed for postsurgical pain. For a majority of people, that choice turns out to be harmless. They manage to drink socially or smoke a joint on occasion without any consequence. They take their opioids as prescribed and never contemplate going to the pharmacy for a refill. Use of alcohol or other drugs might fluctuate during periods of their life, but they have no trouble setting their drug of choice aside when responsibility calls.
Once the choice is made to use or drink, it’s a little like playing Russian roulette. No one knows with 100 percent certainty whose use will become chronic and whether one drug will have more influence than another in establishing addiction. For one person it is wine. For another it is opioids. We have some indicators of who is likely to become addicted, and they are based on two separate influences: genetics and environment. But there is no test. If you come from a family with a history of addiction, you are a candidate. If no one in your family has suffered from addiction, you are less of a candidate, although still at risk. If you lose your job, go through a divorce, or suffer a different traumatic event, you can activate dormant addiction genes, start using the substance in response to certain internal and external triggers, and start the addiction process. Likewise, if you grow up surrounded by drug use, understanding it as a normal part of life, you might use to excess and alter your brain chemistry enough to cross the line into addiction, even though you do not have many of the genes that facilitate it.
Myths About the Nature of OUD
Screening for OUD
If we cannot identify those at risk, how can we help them before it is too late? The gap between suspecting or knowing whether someone has a problem with opioids and getting them to either reduce use or enter evidence-based treatment is frustratingly wide. Frustrating because we have the effective tools necessary to narrow the gap, yet we are slow to implement them. Thousands of people are falling through the cracks.
Screening and brief intervention with referral to treatment (SBIRT), a movement currently under way to close the gap, shows promise.
With SBIRT, health-care professionals can help the individuals who come to them—often in a medical clinic, pain clinic, or hospital emergency room—where they are usually being treated for other conditions. For example, although there is no test to determine whether someone has OUD—or would have it if they started taking opioids—we can screen for it and other addictions. SBIRT is kind of like Addiction 101. It’s a tool any health-care professional in any setting can employ to try to catch problematic behavior early, before it becomes a major problem, and motivate the individual to change. The three-tiered model calls for an assessment using standardized screening tools. If problematic use is suspected, the provider talks about it with the patient, using a somewhat standardized script known to motivate. If the disorder is diagnosed, the doctor refers the patient to treatment or implements treatment in the current setting.
SBIRT is known to reduce use and save money. When SBIRT-trained medical professionals employ the method consistently with people who use alcohol, it has been shown to limit a full-blown progression to alcohol use disorder. Many people do not know, for instance, that having three drinks a day is considered problematic. Once they have the conversation, it is as if a lightbulb goes on, and many agree to start drinking less. Although SBIRT has not shown the same results with OUD, this could change as more professionals use SBIRT and as the help for and conversation about OUD becomes more acceptable, compassionate, and mainstream. Stigma is one of the biggest reasons why addiction is still a taboo subject: Patients don’t mention it to doctors or seek help, and doctors are not asking about it. Talking about addiction is one of the best ways to reduce that stigma.
Once trained, any health-care professional can implement SBIRT in any setting, expanding outreach well beyond the grapevine, which is what many family members go through to find treatment for a loved one they believe is addicted. Early identification of problematic substance use in the medical setting is an opportunity to promptly intervene and prevent the progression of the disorder to the stage when consequences are more severe and treatment may be more difficult.
But like any tool, SBIRT is only as good as its implementation. Getting some health-care professionals and the institutions they work for to accept SBIRT has been slow. It can be difficult to change the behavior of career health-care providers who have been at it for more years than not, and so the current strategy is to target students in training. Another issue involves medical records and confidentiality. Hospitals, ever cautious about being sued, are leery of documenting drug use, lest records get subpoenaed, for instance, and inadvertently condemn the patient who is just being honest when they reveal they occasionally use cocaine and alcohol.
Because of problems with stigma and the need to protect patient confidentiality in addiction treatment programs (to decrease barriers to entering treatment), it was necessary in the past to completely separate medical and addiction records. Now that we are working harder toward integrating addiction treatment into mainstream medical care, the law that has protected patients stands in the way of helping them. Doctors barred from accessing important medical histories cannot act on them.
The benefits of SBIRT, however, outweigh the legal risks. At Columbia University, we have a program where we train medical students in SBIRT. We see firsthand how students’ attitudes toward patients with SUD change. When these students become doctors, their heightened awareness and openness will make them better able to detect the disorder in patients early on. Hopefully, as doctors, they will be open to treating addicted individuals. A lot of these programs exist for medical residents, nursing residents, and nurses, in settings ranging from clinics and hospitals to public health offices, social worker services, and school services.
Harm Reduction
For those deeply mired in the world of addiction, the conversation begins not with prevention or treatment options but the delivery of free condoms, clean needles, and instructions for how to use drugs safely. This is harm reduction, or using known ways to reduce some of the risk associated with drug use. Intervening on those who suffer from severe OUD and either see no way out or have no desire to quit drugs requires a different, more subtle and basic approach. We attempt to reduce harm by protecting people who use drugs from unsafe sex and soiled needles, and thus infectious diseases, such as HIV and hepatitis C. Some harm reduction centers will test heroin brought in by clients to make sure it does not contain deadly fentanyl, offer to exchange clean syringes for dirty ones, dispense disinfectant, provide a safe space for injecting heroin, and even give naloxone to reverse an overdose if necessary. Outreach workers refer people who use drugs to places where they can find free food, clothing, and shelter.
As outreach workers develop an informal relationship built on trust, they gently try to coax users into getting help. They lend an ear, have accepting and nonjudgmental conversations, and share information about access to social or public health services. Although outreach and harm reduction might resemble a propaganda effort, they are really more altruistic—public services built on compassion and the desire to save lives and reduce the amount of heartache OUD can manifest. No one is forced into treatment. No one is arrested for being in possession of illegal substances. Survival and the preservation of human dignity outweigh all else.
Outreach workers are trained to replace social exclusion with acceptance, and as the addicted individuals open up to the positive experiences they have with an outreach worker, they open up to the idea of treatment and recovery. Even something as simple as a syringe access program, available in some states, is effective. By simply interacting with outreach workers, users are five times more likely to enter treatment.