New York Times - Health
"A General in the Drug War"
The following is an article I just read in the "Health" section of the New York Times. Much of the information may not be new to PSST regulars, or the professionals we work with...NEVERTHELESS..it is very interesting from a medical and political perspective. I made minute edits to keep the article focused on our subject of choice, the world of addiction. For the full article, click on A General in the Drug War.
From heroin and cocaine to sex and lies, Tetris and the ponies, the spectrum of human addictions is vast. But for Dr. Nora D. Volkow, the neuroscientist in charge of the National Institute on Drug Abuse, they all boil down to pretty much the same thing.
A driven worker with a colorful family history and a bad chocolate problem of her own, Dr. Volkow (pronounced VOHL-kuv), 55, has devoted her career to studying this chemical tide. And now, eight years into her tenure at the institute, the pace of addiction research is accelerating, propelled by a nationwide emergency that has sent her agency, with a $1.09 billion budget, into crisis mode.
The toll from soaring rates of prescription drug abuse, including both psychiatric medications and drugs for pain, has begun to dwarf that of the usual illegal culprits. Hospitalizations related to prescription drugs are up fivefold in the last decade, and overdose deaths up fourfold. More high school seniors report recreational use of tranquilizers or prescription narcotics, like OxyContin and Vicodin, than heroin and cocaine combined.
The numbers have alarmed drug policy experts, their foreboding heightened by the realization that the usual regulatory tools may be relatively unhelpful in this new crisis.
As Dr. Volkow said to a group of drug experts convened by the surgeon general last month to discuss the problem, “In the past, when we have addressed the issue of controlled substances, illicit or licit, we have been addressing drugs that we could remove from the earth and no one would suffer.”
But prescription drugs, she continued, have a double life: They are lifesaving yet every bit as dangerous as banned substances. “The challenges we face are much more complex,” Dr. Volkow said, “because we need to address the needs of patients in pain, while protecting those at risk for substance use disorders.”
In other words, these drugs must be somehow legal and illegal, encouraged yet discouraged, tightly regulated yet easily available.
The experts are looking to the institute for scientific tools that might help by loosening the tight bonds between pain relief and addiction in the brain.
And that, Dr. Volkow told her audience with a small smile, is all about the dopamine. She knows a little about dopamine firsthand: She is a dedicated runner and a helpless pawn in face of dark chocolate. Her most significant long-term addiction, though, has been to the science of scanning the brain with techniques that expose its workings like a map, a passion she has pursued like a guided missile since medical school.
Dr. Volkow’s research career, still based at Brookhaven, has been notable for its “brilliant science,” said Don C. Des Jarlais, an expert in drug addiction who directs the Baron Edmond de Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York. Dr. Des Jarlais cited her recent widely reported study showing that cellphones alter brain metabolism as a typical example of her unusually creative scientific thinking.
A Merging of Missions
Her days now veer from reviewing raw laboratory data with her research colleagues to leading the back-to-back meetings of a government functionary, but the two roles are joined by the mantra of her time at the institute: Policy should be grounded in valid science.One recent decision in the upper echelons of the National Institutes of Health reflects a similar conclusion: The drug abuse institute and the National Institute on Alcohol Abuse and Alcoholism are on track to be merged into a joint institute on addiction still in the planning stages.
National Institutes of Health watchers have already started a body count. “It will be a big loss that Nora Volkow, current N.I.D.A. director, cannot possibly be selected to head a new institute,” wrote one anonymous blogger on the Scientopia Web site. “This would be too much like N.I.D.A. ‘winning.’ ”
But Dr. Volkow says she is all for the merger, calling the current structure “an artificial division with many missed opportunities,” like having an institute for every particular variety of cancer. Addictions tend to move together, she said, sharing many triggers and a great deal of biology.
Again, it is all about the dopamine.
All addictive substances send dopamine levels surging in the small central zone of the brain called the nucleus accumbens, which is thought to be the main reward center.
Amphetamines induce cells to release it directly; cocaine blocks its reuptake; alcohol and narcotics like morphine, heroin and many prescription pain relievers suppress nerve cells that inhibit its release.
Addicts and first-time users alike get the high that correlates with the dopamine wave. Only a minority of novices, however, will develop the compulsion to keep taking the drug at great personal cost, a behavior that defines addiction.
Researchers now postulate that addiction requires two things.
- First is a genetic vulnerability, whose variables may include the quantity of dopamine receptors in the brain: Too few receptors and taking the drug is not particularly memorable, too many and it is actually unpleasant.
- Second, repeated assaults to the spectrum of circuits regulated by dopamine, involving motivation, expectation, memory and learning, among many others, appear to fundamentally alter the brain’s workings.
For instance, Dr. Volkow’s group showed several years ago that when cocaine addicts watched videos of people taking drugs, dopamine levels surged in the part of their brains associated with habit and learning, correlating with the intense drug cravings the subjects began to experience. Her research and that of others has also shown that even after addicts are successfully detoxed and long clean, their dopamine circuits remain abnormally blunted. Substances that elevate dopamine levels in normal subjects had notably muted responses in ex-addicts.
This observation, experts say, may explain the intense difficulty addicts have staying clean, as the ordinary rewards of daily life may have little effect on the recovering brain. Only the drug of choice will send dopamine levels high enough for any kind of pleasure.
“Nora is as responsible as anyone,” Dr. Des Jarlais said, “for showing that addiction really does cause changes in brain function. Her work is a primary basis for considering it a disease, rather than poor choices or immoral behavior.”
Arming Doctors With Tools
Dr. Volkow has watched the microscopic events of addiction play out in fluorescent rainbow colors on brain scans for decades now. But those scans are used entirely for research, not for patient care. To the average doctor, she knows, the addict’s brain is impenetrable. All that is visible is irrational, illegal and sometimes threatening behavior. Surveys show most doctors prefer to keep their distance from addiction and addicted patients.
“My obsession is to engage the health care system in addiction,” Dr. Volkow said, to medicalize what is often considered mainly a criminal problem by arming doctors with their accustomed tools: effective treatments, even a vaccine.
“She’s been a champion of bringing addiction science into mainstream medicine,” said A. Thomas McLellan, director of the Penn Center for Substance Abuse Solutions at the University of Pennsylvania. Medicine is finally beginning to understand, Dr. McLellan said, that if you pay no attention to the behavioral factors leading to a chronic illness, be it diabetes or substance addiction, you can never catch up.
“That’s been one of Nora’s big contributions.” In a study published in 2000, Dr. McLellan pointed out that while the overall success rate for curing drug addiction with medications, therapy or both is not high (about half of treated individuals return to active substance use within a year), it is quite similar to overall successful treatment rates for other chronic medical conditions like asthma, diabetes and high blood pressure. Failure to take prescribed medications and backsliding to old bad habits is endemic, no matter what the condition.
The success of treatment for addiction is particularly dependent on the social milieu of the addicted individual, Dr. Volkow said. “So, for example, the best successes in treatment generally are physicians, for they are also the ones with the strongest support.”
But treating people with the prescription drug problems is particularly challenging, because, of course, for these particular drugs, physicians are the nation’s pushers.
The number of prescriptions written for potentially addictive pain medications has soared in the last decade, reaching more than 200 million in 2010, Dr. Volkow said. Surveys asking teenagers where they get pills find that relatively few buy from strangers. Many have their own prescriptions, often from dental work. Even more are given pills by friends and relatives, presumably out of other legitimate prescriptions.
Doctors may be flooding the country with narcotics, but most have never learned much about pain control. Dr. Volkow said that some data suggests that medical schools devote considerably less time to the subject than veterinary schools do. The Obama administration addressed exactly this deficiency in April with a call for doctors to undergo special training before being allowed to prescribe some of the most addictive painkillers.
“Students and residents have gotten the message that pain is undertreated,” said Dr. Mitchell H. Katz, an internist who directs the Los Angeles County Department of Health Services. “So they just prescribe higher and higher doses.” Meanwhile, he said, there is no evidence that treatment with opioids for more than four months actually helps chronic pain, or that higher doses work where lower ones fail.
There is good evidence, however, that higher doses raise the risk of overdose and death.
“The dichotomy between good drugs prescribed by doctors and bad drugs sold on the street is just bad science,” Dr. Des Jarlais said. “N.I.D.A. is now having to address the fact that there are real problems with prescription drugs.”
The institute is starting a multipronged effort to teach and to learn more about pain control as it relates to addiction. The teaching part includes sponsoring performances of excerpts from Eugene O’Neill’s “Long Day’s Journey into Night” at medical conferences, in order to humanize for doctors the problem of addiction.
The learning part is continuing: New science for pain control may take some time to devise, Dr. Volkow said.
New Approaches
One promising way to lessen the addictive properties of pain relievers, she said, is to slow the speed with which they reach the brain: A dribble of dopamine is far less addictive than a surge. New formulations to deliver pain relief slowly should minimize older drugs’ addictive potential. Skin patches are one example of this effort (although they can still cause fatal overdoses) and research is under way into others.
Another technique is combining drugs to deter abuse.
The drug suboxone, an alternative to methadone, is constructed with this intent. It combines a methadonelike drug for maintaining addicts on an even keel with another drug that counteracts overdoses and opiate-associated highs. If the suboxone is taken orally, as intended, the methadone effect predominates.
But all hard-core addicts know that if an oral drug is injected into the bloodstream, it will rush into the brain and create a far more dramatic high. If suboxone is injected, the second substance kicks in immediately and prevents the high.
Dr. Volkow generally forswears any interest in politics per se, but midway through a long day of meetings last month she sighed and acknowledged, “science and politics are intertwined.”
We think we have free will, she continued, but we are foiled at every turn. First our biology conspires against us with brains that are hard-wired to increase pleasure and decrease pain. Meanwhile, we are so gregarious that social systems — whether you call them peer pressure or politics — reliably dwarf us as individuals.
“There is no way you can escape.”
Profiles in Science | Nora D. Volkow
"A General in the Drug War"
By ABIGAIL ZUGER
Published: June 13, 2011
It's the DOPAMINE, stupid!
Posted by:Max--Wednesday, June 15, 2011
TWO TIRED TRAVELERS TAKE TIME TO REST UP
Posted by:Rocco--Wednesday, June 15, 2011
CISCO'S SAGA CONTINUES
When we left off the other night Sally and I did not know where Cisco was, who he was with or what his plans were. We knew there was not much else we could do. We had texted him several times with no response. We let him know that we would be at our regular Tuesday meeting and we hoped he would be there.
"The P.O." did not quit.
"The P.O." called us early Tuesday morning to let us know that he had made contact with Cisco and that Cisco would see us later in the morning. Cisco was good to his word and returned home somewhat embarrassed and feeling stupid [his words]. He asked if he could go back to Second Run for our meeting. As we promised him we didn't lecture him [too much] on the way. We also did not buy him cigarettes or stop at McDonald's when he asked.
When we got back to Second Run, Cisco was surprised to see the concern and the feelings of relief expressed by his housemates. They gave him the 'talking to' that we usually gave: "Why didn't you talk to us first?" "Don't you trust us?" "Why didn't you answer our texts? We wanted you to come back." "Don't go doing something stupid." "You know we got your back."
Sally, Cisco and I had our meeting with his counselors Tom and Clair. Tom is very good at reaching Cisco. Most of the meeting was about Cisco receiving more freedom and trust from his program and his parents; getting more chances to develop his life skills and opportunities to return the trust. Tom told him that nobody expected perfection but that we were looking for good choices, openness and honesty. Tom made the observation that the main reason that he drug tested Cisco was what he perceived as a recent trend of Cisco's lack of honesty and openness as well as some bad choices.
In a brief summary, Tom explained how using is just the climax of the relapse process. That overconfidence, deception, cheating and lying are the building blocks of the relapse process. He added that Cisco had already laid the foundations of his relapse in the last few weeks; that his using was just the capping off of his relapse.
He asked Cisco how he felt after using again?
Cisco replied "It felt like sh*t."
Tom said quietly "That's good, that's good. Now how does feeling like sh*t help you?"
Cisco wasn't sure.
Tom and Clair explained how his honesty about his relapse now gave Cisco a small window of opportunity to become completely honest; how he had just a brief time, before the window closed, to tell us what happened. Not just the night before but for the last few weeks. Where he was, what he was doing and who he was with.
Cisco opened up a little and explained some of what he had been up to. Tom challenged Cisco again. He explained that this was not the time to give us little bits of qualified details of what was going on. The window was now open but he needed to tell as much as he could before it shut. Cisco opened up one more time and Tom challenged him again and reminded him that omitting information was a form of dishonesty also. Cisco told a little more and Tom asked Sally what she thought about her son's honesty. Sally looked Cisco in the eye and told him that she had heard it all before and [asking him to look her in the eye] told him that quite frankly he was not telling the whole truth. Tom told Cisco that if nothing else; the least he could tell us is that he is "not ready to be completely honest" at this time.
He assured Cisco that he wanted to keep working with him but that he would need to go back into a rehab facility for a few weeks and that then he would need to reapply for Second Run. Then his housemates would need to interview him, be assured that he was serious about his recovery, and vote him back into the house. Tom said, if they voted him in, that Cisco would be starting at square one again and that he would not rush the program. He would need to do it step by step. Cisco agreed that this was a good plan.
At this time Cisco is to be evaluated for voluntary admission to an inpatient facility [his housemates voted to let him stay at Second Run until then. ]
As Sally noted; Cisco has a large tool box with a lot of shiny tools that he has worked for for the last two years; now he needs to get serious and use them. Or as Tom noted Cisco is a big boy and is much too large for anyone to carry anymore.
Sally and I see real progress in this latest episode:
- Cisco ran, not so much to get away from his program but because he was drug tested and knew he would show positive. He admitted that he felt shame for using and "it made him feel like sh*t."
As Tom said "That's good..." It has been a long time since Cisco has felt shame for using.
- Cisco came back quickly and faced his housemates and owned up to what he did.
- Cisco is voluntarily going into an inpatient rehab.
- Cisco wants to stay with his recovery program.
Sally and I are feeling good on how we handled this together. We are going back to our remodeling projects, our yard work, our classes and our Summer of 2011 [and our PSST Meetings].
We, once again, extend our thanks to the Allegheny County Juvenile Probation Program, PSST, Wesley Spectrum and Cisco's Halfway House, his housemates and especially his counselors, Tom and Clair.
This story will be continued, I am sure.
A Proud Parent Promises to Work Her Own Program
Posted by:Sally--Tuesday, June 14, 2011
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| Front of shirt: Click 'read more' to see back. |
It is necessary for me to start off each and every new day with the following promise to myself: I will remind myself that I am powerless over my sons addiction and promise to work at staying in control of my own life. I will pray each morning that I do not enable or act in a co-dependent manner.
Even though Rocco and I were weary yesterday and things looked bleak since Cisco walked away from his program and we did not know where he was, I felt a calmness from within. I know the source of that calmness came from God.
Cisco is now safe. Lloyd spoke with Cisco last night and Cisco told him he would meet us at our bi-weekly meeting at Second Run. I was not 100% certain that he would show up, however, Rocco and I got a good nights sleep. We stayed in our regular routine this morning and around 10 o'clock, Cisco called to ask if he could stop home and if we would drive him to Second Run.
I had a hard time facing the previous relapse that Cisco had. I think this one was harder on Cisco. He seemed embarrassed to face the men at Second Run who are diligently working their own programs.
The meeting went better than expected. Tom has a way of dealing with Cisco that is so effective. He is by far the best 'counselor' on addiction that Cisco ever had.
Cisco is going to a rehabilitation facility for a few weeks until he is detoxed.
Then he will have a chance of getting back into Second Run; the men who live there will have to vote on it. There will be a meeting and they will talk with Cisco and then make their decision. I got a first-hand glimpse at how AA and NA truly work. These men hold each other accountable. Some of them may be rough around the edges but they have hearts of gold and they care about each other.
I am proud of Cisco. Addiction is a very tough disease to handle and he is handling it well.
Share Read More......
Two Tiresome Travelers Tell Their Troublesome Tale
Posted by:Sally--Monday, June 13, 2011
Rocco and I are the weary travelers on this treacherous road of recovery. We have been at it now at continuously persistent speed for at least four years. Even before we met all the wonderful people at PSST and his recovery facility we will call Second Run we tried many avenues to aid our son in his recovery.
Cisco left Second Run tonight. He walked away from the facility after taking a drug test that he knew would come out positive.
I cringed when I saw the number of Tom, the director of the facility, show up on my phone. After a few years, you develop a sixth sense about a phone call and you realize when you are about to hear bad news.
We sent Cisco a text and explained that he should make a good choice and go back to New Beginnings so that Tom could work with him on this. He texted back that he was interested and we told him we would transport him back (with no lecture) if he would tell us where he was. We did not hear anything else from him. We do not know where he is or what he is doing. We let him know that we would be at our regular Tuesday meeting and we hoped he would be there.
I am simply hoping that we do not get a phone call tonight from the police or worse.
As for Rocco and I, we are seeing this in a very similar manner. I am thankful for this because it is so easy for an addict to drive a wedge between his parents. It is difficult to agree on some of the decisions that need to be made at a time like this.
Maybe it did not fully sink in yet or maybe I have finally mastered the art of detachment but I am in control of my emotions on this one. Rocco said that Cisco needs to 'hit bottom' and even though the weather is nice at this time of year, (he will not freeze his a$$ off - this became a controversy between Rocco and I last winter when Cisco walked away from a different program) he can hit bottom when he gets hungry and tired and has nowhere to rest. 
I agree with Rocco on this one.
We have done all that we could to help our son. We are running short of tools in our tool box. There are just some loose screws and nuts rattling around in there at this point.
On the other hand Cisco is carrying around a lot of good tools with him. He better put his Tools for Recovery to good use.
He is the only one who can build a strong structure called recovery.
The Prodigal Son is Given a Choice - by Joy Y, a PSST Mom
Posted by:Sally--Monday, June 06, 2011
The Prodicgal Son is Given a Choice ~ by Joy Y
The Prodigal came in at 9 a.m. after being out all night, not sleeping and got ready to go to work. As he was eating what I prepared for him, I asked him to please send me the drug test results (still hasn't) and he agreed.
I asked if he blazed last night, to which he responded "a bit". I said "You know if you stop blazing now that you will be able to remain at home after your final exam on June 24th".
P.S. said "If you stop giving me drug tests I can live at home".
I replied "To live at home we will continue to give you drug tests AND they need to be negative".
"As long as I follow the rules I should be allowed to live at home" he answered.
I told him, "Your right, and the rules are to live at home you need to be off drugs and to remain in drug counselling".
There was a silence for a bit then I noted "So I guess you are planning to move out?".
He looked up and asked "what do you mean?".
I said "Well, You know that you can't remain at home if you keep getting positive drug tests. So you must have plans of where you plan to live. It would be good to know if you are moving out".
He replied "Okay then, I will move out".
I told him "That's good to know, it will help with my plans".
He paused again "What plans?".
"Well", I informed him, "This house costs me $2000 a month. If we are only going to be the four of us, we can downsize to a smaller place and live in a place that works for all of us".
He exclaimed "WTF, why would you do that?".
I explained to him that we had been discussing for a while now about moving once you guys are out of high school to a place that is less expensive since we don't need to remain in this area. So knowing that you are planning to move out helps me plan better".
I went into the other room and asked one of the Prodigal's brothers if we moved to a smaller, less expensive place, where would he want to live. His other brother wants to live south of where we are, because it is near the university he wants to attend. But I asked where would he want to live. We discussed it for a bit, all the while, with the Prodigal is muttering from the other room "shut about about that".
We kept talking.
As I drove him to work, I asked if he started to get negative drug tests and remained at home, where would he want to live, if we moved.
He told me "I don't know".
I said "Well think about it, because we will definitely take your input into the decision".
He said "Well me and a bunch of friends are thinking about moving out for the summer".
I told him that was good to know".
He asked "Why?".
"Well, if you are moving out, then we will make the choice of where to live and how big a place we need, accordingly" I explained
"Well, what if I want to move back later?" he asked.
I told him "If you got off and stayed off drugs you'd be welcome to live with us wherever we were living. Hopefully there would be enough room for five of us and it would be in a location that would work for you".
He replied "I am not on drugs! I smoke weed".
I let him know that he is entitled to look it that way, neverthe less, for him to live at home he needs to have negative drug tests, which he doesn't.
He asked "Well nothing is carved in stone yet about moving out?"
"Well, we only need to give a month's notice on the house so if you move out we will take it from there" I explained.
He retorted "I don't see why I can't blaze and not do drug tests!"
I replied "If you live on your own, you can do whatever you see fit. However that is what it will take for you to live at home. We would like you to live at home, but you need to make a choice".
Then the Prodigal said something about "I bet you wish I was like my brothers".
I replied "No, I like you just the way your are, you are you and they are them".
He told me "That's not true! You wish I was like them!"
I said "I'm sorry you feel that way, but its not true".
By then, we had arrived at work. He just opened the door and left, saying nothing.
He is now finally in that place where he actually has to choose what he wants to do.
If the discomfort of remaining the same is greater than the discomfort of changing, then, who knows, maybe the Prodigal is ready to make some choices.
Stay tuned.
~Joy Y.
