Top 10 great things about being addicted

Here at All About Addiction we keep talking about fixing addiction and treating addiction given the suffering that addicts go through. But there are certainly some positive things that go along with being addicted and we figured we should point those out. SO here they is are top 10 addiction list:

Top 10 great things about being addicted

1. You get to do whatever you want whenever you want to do it – For many addicts, schedules are not an issue and consistent commitments no longer exist. This means that any given day can feel like a vacation. It’s a great thing, although much of it gets taken up by looking for drugs, preparing drugs, trying to get money for drugs, or recovering. Still – vacation time!

2. Being comfortable sleeping on a floor – This is a bit dependent on the specific drug (or drugs) you’re addicted to but it’s pretty common for addicts to be seen sleeping in bizarre places, positions, and clothing. Passing out on the floor may not sound good to you if you’re not actively using drugs, but it can’t be that bad if so many people do it for hours at a time. Hey, I once passed out half on a couch and half on the floor while on the phone!

3. You don’t have to bother yourself with family obligations – Not only has most of your family probably stopped inviting you to events because being seen with you embarrasses them, but when invited you rarely show up (see #1 above) so they stopped trying. Besides, not liking to be tied down to specific times, addicts would rather do other things (like drugs) then hanging out with family and having to listen to stories, eat food, or play with children.

4. People don’t annoy you with conversation – Whether because addicts seem aloof or unhappy or because they can smell bad, people seem less likely to engage addicts in random conversations. Of course, this doesn’t apply to other people you meet at your drug dealer’s house or the late-night liqueur store, but those “friends” can often tell you where to get more drugs, so it’s not really a bother (more on this later). Cops also don’t apply to this category.

5. Not having a boss breathing down your neck – Having a boss who can tell you what to do and when to do it can suck. Most addicts can’t hold a job for too long though, so they don’t have to worry about it. Granted, not having a job can affect you finances (as in cause you not to have money), which puts a damper on #1. Still, since you can be comfortable sleeping anywhere (see #2) it doesn’t really matter if you can’t afford a place to live. Besides, if you owe your dealer money, he’ll be breathing down your neck enough.

6. Pesky mortgage, rent, and car payments are rarely an issue – Money issues like rent, mortgage, and such are without a doubt one of the most troubling aspects of living in a capitalistic society. For addicts who have homes and cars, the competition between paying for those or paying for drugs can be fierce (worse if you’re addicted to gambling). Often times, drugs win, which removes the need to worry about it. As listed in the above points, not worrying about these things leaves you free to be on permanent vacation, sleep on the floor, or enjoy not having a boss… or job.

7. You can be late to anything when you’re an addict – Most people get yelled, or at least scoffed, at when late to events but not addicts. As we pointed out above, addicts don’t get invited to as many things and rarely make it at all when they do. Being late is actually a successful outcome for a drug addict. Drug dealers are often late themselves, and while they can be upset if you’re late when picking up, they’ll take your money and give you drugs, which is all that matters anyway.

8. Sleeping in becomes a way of life – We already mentioned that addicts seem to be able to sleep anywhere, but we didn’t mention that they can also sleep in late, or even all day. Meth addicts can crash for days and others simply don’t get out of bed or their room for days at a time. Of course, if you’re a heroin addict or alcoholic and have been using for a while, you may have to wake up in the middle of the night to get a fix because withdrawal can start within a few hours. But then you get to stay there as long as you’d like. Neat!

9. Not worrying about hygiene, looking good or fit – Vanity is for the meek and worrying about things like health, skin, hair, and showers is beneath those who are concerned with more basic needs like feeling good and surviving. You might be thinking already that given some of the above points about lack of work, money, and a reliable living situation, vanity might also be difficult for many in active addiction. You’d be right. The choice between brushing your teeth, taking a shower, or working on your next hit is not one that requires much thinking. Hygiene can wait.

10. Getting a group of very close friends that relate – Like in recovery, addicts tend to associate almost exclusively with others who use their drug(s) of choice. This means that your friends know, and care, a lot about everything you care about. They can recommend good spots to shoot up, places to get rigs, smoke-shops that are open late, and other relevant information most people would be stumped about. Those friends are likely also experiencing the rest of this list, so they can relate! Unfortunately, some of these friends might steal from you, lie to you, or even beat you up because they want your drugs, money, or due to a psychotic break. Nothing is perfect though…

We could probably think of more, but I think that this top 10 list gets at some of the most basic things that active addiction is great at providing. We’d love to hear more thoughts from people who are either still using or those of you who have quit. Family members’ thoughts would also be welcome but annoyingly they usually notice the “bad” things about addiction more often and that’s a bummer.

Is opiate pain medication safe for addicts? Part I

A recent user question on VYou (see my response here) addressed the issue of prescribing addicts with opioid pain medication. Since prescription medication abuse and addiction is on the rise and getting more and more attention in the media every year, the question of whether addicts in recovery, or people who have dealt with substance abuse and addiction problems in the past, should be prescribed these medications is a very relevant one.

Chronic pain affects a substantial portion of the population worldwide (as many as 30%, see here). Opiate medications are one of the most commonly used approaches to treating such pain, which if untreated can cause serious disruptions to sufferers’ lives. Even when treated, chronic pain can be pretty debilitating. Some research (1) brings up good questions about the true effectiveness of opiate therapy for chronic pain, especially among long-term opiate users (like heroin and prescription pain medication addicts) but also among other drug using populations.

So how common is the practice? What sort of results do drug addicts usually get from these opiate therapies? And finally, how many of the addicts or drug abusers who receive these therapies end up abusing them and can we identify those people early so we can stop prescribing to them? In this three-part series of articles we’re going to cover these questions in-depth.

Prescription pain medication use in addict populations

Clinicians treating chronic back pain choose from a range of options, including opioid medications, exercise therapy, nonsteroidal anti-inflammatory medications, tricyclic antidepressants, acupuncture, and electrical stimulation. One study (1)  found wide variability in the percent of chronic pain patients prescribed opioids (from 3%-66%) although the studies varied widely in their size and population served – some even looks at general back pain and not chronic pain alone (they tended to have much lower opioid prescription percentages). Among chronic pain clinic patients, chronic opioid pain medication use was estimated at 19% (2).

Among addicted populations, concerns about tolerance, withdrawal, and abuse tend to cut prescription rates for opioid pain medications. However, past drug abuse can exacerbate pain issues, especially for people who abuse, or have abused, opiates in the past. For this reason, it can sometimes be difficult to properly manage pain in people with a history of addiction. One study (3) found that as many as 67% of patients in a Methadone Maintenance Program and 52% of patients in short term residential treatment programs were being prescribed opiates for pain. It’s important to note that these numbers are higher than those reported in other studies but that populations in treatment do generally show prescription rates higher than the general population. A study in Finland (a country that has great medical record data) found that opiate prescription rates in substance abuse populations were equivalent (not higher or lower) to those in the general population. The College of Problems on Drug Dependence itself had released an official statement noting that a balance must be reached between fear of opioid prescriptions for pain and the usefulness of opioid pain medication for chronic and severe pain (4).

Interestingly, it seems that of all opioid pain medication prescriptions, the largest increases in troubling use has been around oxycodone (Oxycontin), which gets mentioned as often in emergency departments (ED) around the country even though it is prescribed about one-third as often as hydrocodone (Vicodin). This is less surprising when you consider the fact that many addicts report using oxycontin in different ways including smoking, snorting, and injecting the stuff, which is stronger and does not have the same amount of fillers as most hydrocodone preparations. The fact that oxycodone is stronger also means it is more effective for pain relief through higher activation of the opioid system that is relevant for addiction.

In our next piece we are going to explore whether opiate pain medication is helpful in controlling pain among addicts and substance abusers, see you then!

Citations:

1. Martell, O’Connor, Kerns, Becker, Morales, Kosten, Fiellin. (2007). Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction. Annals of Internal Medicine, 146, 116-127.

2. Chabal, Erjavec, Jacobson, Mariano, Chaney (1997). Prescription Opiate Abuse in Chronic Pain Patients: Clinical Criteria, Incidence, and Predictors. Clinical Journal of Pain, 13, 150-155.

3. Rosenblum, Joseph, Fong, Kipnis, Cleland, and Portenoy (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. The Journal of the American Medical Association, 289, 2370-2378.

4. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement.

New Year’s Eve without drugs or drinking alcohol?

For many people all around the world, New Year’s Eve celebrations mean a lot of partying. Often, that partying includes drinking alcohol, doing drugs, and generally engaging in one last night of “things you’ll forget about” in the year that has passed. I know the ritual and I took part in it often. Hell, the virtual symbol of NYE is the Champagne toast (talk about a trigger).

Champagne glasses are essentially the symbol of NYE celebration. No big deal for most people, trigger for addicts.Since high-school, NYE celebrations meant little more than getting so &#@$-faced that I wouldn’t be able to remember what happened the next morning. Actually that’s not true – I’ve only experienced one blackout in my life – I always remembered what I did on New Year’s Eve. From my early days of drinking as close to an entire bottle of vodka as I could along with some gravity bong hits for my CB1 and CB2 receptors to fully light up to later parties that involved acid (LSD), ecstasy (MDMA), cocaine, and finally crystal meth, it was all about excess in its rawest form.

Humans enjoy celebrations in a way that other animals simply don’t. It comes with our keen awareness of past, present, and future. It’s the way we mark special events that only have true meaning because we assigned it to them. It’s part of what makes us the most social of animals and is tightly connected to our brains and their massive supply of executive function. But none of that matters when you’re loaded on drugs or alcohol on New Year’s Eve. All that matters is that you’re having fun.

For most people, this sort of partying doesn’t cause any problems. As long as they don’t drive under the influence, getting a little messed up is just not that big a deal. Hey, getting high on drugs and alcohol has left us with some of the best art, music, and writing I can think of and out livers and kidneys can handle the stress pretty well. But for some people, that same seemingly innocent set of behaviors can lead to a far darker place.

For addicts who have become dependent on drugs or alcohol, or for those people teetering on the edge of addiction with drugs and alcohol as still fully functional crutches that make the world slightly more tolerable, that same partying can get dangerous. It can lead to memory loss and accidental death. It can lead to the destruction of property, relationships, and self-esteem. It can lead to handcuffs and metal bars that don’t go away when the effect of the drugs or alcohol wears off.

As I’ve talked about so often here, we’re still pretty bad at telling the difference between those who are simply partying hard and those who have a real problem. We can tell after the fact, looking back at how long someone struggled (hard-core addicts can spend decades struggling with addiction while the more tame abusers/addicts only last a few years) but that doesn’t do anyone much good now does it?

I’ve sat in many groups with addicts trying to plan for these holidays so that they can make it to the other end without throwing away everything they’ve worked so hard for. The temptation of shooting up, smoking a bowl, or drinking a fifth of your favorite liqueur (or 2 bottles of wine)  can be too much when everyone around you makes it seem like so much fun. Many make it through with little more than resolved anxiety and a sense of relief. But every year, a few get left behind, some to return a bit later with a little more of a war story than they had previously.

The point – Making it through the holidays

The holidays, and New Year’s Eve in particular, are a bad time to try to figure out which of these groups you belong to exactly because everyone else is being excessive too. An addict can easily cross the line and seem no different. Until the next day that is. So this holiday, do yourself a favor and hold off on any grand experiment. Take it easy, spend some time with real friends who have your best interest at heart, and make it to the next year in style. You can always test yourself another day.

Addiction treatment in Vietnam – Beatings and forced labor

You’ll never think of Cashews in the same way after reading the first few pages of this recent report by the Human Rights Watch group that looked into the abuses in Vietnamese “drug treatment” centers.

These drug treatment camps in Veitnam are little more than forced labor jailsThe detainees in these facilities, whether they checked themselves in voluntarily or were committed after being arrested for using or possessing drugs, describe terrible conditions, hard forced labor, and extensions to sentences that make their experience seem much more like jail than any form of drug treatment. Indeed the report states that “no one who had been detained described any form of scientifically or medically appropriate drug dependency treatment within a center. Psychosocial counseling involved lectures on the evils of drug use and morning exercises while chanting slogans such as ‘Healthy! Healthy! Healthy!’ .”

It should be pretty obvious that relapse rates are extremely high since, as we’ve talked about numerous times here on A3, at least part of addiction involves compulsive behavior affected by biology and early experiences and therefore punishment alone will simply not work for true addicts… And still we put all of our addicts in jails and prisons with little actual drug treatment in our own country – I guess at least we don’t have forced labor.

Read this thing  by the Human Rights Watch group – it’ll leave you just a little speechless.

Money or cocaine? It all depends on timing

People who are looking for treatment for their cocaine addiction still really like cocaine, but they’ll choose money as an immediate reward if they can only get their drug of choice later.

Cocaine or money? Depends on how long the wait is

Although it might be somewhat surprising, the above finding is the result of a recent study by a team of researchers spanning the U.S. and Australia that was recently published in the journal Psychophramacology.

We’ve talked about the concept of relatively high impulsivity among addicts on A3 before and the concept isn’t a new one — Addicts make drug-focused choices in the short term even if there are larger rewards far off in the horizon. In fact, this sort of delay-discounting (considering future rewards as being worth less) is a general human phenomenon that has simply been found to be exaggerated among addicts.

Think about it – Would you prefer $50 now or $1000 in 6 year? What about $100 now?

By asking a set of similar questions researchers can determine an individuals discounting rate or the amount of discounting people put on the delay in getting the later reward. Up to now, most of this sort of research has been conducted using the same “now” and “later” rewards. People were asked to decide between money now or later, cocaine now or later, cigarettes, meth… you get it.

This recent study made things more interesting by creating a few different conditions:

  1. Money now Versus Money later
  2. Cocaine now Versus Cocaine later
  3. Money now Versus Cocaine later
  4. Cocaine now Versus Money later

The goal was to see if people discount money and drugs equally. Since one of the hallmarks of addiction is that addicts seem to undervalue everything else while overvaluing drugs, figuring out whether bringing delay into the mix was at the least interesting but at best possibly useful in treatment.

The researcher used participants who were actively looking for cocaine treatment and ended up with a relatively small sample of 47 individuals who met criteria for cocaine addiction. As is usually the case with these sorts of studies, most of the participants were men, the average education equaled high-school and the average age was early 40s.

Participants were asked how many grams of cocaine a $1000 was worth and that unique number was used for each participant as the equal point between money and drug. Then they were presented with options such as the above (X number of dollars now or X number of dollars in six months).  As participants made selections, the immediate amount was changed by 50% to counter their choice (it was reduced if they chose immediate and increased if they chose delayed rewards) and the procedure repeated six times for each of seven different delay periods (1 day, 1 week, 1 month, 6 months, 1 year, 5 years, and 25 years).

So, let’s say a participant was first asked if they wanted $500 now or 20 grams of cocaine. If they chose cocaine, their next choice would be $750 now or 20 grams of cocaine later; now if they chose money, the choices became $375 now or 20 grams of cocaine later… and on the experiment went.

Cocaine addicts choose cocaine if they can get it now, but not later

First of all, it’s important to note that the research showed that different participants had pretty stable discounting characteristics. That is, if a participant preferred to get things now rather than later, that was likely true across all conditions regardless of whether the reward was drugs or money. However, the different rewards also had a large influence on this equation.

The main finding from this study was that when faced with the option, cocaine addicts chose immediate money over later cocaine even if the immediate money amount was relatively low. That finding might seem surprising at first given what we think we know about addicts. Aren’t they supposed to always choose drugs regardless of what else we put in front of them?

Apparently, what matters is not only what we put in front of them but also when. Of course, anyone who actually knows an addict (or is one themselves) already understands that trying to simplify addiction to an ability to only choose drugs is silly. Addicts would die of starvation or a host of other issues pretty quickly if that was true. Addiction is much more nuanced than that, and as I mention at the end of this piece, this finding might not be as clear as one might think.

In fact, this finding has already been greatly supported by at least one addiction treatment tactic that we’ve discussed here on A3 – Contingency Management (CM). In CM, individuals in treatment are rewarded for staying clean and doing well in treatment. They’re not given cash but instead are rewarded with vouchers that let them buy food, clothes, etc. for providing drug-free urine tests and going to their assigned group meetings. This addiction treatment method follows the basic tenant of the psychology of learning – people do what they’re rewarded to do. This study offers a fresh perspective on the matter, suggesting that one of the reasons people do well and stay longer in treatment when given CM is that the immediate money reward is thought to be worth more than the possibility of getting drugs later. It might also explain why CM has only really been shown to work well while people are in treatment and not when they leave…

I mentioned earlier that I think these findings may be a little more complicated than they first seem. One of the major issues I have with this study stems from my life as a drug dealer. The users I know quickly equate money with drugs and so it is very possible that in their minds money now also equals cocaine now, although a smaller amount of it and they’ll take whatever drug they can get now instead of having to wait for it. Most regular users I’ve met would easily choose a single gram of meth now instead of 4 or 5 in 6 months. They simply don’t want to wait that long to get high. Money holds its value much better in the long run and this research supports that idea.

Citation:

Bickel, Landes, Christensen, Jackson, Jones, Kurth-Nelson, Redish (2011). Single- and cross-commodity discounting among cocaine addicts: the commodity and its temporal location determine discounting rate, Psychopharmacology

Shame on me – Stigma and addiction in treatment

I keep hearing that back in the old days of addiction treatment, shame was the main motivating factor used by rehab counselors. Everyone admits that it proved to be a horrible motivator. It simply didn’t work! With all the advances in research into addiction, that must have changed, right?

I don’t think so. I see shame and stigma every time I hear an addict talk about their drug use. The shame is there in their eyes as they tell the stories of their trouble and the struggles of their recovery. Given the low rates of success in addiction treatment, the shame rests firmly in the inability to quit as well. A relapse is often seen as the ultimately shameful experience for an addict. The stigma of addicts as hopeless is rampant.

Still, we have evidence of genetic predisposition to drug abuse and addiction, we know of environmental factors that make it more likely that people will get hooked. The effect of many drugs on the brain make unsuspecting lab animals as likely to become addicted as any one of us and I’m pretty sure that shame doesn’t play a role in their process.

With all this evidence, why is the stigma of drug addicts still around? Why are they the only ones being blamed for their condition?

The evidence I cited isn’t that different from that known for cancer, yet we scarcely blame cancer patients for their disease. Even in the case of smokers who become ill, their is still sympathy for their suffering. So why are addicts different?

There are good addiction treatment options out there, as long as we don’t give up on the person and simply view their addiction as evidence of their weak character. Given the changes that long term drug use produces in the brain, it’s a miracle anyone recovers at all. We should be grateful for that.

Is personal experience necessary for successful addiction treatment?

In the “recovery” community, one often hears about how the best person to reach an addict is another addict in recovery. The question is whether personal experience with, and victory over, addiction is necessary for a counselor or therapist to be successful in providing successful addiction treatment?

I’ll spoil the surprise by telling you that I personally don’t believe such personal experience is necessary, and that is despite my own personal experience with addiction. I also think that spreading the notion that the above is true is counterproductive to addiction treatment as a field and that it creates an atmosphere whereby mental health professional are a little weary of getting involved in treating drug addicts.

Personal experience as a requirement for treatment in general?

Imagine for a second that you had acne and needed to get a treatment for it, would you only seek out dermatologists who have had severe acne as teenagers themselves thinking they will be best able to assist you? What about if you were diagnosed with cancer or diabetes? I’m assuming most of you can see that requiring the ones treating us to have experience with the same issues we’re dealing with is a bit silly, at least in the physical health sense. We need clinicians that know what they’re doing, can diagnose problems quickly and accurately, and who are familiar with appropriate treatment options and keep up with the latest advancements. They don’t need to have personal-experience with the problem.

But what about mental health issues like depression, schizophrenia, or bipolar disorder, would having one of those require a therapist who suffers from the same disorder in order to truly provide tangible results? Should schizophrenics only be treated by schizophrenics? Here again I think that most people can see that experience is not necessary. It might be nice to have a therapist who sympathizes, but really, what we need is knowledge and ability, which often involved empathy, but not necessarily shared experience.

So what makes addiction so different and special?

There’s no doubt that addicts like to think of themselves as special. I would certainly place myself in that group and have personally heard countless addicts who are no longer using exclaim that once addict recover “we are a special and capable bunch.” All of this makes sense in the whole “in-group/out-group” mentality that is so familiar to everyone in psychology as an effect generally observable in the population. But my sense is that when it comes to treatment it can be a dangerous premise.

Think about it – There is no question that addicts are far less common than the general non-addicted population. This means that in essence, believing this dogma – that addicts are best treated by other addicts – leaves the field less open to outside influence that are no doubt able generate great insight into the addiction treatment field. We can feel as special as we want, but I hope that no one believes that addicts somehow have a monopoly on knowledge, expertise, ability, and empathy. We don’t, and thinking we do is at best narcissistic and at worst ignorant and stupid.

I work with dozens of researchers who have no first-hand knowledge of what smoking crack uncontrollably is like (and probably a handful who do) and I can tell you that each of them has had incredible insight into the problems of addiction. I can also tell you that I’ve met many addicts in recovery who think they have found the end-all-be-all answer to our collective problems simply because these things have worked for them. Experience as an addict does not equal insight into addiction treatment. Experience in recovery may give some insight, but thinking that it is necessary and sufficient for providing great treatment is… unwise.

I believe that we need to get better at measuring, identifying, and replicating good addiction treatment, not setting up barriers for clinicians interested in treating addicts based on their own personal experience. My guess is that as we do this we’ll find that some addicts are great at treating addiction and some are horrible and that the same goes for “normies.”