A&E’s Intervention – Joey, the middle class, heroin addiction, and hepatitis C

A&E’s Intervention built quite an initial popular following for itself by choosing subjects with disarmingly unique stories and addictions. However, as the show has progressed, it has found strength in an ability to show America the true face of addiction: the so-called normal, everyday people battling their demons in private.

Heroin addiction doesn’t understand “class”

Joey, a 25-year old father from Pennsylvania, stands as a prime example, a young male who grew up with a supportive family in a comfortable suburb and nevertheless found himself in the grip of heroin addiction. By his own account on Intervention, Joey began experimenting with drugs at the age of 13, and by 15 was regularly smoking marijuana. By 17, he was using ecstasy, LSD and had developed a heroin addiction, which several trips through a 12-step rehab program did little to slow. As his tolerance for heroin built, Joey found himself shooting heroin at the rate of up to 7 bags a day to maintain his high. Despite steady work as a tattoo artist, his money was increasingly feeding his heroin addiction, preventing him from even making his child support payments. Sharing dirty needles had also most likely been the cause of his recent contraction of Hepatitis C, an infection that now shows up in a staggering 80% of all regular injection drug users.

A&E’s intervention – A glimpse into the face of addiction

As per the show’s format, this episode revolved around a forthcoming intervention planned by Joey’s family, who were growing more and more desperate as his heroin addiction continued to eat away at his life. In accordance with the Johnson Model, the classic standard of addiction intervention, the family resolved to present Joey with an ultimatum- either he could voluntarily enter rehab treatment, or he faced losing contact with all of his family members, losing any rights to his young daughter, and could even face jail time for violation of his probation.

Even with the gravity of the consequences facing him, Joey’s heroin addiction was such that he still could not come to terms with his situation. Anticipating the intervention, he ran, going into hiding for two days while his family camped outside of his home, his job, and the homes of his friends, waiting for the chance to confront him with reality. Ultimately, they spread the word that they were prepared to have him arrested. With nowhere left to turn, Joey finally resolved himself to rehab, though not without one final fix.

Difficult recovery and relapse

Though the treatment originally seemed to take well, giving Joey 9 months of sobriety, he was depicted on the program suffering a late relapse. This time, he willingly returned to treatment. According to A&E’s Intervention, he has now been sober since April 25, 2010.

Joey’s story resonates because of how tragically common his themes are: the complete loss of personal wealth, the hardship that the addict’s behavior has on family and friends, and the willingness to put oneself in extremely dangerous situations for the chance to use just one more time. Time and again, Joey demonstrated an extreme lack of caution as he shot up heroin with dirty needles, putting himself at risk for Hepatitis, HIV, and any other number of serious diseases. This brings up the issue of so-called “harm reduction” programs designed not to prevent injection drug users from using, but rather to provide them with clean needles and education in order to minimize the threat to public health and guide, not force, the addict towards potential treatment. The long-standing counterargument to such programs has been that they implicitly condone drug abuse, but research has shown that needle exchange programs do not increase drug abuse but merely decrease disease and dirty needle use. In this way, it is increasingly becoming regarded as analogous to sex education and the distribution of birth control, another common-sense public service that has too often fallen victim to the agendas of culture warriors.

Though for some a lurid escape, it has become increasingly clear to us at A3 that A&E’s Intervention, by presenting a straightforward view of the true complexity of modern drug use and addiction, has become an invaluable tool for those attempting to understand the face of this issue. As is usually the case with television content though, it pays to go a little deeper, and hopefully the show motivates people do just that.

Time to get high- Circadian rhythms and drug use

Contributing Co-Author: Andrew Chen

Like most living creatures, humans have internal biological clocks known as circadian rhythms. These internal cycles synchronize our bodies with the Earth’s 24-hour day/night cycle and prepare us for predictable daily events (1). Circadian rhythms regulate a number of bodily functions including temperature, hormone secretion, bowel movements, and sleep (2). Recent research suggests that drug use may disturb our circadian rhythms, possibly influencing our decisions to take drugs.

Moon

Environmental drivers of drug use

Our biological clocks are set by external cues from the environment, called zeitgebers (3). The most familiar to us are light and food. However, research on rats has shown that opiates, nicotine, stimulants, and alcohol also have the ability to alter the phase of circadian rhythms independent of light or food (1). Drug use has long been associated with major disruptions in the human sleep cycle. Cocaine, crystal meth, and MDMA users often go without sleep for days, and these sleep disruptions can continue long after people stop using drugs. In fact, sleep disturbance outlasts most withdrawal symptoms and places recovering addicts at greater risk for relapse (3).

The rhythm of drug use

Circadian rhythms could also be the reason why people show 24-hour patterns of drug use. A study of urban hospitals found that overdose victims are admitted to hospitals more around 6:30PM than any other time of the day (2). Fluctuations in drug sensitivity, effect, and reward value are believed to be regulated by genes that control circadian rhythms. In other words, our biological clocks are telling us when to get high.

Researchers are just beginning to explore the relationship between circadian rhythms and drug use. Future understanding of this relationship will help us explain how drug addiction develops and develop better ways to treat it. It’s possible that offering specific aspects of treatment as certain point in the circadian rhythm can improve the probability of success.

Citations:

1. Kosobud, A. E. K., Gillman, A. G., Leffel, J. K., Pecoraro, N.C., Rebec, G.V., Timberlake, W. (2007) Drugs of abuse can entrain circadian rhythms, The Scientific World Journal, 7(S2), 203-212

2. McClung, C.A. (2007) Circadian rhythms, the mesolimbic dopaminergic circuit, and drug addiction, The Scientific World Journal, 7(S2), 194-202

3. Gordon, H.W. (2007) Sleep, circadian rhythm, and drug abuse, The Scientific World Journal, 7(S2), 191-193

Crystal meth withdrawal – It’s not like heroin, but don’t expect it to be easy

Heroin, or opiate, withdrawal symptoms is the gold standard of addiction withdrawal. Imagine the worst flu of your life, multiply it by 1000, and then imagine knowing that taking a hit of this stuff will make it all better. Think sweats, fever, shaking, diarrhea, and vomiting. Think excruciating pain throughout as your pain sensors get turned back on after being blocked for way too long. Now you have an abstract idea of the hell and it’s no wonder why heroin withdrawal has become the one every other withdrawal is judged against.

Crystal meth withdrawal

Withdrawing from crystal meth use is nothing like opiate withdrawal and there’s no reason that the withdrawal symptoms should be. Opiates play a significant role in pain modulation and opioid receptors are present in peripheral systems in the body, which is the reason for the stomach aches, nausea, and diarrhea. Dopamine receptors just don’t play those roles in the body and brain, so withdrawal shouldn’t be expected to have the same effect.

But dopamine is still a very important neurotransmitter and quitting a drug  that has driven up dopamine release for a long time should be expected to leave behind some pain, and it does.

One of the important functions of dopamine is in signaling reward activity. When a dopamine spike happens in a specific area of the brain (called the NAc), it signifies that whatever is happening at that moment is “surprisingly” good. The parentheses are there to remind you that the brain doesn’t really get surprised, but the dopamine spike is like a reward signal detector, when it goes up, good things are happening.

Well guess what? During crystal meth withdrawal, when a crystal-meth user stops using meth, the levels of dopamine in the brain go down. To make matters worse, the long-term meth use has caused a decrease in the number of dopamine receptors available which means there’s not only less dopamine, but fewer receptors to activate. It’s not a surprise than that people who quit meth find themselves in a state of anhedonia, or an inability to feel pleasure. Once again, unlike the heroin withdrawal symptoms, anhedonia doesn’t make you throw up and sweat, but it’s a pretty horrible state to be in. Things that bring a smile to a normal person’s face just don’t work on most crystal-meth addicts who are new to recovery. As if that wasn’t bad enough, it can take as long as two years of staying clean for the dopamine function of an ex meth-addict to look anything like a normal person’s.

This anhedonia state can often lead to relapse in newly recovered addicts who are simply too depressed to go on living without a drug that they know can bring back a sense of normalcy to their life. The use of crystal-meth causes the sought-after spike in dopamine levels that helps relieve that anhedonic state.

When it comes to more physiological sort of withdrawal symptoms, the meth addict doesn’t have it that bad, I guess. After an extended period of sleep deprivation and appetite suppression that are some of the most predictable effect of meth, the average addict will do little more than sleep and eat for the first week, or even two, after quitting the drug. Many addicts experience substantial weight gain during this period as their metabolism slows and their caloric intake increases greatly. Like everything else, this too shall pass. With time, most addicts’ metabolism return to pre-use levels and their appetite catches up and returns to normal as well. Still, there’s no doubt that a little exercise can help many addicts in early recovery steer their bodies back on track.

There’s some research being talked about around the UCLA circles to see if detoxification from meth may help people do better in treatment for meth addiction by reducing the impact of their withdrawal. Detox before addiction treatment is an accepted fact in opiate and benzodiazepine addiction, but because of the supposedly “light” nature of crystal meth withdrawal, it’s been ignored. Hopefully by now, you realize that was a mistake.

Triggers and relapse, a craving connection for addicts

I’ve already written about one reason why cravings make quitting difficult (find it here). However, cravings and triggers are not just abstract concepts; they are well known, important players in addiction research and I think they deserve some more attention.

What are triggers?

A trigger can be thought of as anything that brings back thoughts, feelings, and memories that have to do with addiction (like a computer reminding a sex addict of porn). In addiction research, these are often simply called cues. The word comes from learning research in which a reward (or punishment) is paired with something (the cue).

For instance, in Pavlov‘s classic experiment, a dog heard a bell ring right before it would get served its daily portion of meat. The dog quickly learned to associate the bell with food, and would begin salivating as soon as the bell would ring, even before the food was presented. In this case, the bell was the cue, and food the reward it was paired with.

The story in drug addiction is similar. I’m sure many of you can relate to the overwhelming memories and emotions that seem to come out of nowhere when you hear music you used to get high to or pass a street where you used to buy drugs (or sex). Each of those examples is a trigger that is simply bringing about a similar reaction to Pavlov’s dog’s salivation. Seeing these things, or hearing them, creates an immediate response to the reward that it was paired with, the drug!

Triggers, cravings, drugs, and relapse

As if matters needed to be made worse, triggers not only bring about responses that make you think about the drug. In fact, over and over in learning and addiction research, it’s been shown that triggers actually bring back drug seeking, and drug wanting, behavior. As soon as a cue (or trigger) is presented, both animals and humans who have been exposed to drugs for an extended period of time, will go right back to the activity that used to bring them drugs even after months of being without it. In fact, their levels of drug seeking will bounce back as if no time has passed. Sound familiar?!

Given these findings, is it any wonder that cravings bring about relapse in so many addicts who are trying to quit? If simply thinking about, or hearing, something that was always tied to drugs can bring about such a strong response, what is an addict to do?

Is there a solution for addicts??

For now, the simplest way to break the trigger-response connection is simply repeated exposure without the reward. As bizarre as this may seem, staying away from the triggers can make their ability to bring back the old drug-behavior stronger. Obviously, this isn’t something that should be undertaken lightly. I’m currently working on putting together a drug treatment system that specifically addresses these issues so that with help, users can eventually release the hold that triggers have over them.

In the meantime, be honest with those around you, and if you’re seeing a therapist, or a good case manager, tell them about your triggers so that you can hopefully start talking about them, and re-triggering them in a safe environment. As always, feel free to email me with any questions you might have.

Ancestry, Addiction, and trauma – Addiction research into genetic differences based on race

We all know that drug use and drug related crimes are a big problem within African American communities. It’s not a secret, but it can be interpreted very differently by different people. Do the differences between African Americans and Americans from European descent mean that Black people are simply meant to have more problems?

A recent study suggests that at least when it comes to addictions, the opposite might be true.

A genetic study of addiction and ancestry

Researchers at the New Jersey VA (Veterans’ Affairs) office collected data from 407 addicted African American patients as well as from 457 comparison participants at a local hospital’s ophthalmology clinic. Like in most studies of this nature, both groups was screened for other psychiatric problems and participants from the control group were excluded from the study if they showed any signs of addiction problems themselves.

The researchers then used 186 different genetic markers that relate to ancestry to determine the proportion of African, European, and Asian descent for each participant. After following this up with some questionnaires about childhood trauma and an estimations of participant socioeconomic status (things like income, education, age, etc.), the researchers ran analyses to see if African ancestry was related to drug problems, childhood trauma, and poverty.

The ancestry of the participants was verified to be mostly (average 80%) African, with European, Middle East, and Central Asia contributing between 5% and 7% more.

What did they find?

Addiction research about race and genetics - The proportion of African ancestry among the different groupsThe first interesting finding was the fact that patients with alcohol, cocaine, or opiate dependence had lower proportion of African ancestry than non addicted individuals. The differences ranged from 5% to 3% but certainly reached significance levels. Since its already known that Europeans are more likely to show alcohol, but not drug, problems, the researchers checked to see if that was the factor responsible for the difference – it wasn’t.

Interestingly, even though childhood abuse or neglect were very much related to addiction in this sample (as we’ve talked about before), there was no relationship between African Ancestry and abuse or neglect.In fact, the two factors that were almost significant (childhood physical and sexual abuse) showed trends similar to those for addiction – African descent was associated with lower problems in those areas.

The final, and not surprising finding, had to do with an association between African ancestry and lower socioeconomic status. The differences in these categories were significant for income and education. This finding can almost serve as a validity check on the whole experiment, since census data has long shown lower SES for African Americans in the united States.

What does this all mean?

Okay, I know this isn’t necessarily the easiest study to understand, so let’s break it down:

Given the known drug problems among African Americans, the researchers wanted to know if African descent could have something to do with underlying genetic factors that make it more likely that Black individuals will end up as drug addicts. There are a host of genetic differences between Europeans, Asians, and Africans, and this was a way to get at a lot of them in one shot. The problem is that African Americans are also poorer than many European Americans, and since poverty is a known risk-factor for addiction, meaning it makes it more likely that someone will end up an addict, the researchers were interested in separating the two. They threw trauma in because it, like poverty, has already been shown to be related to addiction.

The results seemed to indicate that the two factors (poverty and addiction) as indeed separate. While African descent was associated with more poverty, it was actually found to be associated with less drug, and alcohol problems. This suggests that it’s the poverty, and all the factors associated with it, that may be driving the higher addiction rates among African Americans and not some predisposition to drug problems.

The good news is that this suggests that efforts at improving the SES and quality of life for African Americans in the United States will indeed lower their substance abuse rates. In fact, when it comes down to it, this research suggests that European Americans are the ones we need to watch for in terms of genetic risk for addiction.

As always, limitations

As usual, we need to remember that these are associations and don’t prove causality. Also, given the very specific sample used (veteran addicts), the results should be replicated in other populations. Lastly, remember that the ancestry-based differences weren’t huge, but given the fact that this was a strictly African American sample, that’s probably part of the package. Again, more research with  broader populations should help to resolve that.

Citation:

Francesca Ducci, Alec Roy, Pei-Hong Shen,Qiaoping Yuan, Nicole P. Yuan,  Colin A. Hodgkinson, Lynn R. Goldman, and David Goldman (2009). Association of Substance Use Disorders With Childhood Trauma but not African Genetic Heritage in an African American Cohort. American Journal of Psychiatry, 166, 1031-1040.

Heroin Addiction and HIV infection – Dirty needles and a place for harm reduction

Co-authored by: Jamie Felzer

Many people today know about the dangers and risky behaviors (sharing needles, unsafe sex, and mother-to-child transmission) that can increase the risk for HIV/AIDS infection. The question lies in whether or not they are able to take appropriate actions to prevent contracting the disease themselves.

Heroin addiction, dirty needled, and HIV infection

Many heroin addicts, especially those that are homeless or extremely poor, will use whatever heroin they can get, regardless of the risk it puts them in.  A study done in a San Francisco park frequented by almost 3000 IV drug users found that in times of heroin withdrawals, addicts would use dirty  needles, sometimes with visible traces of blood still on them. The need to overcome their withdrawal was more important to them than worrying about the risk of contracting HIV or any of the other countless diseases that can be contracted from such use.

Many of the users surveyed were poor and sometimes didn’t even have enough money to buy their own supply of heroin so they often pooled together what they had with others. They all shared the heroin, cooker and needle to get a fix for the time being.

Regardless of the consequences of HIV contraction, users needed their heroin.

In this community many of the users knew about the risks of sharing needles and were well aware of recommendations that they not share needles or bleach them.  The users actually found health outreach workers slogans patronizing because although they would have  loved not to have to worry about sharing needles, often the more imminent need is getting that fix or suffer being extremely sick from withdrawals.  Given the relatively rare harm-reduction sources available, they were able to use the clean needles given out by some health organizations but at other times had to be resourceful and use what they had regardless of the possible consequences.

There are 1.2 million people living with HIV in the US right now out of a 33.2 million total in the world. 2.5 million people recently acquired the disease and 18% of those new infections were from injection drug users (IDU).  HIV/AIDS is a preventable disease. If we allow users to have easier access to clean needles, we can help decrease the number of IDU infections. If you aren’t sure what your status is, get tested! HIV Testing

Here’s a great resource for finding needle exchanges operating in the U.S. : NASEN

Citation:

Social Misery and the Sanctions of Substance Abuse: Confronting HIV Risk among Homeless Heroin Addicts in San Francisco. Philippe Bourgois; Mark Lettiere; James Quesada. Social Problems, Vol. 44, No. 2  (May, 1997), pp. 155-173. University of California Press on behalf of the Society for the Study of Social Problems.

UNAIDS Website

Alcohol, benzos, and opiates – Withdrawal that might kill you

Along with teaching and telling stories, part of my goal here at All About Addiction is to get important information out to those who can benefit from it.

Most drug users who quit drug use “cold turkey” have to go through withdrawal of some sort. Withdrawal is never comfortable, but sometimes it can actually be dangerous. The list below outlines some drugs that should NEVER be quit suddenly without medical supervision. This is the reason why some rehab treatment is preceded by a medical detox period lasting anywhere from 2 days to a week or more.

Which withdrawals can actually kill?

  1. Alcohol – Yes, after long term use, withdrawal from alcohol can kill. Alcohol withdrawal syndrome can take on mild, moderate, or severe forms. If while withdrawing from alcohol a person develops a fever, extreme nausea, diarrhea, or DT (delirium tremens), they need to be rushed to see a doctor as soon as possible. In fact, alcohol withdrawal after heavy, chronic use is best managed under the care of a doctor or a professional medical detox unit. By using medications that relieve withdrawal symptoms, these professionals can essentially eliminate any of these risks.
  2. Benzodiazepines – Benzos were introduced as a replacement to barbiturates that were causing common overdose cases, many of which resulted in death. Nevertheless, withdrawal from extended use of benzodiaepines can kill. Whether Xanax (alprazolam), Ativan (lorazepam), Valium (diazepam) or other variations, long term use of Benzodiazepines requires medical supervision to be completed successfully with minimal side-effects and risk to the patient. Normally, the withdrawal process is managed by slowly reducing the dose and transferring the patient from a slow acting, to a long acting, form of the drug. Still, full resolution of benzodiazepine withdrawal syndrome can take up to 6 months (or even longer).
  3. Opiates – Many people are surprised to learn that in most cases, withdrawal from many opiates is not deadly. Still there are some very important exceptions. Methadone, a long-acting opiate often prescribed as a replacement for heroin can cause death during withdrawal if it’s consumed in high enough doses for a long enough period. The debate of whether the state should be prescribing something like this should be saved for a later date. It is one of the better ways of getting people off of heroin, though obviously, all it does is replace dependence on one substance with another, more manageable one. Also, some of the recently popular methods of rapid-detox from heroin addiction can themselves cause death, and many other negative side-effects. Overall, I would recommend checking in with a physician and conducting opiate withdrawal in a controlled setting. Withdrawal under Suboxone or Subutex can be far less horrific.

Much of the danger in withdrawal from all of these drugs has to do with the body’s response to the extreme changes in the chemical processes going on in the brain and the rest of the body. Alcohol, Benzos, and Opiates interference with the GABA system, the body’s most common downregulator.

Withdrawal from these drugs is like trying to turn the heat up in a cold house with a broken thermostat and an out of control heater – It won’t always lead to disaster, but it’s a bad idea.

The withdrawal danger summary

That’s pretty much it. “Cold Turkey” withdrawal from cocaine, marijuana, crystal meth, ecstasy, GHB (never mix GHB with alcohol though!!!), and many other recreationally used drugs will not lead to death in the vast majority of cases. While it may make you uncomfortable, and you may feel moody, constipated, dehydrated, hungry or nauseous, and a whole slew of other symptoms, the chances of someone actually dying from withdrawal are very small.

If you have any more specific questions regarding your case though, don’t shy from asking me!