The Anatomy of Addiction (14 page)

A new generation of extended-release naltrexone, sold under the brand name Vivitrol, is especially helpful in preventing relapse
of opioid addicts. A study published in 2013 in the journal
Addiction
confirms what I was already seeing in my clinical experience: Vivitrol blocks the effects of the opioids (heroin was the focus in the study) on brain receptors and prevents relapse by reducing “euphoria, pain relief, sedation, physical dependence and cravings.” That Vivitrol is injected once a month, rather than taken as a daily pill as with standard-release naltrexone, also circumvents the need for the patient to closely and constantly manage medications.

Ongoing psychosocial therapy would provide the patient with mechanisms for coping with stress and other situations that might trigger a flare-up of the disease. An overall health regimen of good nutrition and regular exercise would further reduce stressors that might cause a relapse.

Extreme Addiction Cases

Managed maintenance is a program with proven success in restoring health, life, and hope to those unique individuals who, because of either systemic or acquired medical conditions, have become completely dependent on opiate pain relievers. These special cases are patients with addiction histories, ten-to fifteen-year medical condition such as hepatitis C, HIV, heart problems, and/or psychiatric complications. These cases are not the norm, but not being a “normal” addict is no reason to be denied effective life-saving, health-restoring treatment.

Without managed maintenance, 80 percent of these extreme cases immediately fall right back into dangerous addiction. An
addiction medicine specialist knows the proper and effective way to replace dangerous and illegal substances with FDA-approved Suboxone, a prescription medication also used in detox that keeps patients from experiencing life-threatening, debilitating withdrawal and allows them to remain physically stable.

Heroin Dependence

Previously, I noted how an advantage of Suboxone, a medication used in the treatment of heroin addiction, is that no tolerance developed, but there is a ceiling on the drug's effect. In other words, if you take more than your required amount, you won't get more high. Suboxone is available only by prescription and administered only by a physician.

Other advancements include new treatments for opioids and stimulants. For opioids, this includes long-acting injectable or implanted naltrexone, and antagonists; oral or implanted buprenorphine, a partial agonist; and innovative detoxification methods using buprenorphine.

Cocaine Dependence

New developments for cocaine dependence include vaccines that provide either active or passive immunization, agonists that could decrease craving without producing euphoria, blocking agents that do not block normal pleasures, and corticotrophin-releasing factor (CRF) antagonists that could decrease both craving and relapse. In the short term, modafinil, tiagabine, topiramate, and
disulfiram, medications currently marketed for other conditions, show promise for cocaine addiction.

Psychiatric Realities

Failure to address psychiatric realities dooms a person to unnecessary consequences. One of my patients had been active in Alcoholics Anonymous for many years. He would stay sober with little or no difficulty for ten months and then relapse. This pattern continued for years. Finally he sought medical help. As it turns out, he had bipolar disorder with a ten-month cycle. Every ten months, he would enter a manic phase, during which he would relapse. All it took to rectify this long-standing problem was a daily dose of a readily available prescription medicine.

If this man had been psychiatrically diagnosed in the first place, years of disappointment and feelings of failure could have been avoided.

With addiction, there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often exhibit a lower readiness to change their dysfunctional behaviors, despite mounting concerns expressed by significant others in their lives. They also display an apparent lack of appreciation of the magnitude of cumulative problems and complications.

However, addiction is more than a behavioral disorder. Features of addiction include aspects of behaviors, cognitions, emotions, and interactions with others, including:

• Excessive use and/or engagement in addictive behaviors at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for, and unsuccessful attempts at, behavioral control.

• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (for example, the development of interpersonal relationship problems or the neglect of responsibilities at home, school, or work).

• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems that may have been caused or exacerbated by substance use and/or related addictive behaviors.

• A narrowing of the behavioral repertoire focusing on rewards that are part of the addiction and an apparent lack of ability and/or readiness to take consistent action toward change, despite recognition of problems.

Over time, repeated experiences with substance use or addictive behaviors are not associated with ever-increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, and unstable emotional experience related to suboptimal reward and the recruitment of brain and hormonal stress systems. This response is associated
with withdrawal from virtually all pharmacological classes of addictive drugs.

While addicts develop tolerance to the high, they do not develop tolerance to the emotional low associated with the cycle of intoxication and withdrawal. Thus addicts repeatedly attempt to create a high. But what they mostly experience is a deeper and deeper low. While anyone may
want
to get high, those with addiction feel a
need
to use the addictive substance or engage in the addictive behavior to try to resolve their uncomfortable emotional state or their physiological symptoms of withdrawal. People with addiction compulsively use even though it may not make them feel good.

Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in activities that promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery.

The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction from those in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to

• Decrease the frequency and intensity of relapses.

• Sustain periods of remission.

• Optimize the person's level of functioning during periods of remission.

In some cases of addiction, medication management can improve outcomes. In most cases of addiction, psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provide the best results. Chronic disease management is important for decreasing episodes of relapse and their impact.

Support Services

Because many addicts have often destroyed their lives by the time they get effective treatment, it's important to treat the whole person rather than just the disease. They may find themselves unemployed, homeless, needing childcare, facing criminal justice problems, and embroiled in family problems.

In addition to medication and psychosocial therapy, a long-term maintenance program might include support services such as family counseling, mental health care, supplementary medical care, housing and legal assistance, and vocational services.

A Late-in-Life Addict

My patient Augustus, or “Gus” as he prefers, isn't anyone's idea of a drug addict. A sixty-six-year-old family man with a loving wife, three children, and one grandchild, Gus was connected to the sea for his entire career. He joined the navy right out of high school, spending his twenties bumming around the Hawaiian Islands as deck crew on fishing charter boats. There was lots of drinking and drugging in those days, he recalled. “Doc, if you ever been on a
fishing charter boat, you know they're really just an excuse for spending the day having a big party. Yeah, it's nice to catch a fish or two, but if that doesn't happen, it's just more of an excuse to get high. Now imagine doing that seven days a week,” he told me when we first met.

You might surmise that Gus was a primary candidate for becoming an addict. But a remarkable thing happened when he was thirty-two-years old. He met his eventual wife, a schoolteacher, and he decided to stop his dependency on alcohol and cocaine. “OK, to be honest, my wife had a lot to do with it. She gave me an ultimatum. You can continue to pretend you're still a kid out of the navy and party every day, or you can settle down and live happily ever after with me,” he said.

They soon started a family, and he went on to having a successful maritime career, first as the captain of his own sports fishing charter boat, then eventually earning his Merchant Marine credential and his tugboat license. He capped his career as the captain of one of the first-respond boats that rescued the crew from the BP oil disaster in the Gulf of Mexico.

Then, the real trouble began. He retired at age sixty-five with a good pension and, of course, the benefits of Medicare. One of the first things he did was to get some badly need orthopedic surgery. A long career involving heavy physical labor had ground away his cartilage, and so, in quick order, he got joint replacement surgery for both hips. His surgeon prescribed him Vicodin, an opioid analgesic, for the postoperative pain. A year later, after his prescription ran out, he began buying it on the black market. “I was hooked. I knew I was hooked but I couldn't stop. It was no longer so much
about the pain but just being able to function as a human being. Without my Vikes, I would get very anxious during the day and couldn't sleep at night,” he said.

When prescription pills became hard to find on the street, he switched to heroin. “I never thought me, a grandfather for God sakes, would ever become a heroin junkie. Even when I was a young buck, I steered away from the stuff. That was what hoods and losers took. But this new stuff was so powerful you could just snort it. I think it would have been different, harder to rationalize using it, if I had to inject myself with a needle,” he said.

Gus was motivated to change. He was just beginning his retirement and, with two new hips, figured that he had at least two good decades ahead of him to enjoy traveling with his wife, visiting his kids, and even doing some sports fishing. To stop his cravings for opioid, I prescribed a regimen of Vivitrol, a kind of extended-release naltrexone, which has had years of proven results. Now that he once again was mobile, I also put him on a regular regimen of exercise (walking, alternating with biking) and a whole-food diet, all to reduce stress that could trigger a relapse.

Today, three years later, his addiction is under control. He occasionally drinks but only moderately. “Doc, the days when I would get blind drunk or fall-down high are over. I've too much to live for to let drinking or drugging get in the way,” he says.