In 2005, Nature Neuroscience published a special issue on the neuroscience of addiction that summarized the advancements in unraveling the biological mechanisms that contribute to the etiology and progression of addiction to a wide spectrum of psychoactive drugs. The technical papers included in the 2005 special issue stood as a progress report on the biological model of addiction that has been aggressively promulgated by National Institute on Drug Abuse Director Nora Volkow, MD, and National Institute on Alcohol Abuse and Alcoholism Director George Koob, PhD. The state of addiction science was updated in 2011 in Nature, and Nature has just published a special supplement of articles on addiction that provides a further update.
In reviewing this series of collected papers, it is difficult not to be swept up in the advancements in our understanding of the neurobiology of addiction. These papers mark an evolution from a deeper understanding of the underlying mechanisms of addiction, to new treatment options that will grow exponentially in the coming years, and, in this latest review, to increased interest in the neurobiology of long-term addiction recovery. The addiction IS / IS NOT a brain disease debates that have accompanied these scientific breakthroughs do not diminish the potential clinical import of this work and what it could mean to future generations of people seeking help for alcohol- and other drug-related problems.
While the neurobiological research and the public/political promulgation of biological models of addiction are extolled for their great promise, history suggests that social context plays a major role in whether such models help or harm affected individuals, families, and communities. We should not forget the untoward effects of earlier biological models of addiction. Such a view rose within the early twentieth century eugenics movement on the heels of the American temperance movement’s proclamation “Drunkards beget drunkards.” The eugenics movement promoted the prolonged sequestration (e.g., inebriate colonies, psychiatric state hospitals) of people addicted to alcohol and other drugs (AOD) and their inclusion in mandatory sterilization laws—laws that, in the name of purifying the racial stock, also included people who were mentally ill, developmental disabled, or members of sexual minorities. African Americans were inordinately targeted for such interventions within all of these groups.
Biological views of addiction’s intractability justified other horrific interventions into AOD problems, including electro- and chemo-convulsive “therapies,“ psychosurgical interventions (prefrontal lobotomies), and toxic and lethal drug therapies—each wrapped for a time in the mantle of science and medicine. The “harm in the name of help” spawned by biological models within the history of addiction treatment bodes caution in exploring how such models may generate unforeseen and unintended consequences when embraced within larger social and political agendas. How to best prevent such eventualities must be part of the conversation as neurobiological research on addiction proceeds.
In 1998, Dr. Barry Brown also voiced concern that characterizing addiction as a “chronic relapsing disorder” rendered addiction a “no-fault condition” in which continued drug use was neither the responsibility of the drug user nor the addiction treatment professional. His concern was that such an understanding could potentially lead to social, therapeutic, and personal pessimism related to the prospects of addiction recovery in spite of clinical and community studies revealing substantial rates of long-term addiction recovery. Debates about the role of choice in addiction and addiction recovery are thus important—clinically, professionally, and socially.
A recent study by Wiens and Walker revealed a decrease in personal agency (“This is something I can change.”) related to biological conceptions of addiction, but this may well be determined by which populations such conceptions are applied and how the neurobiology of addiction is communicated. (The Wiens and Walker study evaluated the effects of a quite dated biological model of alcoholism on a small community sample of persons with mild to moderate alcohol problems who had not sought addiction treatment.) Views of the etiology, course, and treatment of AOD problems are best nuanced across the dimensions of problem, severity, and chronicity. Suggesting that addiction constitutes a chronic health condition and that loss of control over drinking and drug use is related to underlying brain mechanisms DO NOT reduce personal responsibility for self-management of that condition. Such concepts are used in the treatment of diabetes, hypertensive disease, cancer, and other chronic health conditions while emphasizing patient responsibility to assertively self-manage such illnesses over the life course.
There is also no guarantee that biological models of addiction (which emphasize personal vulnerability over person culpability via the image of the hijacked brain) will lessen social stigma attached to addiction. I have argued in an earlier paper that: 1) communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems, and that 2) the longer addiction science is communicated to the public without conveying the corresponding recovery science, the greater the burden of that stigma will be. For, example, studies noting that addiction-induced brain changes may extend for years into recovery (see Zou et al. 2015, for example) can further marginalize people in recovery (via reinforcement of the “once an addict, always an addict” stereotype) without tandem communications that such effects are not universal and may be compensated for by the brain itself or by adaptational learning.
Recognizing the potential risks inherent in the conceptualization of addiction as a chronic disorder, Tom McLellan and I argued in a 2008 paper that all such communications should also be accompanied by the following scientific findings:
1. All AOD problems are NOT chronic; most do NOT have a prolonged and progressive course. Some do, and research is needed to identify early signs predictive of chronic progression. (It is critical that we distinguish between mild/moderate and often transient AOD problems in community populations and the alcohol and other drug addictions most often seen in clinical populations. Click here for elaboration.)
2. All persons with AOD problems do NOT need specialized, professional, long-term monitoring and support. Many recover, particularly those with lower problem severity and high recovery capital, with only family or peer support.
3. Among those who do need treatment, recurring episodes of post-treatment AOD use are NOT inevitable, and all persons suffering from substance dependence do NOT require multiple treatments before they achieve stable, long-term recovery.
4. Not everyone at risk for a chronic disorder contracts the disorder or experiences the same course of the disorder. Chronic disorders exhibit a high degree of variability in pattern of onset, course and intensity (self-accelerating, constant, alternating cycles of remission and relapse, or decelerating).
5. Both full and partial recoveries are possible. Millions of individuals and families throughout the world live full lives in long-term recovery. Partial recovery is common and can constitute a prelude to resumed substance dependence, a permanent state, or a stage of ambivalence and instability that precedes the achievement of full recovery.
6. Recovery processes vary. There are multiple pathways, patterns, and personal styles of long-term recovery. Greater time and resources are usually required as substance use disorders become more severe and complex and as a personal, family, and community recovery capital diminishes.
7. Intervening early makes a difference. There are brief windows of opportunity within the course of AOD problems and addictions that can be capitalized upon to help initiate and solidify long-term recovery. Family, peer, and professional supports are available that can shorten addiction careers.
8. Recovery from the most severe and complex addictions is a marathon that can bring unexpected gifts. Some individuals and families will be stronger, healthier, and live more personally meaningful and fulfilled lives as a result of their recovery experience.
Breakthroughs in understanding the neurobiology of addiction have profound personal, professional, social, and political implications, and the effects of such breakthroughs could prove immensely helpful to individuals, families, and communities. That said, unforeseen and harmful consequences of these breakthroughs must be anticipated and assertively managed.
Do you want to erase drama and suffering from your life? Then don’t make assumptions. Instead of jumping to conclusions, find out what’s really going on and let it go. Do your best to clarify the situation and clear the air. If the other person doesn’t respond, then at least you tried.
You’ll be amazed at the amount of pain and suffering you can avoid by doing this. And by making this agreement with yourself, you will also be reducing the pain and suffering of other people and the world in general. To begin with, make the decision to spend just one day observing how many times you are making assumptions about other people’s behavior. We also make assumptions about ourselves, and those assumptions usually sell us short. We often assume we aren’t capable of doing something before we even try.
Most of the time, assumptions are just poison in our life. They cut us off from others and from reality. Don’t make assumptions, and you will break free from this nightmarish cocoon. And then you’ll return to what is real, tangible, and true. Then you’ll be saying, “Yes!” to life almost every day.
Excerpted from the article:
The Great Quest for Truth: Seeing Beyond Appearances
Written by Olivier Clerc.
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“…a disease needs to be transformed politically before it can be transformed scientifically.” –Siddhartha Mukherjee, The Emperor of All Maladies (A Biography of Cancer)
Ladies and Gentlemen,
As you are quickly discovering, the effects of opioid addiction on individuals, families, and communities will be a recurring issue in the 2016 Presidential campaign. Addiction to prescription opioids and heroin is increasing in the United States and leaving in its wake legions of overdose deaths, families struggling to find effective remedies, and local community leaders under pressure to forge a public response to these tragedies. As you campaign across the country, it will become clear that this epidemic is reaching into the most and least affluent and the most and least politically connected neighborhoods and families in this country. As you campaign from city to city, affected families, friends, fellow students, co-workers, and employers are going to ask you a pointed question: “What will you as President do to heal this bleeding wound within American communities?”
Historically, political candidates in such circumstances have pledged their commitment to tougher drug laws, intensified international and domestic drug enforcement, expansion of existing approaches to treatment, and expanding prevention resources. And yet these general approaches have neither prevented the rise of the current opioid addiction epidemic nor provided a sustainable framework for effective local responses to it. Leaving the prevention and broader drug supply policy issues aside for a moment, there are a number of science-grounded strategies that would offer support to the individuals and families caught in the net of this epidemic. Based on my experience working on the front lines of this problem for nearly half a century, here are twelve answers I suggest you include in your response to the “What will you do?” question.
Having reviewed the scientific research and talked with local leaders across the country, here is what I will do as your President to help those now affected by the opioid addiction epidemic.
I will help lead a national campaign to educate the public about addiction, addiction treatment, and addiction recovery with a particular focus on opioid addiction as a treatable medical condition (rather than a moral failing) and a threat to public health requiring the full mobilization of national, state, and local resources. This campaign will include a national panel of addiction medicine specialists whose role will be to educate the public and challenge any media-promulgated myths and misconceptions about opioid addiction, its treatment, and the long-term recovery process.
I will assure the national availability of naloxone overdose prevention kits to opioid users, their family members, and to police and other emergency first responders. That availability will be accompanied by an opioid overdose prevention campaign led by our Addiction Technology Transfer Centers and related resources and will include public education on the risks of mixing opioids with alcohol and other psychoactive drugs. Our first priorities must be to reduce the opioid overdose death rate and to assure that persons suffering from opioid addiction remain alive until community recovery support resources can help them achieve drug-free, productive, and meaningful lives. The more than 23,000 opioid overdose deaths per year in the U.S. is a national tragedy that must be ended.
I will help promote programs assuring that every emergency medical response to an opioid overdose is quickly followed by contact by an addiction treatment and recovery support specialist. Each of these medical emergencies is a window of opportunity for recovery initiation that must be capitalized upon.
I will support the local distribution of sterile needles and syringes to confirmed IV drug users to reduce their infectious disease risks and the risks of further transmission of such diseases to other opioid users, family members, and other members of the community. The goals of such support will also include reducing the burden such individuals will bring into a recovery process, to reduce the larger threat to public health of the community, and to provide a point of initial linkage to addiction treatment and recovery support resources.
I will support assertive outreach programs aimed at identifying and engaging opioid users at the earliest stages of drug dependence. At present, years or decades pass between the age of onset of opioid use and initial help-seeking. Such delays allow these problems to become severe, complex, and chronic, elevating the burden on family and community and compromising recovery outcomes. This pattern must be changed.
I will support a full range of medication-assisted and psychosocial treatment options without arbitrary time limits on treatment duration. I will support resources to elevate the quality and accountability of these programs, including integrating a broad range of psychosocial recovery support services with the pharmacotherapy of opioid addiction. The historical isolation and animosity between medication providers and those providing only psychosocial recovery support services must end. Creatively combining and sequencing medication, psychosocial treatment, and peer-based recovery support services may enhance recovery outcomes for opioid addiction in the same way combined interventions fundamentally altered the course of AIDS. I will support a full range of such integrated services for persons addicted to opioids who enter our drug courts, probation and parole services, and our correctional institutions. I will support research to assure that existing treatment models based on a century of treating heroin addiction are effective in treating a more demographically diverse generation of people addicted to prescription painkillers and anesthetic opioids.
I will push regulations requiring addiction treatment programs to measure and publicly report their long-term recovery outcome rates and require all treatment programs to review clinical and cost alternatives with each person/family seeking help. These regulations will also require dissemination of a research-based information brochure prepared by the National Institute on Drug Abuse that would identify effective and discredited treatments for opioid addiction. The purpose of such regulations would be to maximize personal choice and affordability in the selection of addiction treatment and diminish exploitive profiteering within this sector of health care.
I will challenge all programs within the addiction treatment industry to develop more effective methods of patient retention. The current rate of less than 50% completion nationally is completely unacceptable. It is time we made treatment reimbursement contingent upon provision of an adequate if not optimal dose/duration of treatment and recovery support services.
I will promote the expectation that all persons/families leaving addiction treatment will be provided ongoing recovery checkups and support for at least five years. Such long-term personal and family support must become standard care in treating the most severe and complex addictions as it is in the management of other chronic health conditions.
I will call for the expansion of training programs for primary care physicians to aid them in identifying opioid-using patients in need of opioid addiction treatment services as well as to increase their skills in providing post-treatment recovery checkups and support. Primary care physicians, psychiatrists, and their service staff must be fully engaged in supporting long-term recovery from opioid addiction and managing the medical and psychiatric conditions that frequently accompany opioid addiction.
I will support funding of local peer-based recovery support programs—recovery community centers, recovery residences, high school and collegiate recovery programs, recovery-focused employment and training programs, and support services delivered through recovery ministries. Such programs provide assertive linkage to Narcotics Anonymous and other secular, spiritual, and religious recovery support groups and help people in recovery develop a drug-free lifestyle within their natural environments. We must provide the physical, psychological, and cultural space within our local communities in which personal and family recovery can flourish.
I will support funding for local programs whose aim is to mobilize the growing legions of individuals and families who are recovering from opioid addiction as a volunteer force to help those currently experiencing addiction. This Volunteers in Recovery program will increase the visibility of local recovery role models and provide needed resources directly to local individuals and families and will provide added resources to reach people entering our emergency rooms, health clinics, service agencies, and jails. The goal of this effort will be to make addiction recovery contagious within local communities and to assure the availability of cost-effective measures of long-term addiction recovery support for affected individuals and their families.
There is much else to be done at the larger policy level, but I believe these twelve strategies will bring relief to affected individuals and families. These are the strategies I will pursue as your President.
I encourage recovery advocates across the country to make the town meetings and other campaign venues and to ask each presidential candidate the “What will you do?” question and compare their respective responses to these twelve points.
Periodically, you must reinvent yourself. Examine your life and see what needs to be changed.
During your self-examination, expose and remove the obstacles to change and progress in your life.
Excerpted from the article:
The Defining Moment: The Confidence To Change
Written by Keith Johnson.
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Dr. Yih-Ing Hser and her colleagues (Elizabeth Evans, Christine Grella, Walter Ling, and Douglas Anglin) have just published an important review—Long-Term Course of Opioid Addiction–in the Harvard Review of Psychiatry. Findings from their review of 28 long-term studies of opioid addiction that have particular relevance for addiction professionals, recovery support specialists, and recovery advocates include the following.
Studies of recovery from opioid addiction are plagued by a lack of consensus on measurable recovery outcomes. Data on opioid abstinence, for example, differs widely across studies in part because of different meanings of abstinence: continuous abstinence, abstinence at the point of follow-up, abstinence for a prescribed period of time prior to follow-up, and opioid abstinence with or without reference to abstinence from other drugs. If scientists obsessed with precise measurement fail to achieve consensus on measurable recovery outcomes, it is little wonder that clinicians and recovery support specialists follow in this same path.
The trajectory of long-term opioid use is marked by high rates of morbidity. Studies reviewed by Hser and colleagues reported death rates related to opioid addiction 6 to 20 times greater than such rates in the general population. Between 25%-50% of subjects in the longest term studies had died by the 20-year follow-up point. Social reform and public health movements require a sense of urgency; it is hoped the rising death rate from opioid dependence in the United States will stir such urgency.
There is a significant time delay between the onset of opioid use and help-seeking—6-10 years in the studies reviewed. This suggests a long window of opportunity for identifying, engaging, and treating people who are opioid dependent far sooner than is now occurring naturally.
The most common trajectory of opioid dependence is marked by cycles of active use, periods of remission, and return to opiate use and its related problems. The instability of opioid abstinence and the frequent failure to transition from recovery initiation to stable recovery maintenance suggests the need for prolonged monitoring and support and, when needed, assertive early re-intervention.
While opioid abstinence rates erode over time, there is evidence of stable and sustained recovery from opioid dependence. In the studies reviewed, the latter characterized about 30% of the samples studied for ten or more years. Recovery from opioid dependence varies in pattern from early quitters to late quitters, the latter often showing a pattern of slow deceleration of use prior to cessation of use. Neither age nor chronicity of use predicted recovery initiation in the studies reviewed. Those dependent on opioids for prolonged periods were more likely to die than to “mature out.”
Achieving opioid abstinence for a period of five or more years is an important marker of recovery stability, but addiction recurrence can still occur after this benchmark—for 25% in one of the cited studies.
Professional treatment of opioid addiction, particularly prolonged treatment and higher cumulative doses of treatment, is associated with more positive outcomes, but these effects can be ephemeral. In the studies reviewed, resumption of opiate use often followed treatment, and multiple episodes of treatment were often required before stable recovery was achieved. This finding underscores the need for models of sustained recovery management (RM) in the treatment of opioid addiction. These RM models would employ creative treatment retention strategies, assertive linkage to indigenous recovery support institutions, recovery check-ups for at least five years, and sustained family support through these addiction/treatment/recovery careers.
Prolonged opioid addiction is also often marked by developmental trauma and co-occurring medical and psychiatric conditions, suggesting the need for care models that integrate and assure continuity of addiction treatment, psychiatric treatment, primary health care, and prolonged recovery support across these three arenas.
I am continually asked by local community leaders what they can read to gain a better understanding of opioid addiction. Hser and colleagues in their review, Long-Term Course of Opioid Addiction, have provided an invaluable service by synthesizing what we know about the trajectories of opioid addiction and their clinical import. Their review underscores the need to formulate a more comprehensive, science-grounded, and effective response to opioid addiction in the United States. In future blogs, I will try to explore some of the needed critical elements within that potential response.
Over many years of exploring ways to release childhood pain, in my own life and the lives of my patients, I’ve realized that the key to laying down our emotional burdens is letting go of judgment and embracing forgiveness—of those who hurt us, yes, but also of ourselves.
As a medical practitioner, I was delighted to come across the following quote from Joan Borysenko, co-founder of Harvard University’s Mind-Body Clinic, because of the integrative vision blending biochemistry, emotion, and spirit:
I can tell you as a biologist that when we step into the part of ourselves that doesn’t judge . . . enormous biochemical changes accompany that, changes in the neuropeptides from the emotional center of the brain, changes in our immune system and our cardiovascular system that are all consistent with good health.
Excerpted from the article:
Negative Love: Repeating Parental Behaviors
Written by Marcelle Pick
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When we change our way of seeing, we begin to live in a different world. If we approach others with respect and trust, with a great deal of patience and internal toughness, we will slowly begin to find ourselves in a compassionate universe where change for the better is always possible, because of the core of goodness we see in the hearts of others.
In this presumably sophisticated world, it is considered naive to be trusting. In that case I am proud to say that I must be one of the most naive people on earth. If someone has let me down a dozen times, I will still trust that person for the thirteenth time.
Trust is a measure of your depth of faith in the nobility of human nature, of your depth of love for all. If you expect the worst from someone, the worst is what you will usually get. Expect the best and people will respond: sometimes swiftly, sometimes not so swiftly, but there is no other way.
Excerpted from the article:
Actively Cultivating Peace as a Virtue in Day-to-Day Life
Written by Sri Eknath Easwaran.
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