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Overview of Addiction as a Medical Disease by Steven R. Lee, MDProgram Director Young Adult Addiction ProgramRidgeview InstituteGoals of this lecture are to understand:The definition of Addiction Addiction as a medical disease with descriptions of each Use DisorderThe standards of care for the treatment of AddictionWith an editorial – The Interface of the Treatment of Chronic Pain with AddictionOverview of Addiction as a Medical IllnessTable of ContentsWhat is Addiction? Page 1Categories of Addiction - 4Etiology - 4Neuroanatomy of Addiction 6Aspects of Addiction - 9The Obsessive-Compulsive Drive - 9Biological Conditioning - 10Unmanageability - 10PAWS - 11Craving - 11Use Disorder as a Medical Disease - 11Specific Use Disorders - 12Nicotine - 12Alcohol - 14Cannabis - 18Opioid – 21 Harm Reduction Medication - 24 Naloxone - 25 Chronic Pain and Opioids – 25 Kratom - 28Sedative/Hypnotics - 28Stimulants - 31Hallucinogen/Dissociatives - 32Addiction Treatment - 34Recovery - 35Relapse - 35Age - 36Final Comments – 37What is Addiction? Addiction is a persistent, compulsive dependence on a substance or a behavior (i.e. gambling) even though the individual has experienced potentially harmful consequences while doing this substance or behavior. The compulsion to use a substance or to do a behavior comes from an involuntary biological drive located in the pleasure centers of the brain. Once an addict has had an experience that gives "pleasure" or relief, then the memory of this feeling is attached to the substance or behavior that caused it. This is called "biological conditioning". Addiction is a disorder of the brain's reward system."Pleasure", here, is defined as any feeling that gives someone a sense of well-being or relief from a bad feeling. Pleasure could be the ability to laugh when someone is actually depressed. It can also be an escape from a sense of dread when someone is under constant pressure or fear. Therefore, once the addict discovers that using a substance provides pleasure, they are starting a process of biological conditioning. Whenever they are in an unpleasant or boring situation, they know that by using that substance they can get immediate relief. An addict generally uses their substance habitually at the same time of the day or in similar situations such as every happy hour, every evening, or every weekend. They develop a routine. After many repetitions, the brain develops an involuntary reaction to the initial stimulus (biological conditioning). When that time of the day or particular situation occurs, the addict has a very strong desire to use their substance. In fact, if they do not use their substance, they feel like something is wrong. If, in this routine, they find that their substance gives some sense of well-being or stress relief, then every time they are stressed, they feel that they have to have their substance to get relief. Cigarette addiction is the best example of this type of biological conditioning. Let's say that whenever a smoker gets in their car, they have a cigarette. Assume that they do this multiple times over 6 months or longer. Then one day they get into their car and they do not have access to a cigarette. Driving in their car does not feel right without a cigarette. They can try to drive their car without a cigarette but they feel that something is wrong without that cigarette. Chances are they will go out of their way to find their brand of cigarettes. The same habitual reaction with cigarettes possibly develops after eating a meal, getting up in the morning, going to bed at night or dealing with a boring span of time. Smoking a cigarette has become, for the nicotine addict, a biological conditioned response to each of the above situations (stressors). When the smoker realizes that they can get temporary relief of anxiety before a stressful event, such as taking a final examination in a college class, they have to have a cigarette to "calm down". For the cigarette addict, smoking is a compulsive act that has to be done to be able to deal with the anxiety of taking the test. This patterning would be the same for someone who is compulsively dependent on alcohol, marijuana, OxyContin or whatever other substance that is involved. When an addict, who has been depressed for the past year, realizes that they are not depressed when they are using their substance, then their addiction has become, not just a recreational way to get high, but a “necessary” way to deal with their depression. This response will override any concerns about the consequences of using this substance (i.e. driving intoxicated, unsafe sex). They now have a functional as well as a recreational reason to use their substance. A co-occurring disorder is a psychiatric disorder that occurs in someone who also has a Use Disorder (addiction). Those addicts who also have a psychiatric disorder have a dual-diagnosis. The psychiatric disorder can be caused by the Use Disorder or it may have been there before the Use Disorder. It is important to make this distinction because if the psychiatric disorder is a separate diagnosis, then without aggressive medical treatment of this psychiatric disorder, this will become the addict’s number one relapse risk factor. Also, after the addiction has improved, the treatment of the psychiatric disorder has to continue and medications cannot be stopped. Also, addiction is not "caused by" an event or a situation. It is not the result of tragedy in someone's life. These situations may make an addiction worse, but they are not the cause of the addiction. There will be a discussion about the etiology of an addiction further in this paper.Categories of AddictionTo simplify the present discussion, the focus will be about “substance” addictions also called Use Disorders. The behavioral addictions require a separate discussion since the treatment is different though these compulsive behaviors follow the same definition of addiction as presented above. The behavioral addictions include: Gambling addictionInternet addiction including gaming and compulsively viewing pornography Sex addiction including compulsive masturbation, intercourse, or multiple sexual partners Eating Disorders including Compulsive Overeaters, Bulimia, and AnorexiaSelf-mutilation including cutting, burning, compulsive tattoos, and compulsive plastic surgery.EtiologyCognitive control, and particularly inhibitory control over behavior, is impaired in both addiction and Attention Deficit Hyperactivity Disorder (ADHD). Stimulus-driven behavioral responses that gives a reward tend to dominate one's behavior in an addiction.The etiology of an addiction can be categorized into one of four categories: Genetic Epigenetic/Neural Plasticity Medical; Psychological; EnvironmentalPolysubstance/Polybehavioral50% of Use Disorders have a genetic (transcriptional) etiology. An alcoholic (someone who has an Alcohol Use Disorder) who has the variety of genes necessary to be an alcoholic can drink a pint to a fifth of alcohol a day and not die from alcohol toxicity. This is about 15% of the population. An individual who is “genetically prewired” to have an Opioid Use Disorder can take a Percocet and become mentally clear; not worry about what is wrong in their life; feel comfortable and gregarious in groups even with an anxiety disorder; and be motivated to finish the term paper that is due tomorrow. 10% of the population fit into this category. In an epigenetic etiology, the addiction develops over time from chronically high levels of exposure to an addictive stimulus (e.g., morphine, cocaine, sexual intercourse, gambling, etc.) or from repeated behaviors. Epigenetics is the study, in the field of genetics, of cellular and physiological phenotypic (the expression of a gene such as black or blond hair) trait variations that are caused by external or environmental factors that switch genes on and off and affect how cells read genes. We do not know the cause of Anorexia or Bulimia. Possibly under certain stressors, these individuals realize that losing weight or purging gives them some relief of their stress. Over time this obsessive-compulsive pattern becomes delusional (a false, fixed belief) and they cannot stop their behavior. Possibly this could be caused by some epigenetic process in the brain. Epigenetics may be one etiology of some addictions. These alterations may or may not be heritable, although the use of the term "epigenetic" to describe processes that are not heritable is controversial. Unlike genetics based on changes to the DNA sequence (the genotype), the changes in gene expression or cellular phenotype of epigenetics have other causes.Epigenetics may be part of the cause of the functional consequences of the addiction which may occur through altered neural plasticity in the brain. This may affect someone’s ability to think and to make decisions (lowered IQ) resulting in a decrease in functional productivity. Neural plasticity is how the function of a part of the brain (or of the function of an individual neuron) can change after repeated biological reconditioning that occurs through the use of a substance to obtain “pleasure” or of a behavior that is used to relieve stress. In other words, when an addict repeatedly uses methamphetamine to get high or to deal with life, there may be changes in how parts of the brain functions through epigenetics and neural plasticity. You can see how the treatment of this addiction would require repetitive biological reconditioning for months to years to change the brain back to how it used to function (if this can be done at all). The third etiology of addiction are those individuals who were not born with the genes that cause a specific substance Use Disorder or an addictive behavior. These individuals develop an addiction because of what is going on in their life. Possibly epigenetics is involved in these individuals that have genes that “switch on and off” because of a specific environment stimulus such that they develop an addiction. Examples of this third category include three groups of people: chronic pain patients; psychiatric patients; and young adults. Patients with a chronic pain condition that is never adequately stabilized can abuse opioids. Even though they have overdosed in the past and almost died, they continue to abuse opioids trying to get pain relief because the pain is unbearable. They do not get a sense of wellbeing when they use the opioids like a “genetically prewired” opioid addict. Someone trying to get relief from their Major Depressive Disorder may try stimulants, especially methamphetamine or crack cocaine and become addicted to these substances because they get temporary relieve of their depression. Also, with these drugs, intense cravings to continue to use these substances develops in anyone using these drugs such that they are unable to stop using these substances even when their life is shattered because of their use.Young AdultsAbout 25% of all young adults meet the criteria for a Use Disorder. Once they mature past 26 years old, this percentage drops to about 15%. This is a cultural phenomenon of young adults in this generation. Just a generation ago, it was expected that by 21 to 25 years old, a male should be married and have a job supporting a family. Females were expected to marry earlier and to have children. All of this has significantly changed so marriage is more around 28 years old and having children is 30 years old.The “baby boomers” (children born after WWII) as a group have done well financially. As parents they want to give more to their children than they had as a child. These children, in general, have the best of everything and they believe that they are the privileged generation. They got the best education, cars, and clothes without having to work for these things on their own. Many young adults did not learn to appreciate what they have and feel entitled to more without having to work hard for it.The spiritual void in young adults as a group is a set up for an addiction to become one of their gods. Young adults are usually not affiliated with the religions and the spiritual congregations of their parents. Science and common sense are their gods. The importance of the individual supersedes the importance of the group which leads to loneliness and separateness. For these young adults, having a spiritual experience is the high that the young adult obtains when they use a substance. Just as we were producing the most knowledgeable and best educated men and women ever in the history of man (the young adult), there were no jobs available except for entry level jobs. Millennials with a master’s degree did not expect to start the work force working for Chick Fillet or as a gofer in an office in order to work their way up the ladder. Many of these individuals have ended up back at home with their parents in their old room. With too much time on their hands and no responsibilities of a mortgage or children, drinking, smoking marijuana, and doing other drugs becomes something to do. The fourth etiology of people with a Use Disorder is a smaller percentage of the population who are capable of being addicted to any substance and any behavior that can alter their consciousness so that they feel “high”. They will abuse Benadryl, alcohol, opiates, stimulants, inhalants such as glue or paint, hallucinogens, dissociatives (i.e. PCP, ketamine), sex, gambling, eating, and many more. We are not sure if these addicts have a series of genes that make them this way or if this is part of their personality structure. The treatment of this group of addicts is long and requires many different approaches to deal with the complexity of their life style.Neuroanatomy of AddictionAddiction is a medical disease. Usually an addiction involves an activity that gives pleasure or relief. Addicts have memories of what made them feel good in the past (i.e. alcohol, sex, etc.). These memories can be made conscious by events going on in the addict's life or by certain feelings experienced in the present. If they are sad, lonely, anxious or afraid, the brain remembers a solution that gives instant relief to deal with these bad feelings. That solution is the use of a specific substance or to do a specific behavior. Brain has been sliced in half and you are looking at the right side of the brain from inside out. Limbic System is located inside of the purple and the green. The Cortex is located outside of the Limbic System (except for the cerebellum on the bottom).The part of the brain that initially responds to a bad situation or to a bad feeling is the limbic system. It does not necessarily care about the consequences of what may happen when the addict gets intoxicated as long as the individual gets relief of the bad feeling. In fact, the limbic system does not even have memories of the consequences. It only remembers what gives relief. The limbic system is located in the center of your brain. It is the triage part of your brain for all external sensory input. One major triage role is in terms of recognizing the urgency of the situation – “Is this an emergency?”. Otherwise, the limbic system either sends the sensory input information to be stored as memory or it sends it to different areas of the cortex for a decision if there should be some action that needs to be thought through. The limbic system is a more primitive part of your brain in the evolutionary chain. It does very little thinking and more doing. Think of this part of your brain as a dog and how a dog responds to fear, anxiety, hunger, thirst, and sexual pleasure. The Limbic system needs the cortex as its master to think a situation through using past knowledge to make decisions, to have good judgment, and to have tolerance.If the sensory input is deemed an emergency by the limbic system, then the limbic system can bypass the cortex and go directly through the brain stem to release corticotrophins for a “fight or flight response”. This would be necessary if out of the corner of your eye you see what seems to be a car about to run into your car. The limbic system makes you step on the breaks before you have time to think it all through using your cortex.Once the limbic system finds a substance or a behavior that can give immediate relief of anxiety, anger, or boredom then that substance or behavior is demanded by the limbic system to deal with those stressors even if it is not good for you. All of this is reinforced by repetition. This is a classic biological conditioned response. An example is being stressed because of the pressures of your job. You may realize that drinking alcohol when you get home gives you emotional relief almost instantly. The cortex is that part of our brain that remembers all past consequences of behaviors. The cortex also stores what the person has learned such as that lecture on unprotected intercourse. Normally, when a person experiences bad feelings, the limbic system demands that the addict find immediate relief. The cortex filters these demands by flooding the person's consciousness with all of the memories of what happened the last time they decided to respond in that particular way. The person then has to make a decision of whether or not they will respond as demanded by the limbic system. Unfortunately, some substances (i.e. alcohol at large doses) come with a mechanism that disinhibits (disconnects the input of the cortex) the person by not allowing the cortex to bring to consciousness the possible consequences of that behavior. The addict then proceeds with their addictive behavior. The cortex does not fully develop before the age of 26. The limbic system is fully developed by the age of 18. This means that in the young adult, the more mature limbic system has more control over actions taken than someone over 26. Young adults and adolescents who have a Use Disorder will need a more “structured treatment” to keep them sober long enough so that they can just begin their treatment. It is almost impossible to treat these individuals as an outpatient coming from home. Ruth Potee, MD gives an excellent explanation to parents and adolescents of the addicted brain on YouTube. She discusses the Neuroanatomy of Addiction as well as addiction as a medical disease.? of AddictionThe Obsessive-Compulsive DriveBiological ConditioningUnmanageabilityPAWSCravingUse Disorders as a Medical DiseaseThe Obsessive-Compulsive Drive The addict's repetitive use of their substance eventually causes tolerance which is a decrease in the response to their substance due to previous exposure such that the addict has to use larger amounts of their substance in order to get the same relief or high they got the first time they used. At large doses of the substance (i.e. alcohol, Xanax, OxyContin), the awareness that usually would come from the mature part of our brain of potential danger (i.e. Do Not Drive at 100 MPH!) is blocked through inhibition. The addict responds to the limbic system's need for immediate gratification. The rational, objective part of our brain, the cortex, is ignored in order to experience that immediate gratification, regardless of the consequences. Unfortunately, the drive to repeat the same behavior eventually takes top priority in the addict's life. Every other aspect of their life becomes secondary to the need to “get high”. Family, school, job, relationships, God, and the law all become secondary to the addiction behavior. Anyone who tries to prevent the addict from doing the compulsive behavior will be considered the enemy. The addict’s rationalization, minimization, and frank denial become well refined responses to anyone's questions and concerns. Addicts convince themselves that they are righteous in their statements of how others are interfering in their life. They feel that others are trying to take away their right to make their own decisions by questioning their judgment and treating them like children. Addicts even become convinced that their behaviors and use of substances are necessary to deal with depression, to calm down, be able to get to sleep or to be able to focus. In reality, if OxyContin, alcohol, or marijuana were healthy treatments for anxiety, depression or attention deficit disorder, we would prescribe these substances as a standard of care for these problems. Many people in our society, who seem to be functioning well on the surface, suffer from addiction. You do not have to be passed out all the time secondary to alcohol or doing intravenous heroin in order to be an addict. You do not have to be a totally irresponsible person to be an addict. The reality is that most people with an addiction “initially” go about their life as anyone else. The difference is their constant obsessions about when they can use their substance.In the early phases of the disease the addict routinely goes to work or to school then at night uses their substance. This initial phase of the illness proves to addicts that they are in control of their use. They have proven to themselves that they are capable of managing and controlling their compulsive behavior. Addicts use this fact to minimize, rationalize or even flat out deny that the behavior is dangerous. Rational, sane people would quickly admit that this behavior is dangerous and destructive. Addicts have a special type of insanity which is based on the delusion that they are in control of their behavior and that the behavior is essential in order to deal with life. They cannot or will not deal with life on life's terms without their substance.Biological ConditioningEven if an addict is able to stop the compulsive behavior for a period of time, this does not mean that they are not an addict. The problem for any addict is not stopping but staying stopped. Most biological conditioning requires repetition of the stimulus/response behaviors based on receiving a reward for an action that was caused by a stimulus. Once the response is reinforced through repetition then just the thought of the reward can create the response without having an actual stimulus. This aspect of the biological conditioning is the classical Pavlovian conditioning. The limbic system is more animalistic that human. It is part of our primitive mind. Whenever the limbic system experiences a pleasure that is quick and efficient, it never forgets. In addiction, a substance that can give essentially instant pleasure or relief of fear and anxiety fits that bill. In fact, some substances do this so efficiently, that some people are addicted to a substance after doing that substance only once. Crack cocaine and methamphetamine can affect some people this way. The problem here is that what takes one second to make someone addicted takes at least a year to find alternative coping techniques that can at least equal the benefits of using that substance. Teaching the limbic system to use alternative ways to get relief from boredom, anxiety, depression and fear is like teaching a dog to walk on their hind legs. Not only do you have to teach the dog to walk on their hind legs but you have to help the dog to want to. UnmanageabilityAfter about 6 months of using a substance almost daily, most addicts begin to have unmanageability in their life because of their use. This unmanageability occurs in every aspect of their life. The addiction demands that using the substance is the primary thing in the person’s life. Those people in relationship with the addict begin to feel rejected and abandoned as the addict begins to withdraw. Most jobs require that the employee is focused on their job instead of themselves. When the addict has to use during the day or has been using much of the night and not resting right, the addict’s performance begins to wane and is noticed by their employer. Eventually, something significant occurs such as an auto accident, a DUI, or being fired from a job. Bills do not get paid because the income goes to pay for the substance. Medically, the individual becomes weak because of not eating or sleeping right and not exercising. The list goes on. The addict is not able to manage the casual use of that substance without the potential of more unmanageability. Hopefully, when this significant event occurs, either the addict or the addict’s loved ones will realize the unmanageability that has been developing in that person’s life because of their addiction and seek treatment. Without unmanageability in the addict’s life because of the use of the substance, the addict would never stop using the substance. Even with repeated unmanageability in an addict’s life, if the addict does not want to stop the use of a substance, nothing can make that addict stop. That person may die through the continued use of that substance.PAWSPost-acute-withdrawal syndrome (PAWS), or the terms post-withdrawal syndrome, protracted withdrawal syndrome, and prolonged withdrawal syndrome describe a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants and other substances. In some cases, these substance-induced physical and psychological symptoms can persist long after detoxification, such as prolonged sleep disturbance and psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. The severity and longevity of PAWS depends on the potency of the drug and the length of time the drug was used. Drinking a fifth of alcohol a day for 10 years will result in a PAWS for about a year. Daily use of a gram of heroin a day for a year will result in about 6 to 8 months of a PAWS. Of course, the severity of a PAWS progressively gets less each day that the addict is not on their substance and eventually it stops all together. What is different from one person to another are the exact symptoms that make up the PAWS. Usually, disturbed sleep is a problem for at least a couple of months but the disturbance may differ from frequent awakening to vivid dreams all night including using dreams to horrible nightmares such that the person is afraid to go to sleep. PAWS is the cause of many relapses. What can be controversial in the recovering community is the use of medication to manage the severity of PAWS. Trazadone, Vistaril, mood stabilizers (Seroquel), gabapentin, and antidepressants are all used to target specific symptoms. If these symptoms are not stabilized, many newcomers to the recovery process will relapse. This is part of the reason for the use of the “harm reduction” medications for Opioid Use Disorder. Methadone and Suboxone are the main drugs used and will be discussed under the section on opioids. Benzodiazepines cannot be used because of how this recreates the addicted state chemically especially in the limbic system and can lead an addict back to their drug of choice.CravingAs part of PAWS, craving is the desire to use a substance. With an addict, craving is usually better defined as an “uncontrollable” desire. The longer the addict uses a substance that gives pleasure or relief, the more their limbic system feels that they have to have this substance. The limbic system will create an urgency that many addicts cannot resist. Methamphetamine and crack cocaine addicts have some of the strongest cravings of any addiction though alcoholics and opiate addicts can also have just as severe cravings.Use Disorder as a Medical DiseaseA Use Disorder is a life-long medical disease. It is no different than any other medical disease in terms of how much it costs to treat the disease over a lifetime. If a Use Disorder is believed to be just a weakness of character, then, of course, the amount of money it takes to treat this medical disease over a life time seems like a waste of money. “Addicts need to just say no!” We all wish it were this simple. This way of thinking is from someone who does not understand addiction and what it takes to manage the disease.The major-medical illnesses that are the most expensive medical reimbursed illnesses require constant education and reassessment to keep the individual taking their medication, eating the right foods, doing the right exercise, and living the right life style. It is human nature that most the population will not do all that they are supposed to do even with the best education.Adherence Rate to medical treatment:Diabetes - ~60%Hypertension - <40%Asthma - <40%Addiction - ~50%------------------------------------------------------------------------------------------------------------------------------------------Specific Use DisordersNicotineAlcohol MarijuanaOpiatesSedativesStimulantsHallucinogens/DissociativesNicotine Use Disorder25% of the United States has a Nicotine Use Disorder. Young adults ages 18 to 25 have the highest rate of current use of tobacco products (35%). This is the worst addiction in the world. It earns the #1 position because:The loss of life caused by cardiovascular disease, cancer, and lung disease (According to the CDC, more than 480,000 deaths each year are caused by cigarette smoking.) the loss of productivity of a society because of these illnessesthe breakup of families because a parent dies at a young age while their children are still dependent on their parents the numbers of people worldwide using nicotineit is the hardest addiction to treatThere is essentially no unmanageability in the addict’s life until they have developed a disease that is irreversible such as emphysema, lung cancer, or had their first heart attack. Without the addict feeling the unmanageability in their life, there is limited incentive to stop until it is too late. These diseases took at least 10 years to develop and if the addict started smoking cigarettes at the age of 15, then by 25 years old the disease has a good start and by 35 to 45years old the addict may be dead.The evolution of vapes is opening the use of nicotine to younger age groups and more people as an easier way to become dependent on nicotine which is the carcinogenic agent. Very few smokers use vapes for their intended us of helping the addicted nicotine user to stop smoking cigarettes. Vapes were invented to help with the oral fixation part of the withdrawal from nicotine.Lung cancer is now the most common cancer killer of men and women. From 2000-2010 the additional risk of lung cancer for women smokers jumped nearly tenfold to 25.7 x that of nonsmoking women. Men who smoke now have a 25x higher risk of lung cancer than nonsmokers. This latest Surgeon General's report (2014) also evaluated the evidence concerning other cancers, and concluded that smoking is a cause of liver cancer and of colorectal cancer, the fourth most diagnosed cancer in the United States and the cancer responsible for the second largest number of cancer deaths annually. The report suggests that smoking and exposure to secondhand smoke causes breast cancer. The report also found that smoking increases the risk of dying from cancer and other diseases in cancer patients and survivors, including breast and prostate cancer patients though smoking is not a cause of prostate cancer.Recent studies show that the relative risk for COPD (Chronic Obstructive Pulmonary Disease) in women has risen greatly, reaching 22.4x higher risk as compared to “never” smokers, and similar to the risk in men. COPD is a horrible illness. Lung tissue becomes brittle from the smoke and will not absorb oxygen to the blood stream. These individuals literally slowly suffocate themselves to death and there is no treatment to stop this process. People with asthma who are passive inhalers can go into severe attacks and have to be hospitalized. Evidence reported over the last decade is sufficient to lead to a conclusion that smoking increases the risk for tuberculosis and for dying from tuberculosis.Although lung cancer is often assumed to be the largest smoking-attributable cause of death in the United States, cardiovascular disease actually claims more lives of smokers 35 years of age and older every year compared with lung cancer. Exposure to second hand smoke causes significantly more deaths due to cardiovascular disease than due to lung cancer and this new report finds that exposure to secondhand smoke is also a cause of stroke. Exposure to secondhand smoke increases the risk for stroke by an estimated 20-30%.This report concludes that smoking is a cause of type 2 diabetes mellitus, and that the risk of developing diabetes is 30-40% higher for active smokers than nonsmokers. Furthermore, the risk of developing diabetes increases as the number of cigarettes smoked grows.Smoking is a cause of systemic inflammation and impaired immune function. One result of this altered immunity is increased risk of pulmonary infections among smokers. Smoking is known to compromise the equilibrium of the immune system increasing the risk for several immune and autoimmune disorders. This report says that smoking is a cause of rheumatoid arthritis.Maternal smoking during early pregnancy is causal for orofacial clefts in infants, and evidence suggests that smoking could be associated with certain other birth defects. There is a causal relationship between smoking and erectile dysfunction in men.Age-related macular degeneration (AMD) is a disease that gradually destroys the macula in the retina of the eye and can ultimately lead to loss of vision in the center of the eye. This report finds that smoking is a cause of AMD. The age-standardized relative risk, comparing the all-cause death rate in current smokers to that of never smokers, has more than doubled in men and more than tripled for women during the years since the release of the first Surgeon General's report on smoking and health. Smoking shortens life far more than most other risk factors for early mortality. Smokers are estimated to lose more than a decade of life. Smoking cessation by 40 years of age reduces that loss approximately 90%.Treatment can begin only when the addict wants to stop the use of nicotine. Frequent education of the consequences of continued use of nicotine plus experiencing the loss of a loved one because of their Nicotine Use Disorder can eventually be one motivator for the addict to want to stop. My website, , has a section that describes the addiction, a summary of the Surgeon’s General’s report, and an approach to treatment of this lethal disease. Any attempt to explain treatment during this comprehensive lecture on addiction would only minimize what is really needed if the addict wants to stop and get into recovery. Just giving a patient some nicotine patches, Wellbutrin, or Chantix without dealing with the patient’s lifestyle is like giving a heroin addict Suboxone and a return appointment in a month. It will not work and the patient will quickly relapse. This simplistic approach will only cause the addict to feel like it is impossible to stop this addiction. Cravings and the PAWS are very much a part of keeping the Nicotine Use Disorder active. Attempts at abstinence without the right kind of planning and support usually end up in a relapse. Alcohol Use DisorderThis is the second worst addiction though the problems that are the result of this addiction make it seem like the worst addiction. There are more visible relationship issues, violence, unplanned pregnancy, rape, crime, car accidents, and severe withdrawal symptoms to mention a few issues. The majority of these addicts are “closet drinkers” meaning no one knows that they are alcoholics until they develop some medical problem such as dementia or “the shakes”. 15% of the United States population have an Alcohol Use Disorder. An estimated 88,000 people (approximately 62,000 men and 26,000 women) die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities). (According to the 2015 National Survey on Drug Use and Health (NSDUH))Most alcoholics have a set of genes that allow them to consume the large quantities (pint to a fifth daily) of alcohol necessary to create the full syndrome. Being born with this set of genes is like a slot machine in that you need to hit all four 7’s in order to get the jackpot (the addiction). Alcohol causes “disinhibition” which means that alcohol disconnects your limbic system from your cortex. You are then able to say and do what your more primitive drives want you to say and do. Without the cortex to interfere, lessons learned from the school of life cannot be used to appreciate the consequences of what you are saying or doing. Disinhibition is more complete in the following situations:Higher the amount of alcoholAddition of a benzodiazepine to the alcoholHistory of a Head injury< 26 years old when the cortex is still maturing and the limbic system matured by 18 years old.Cancer Caused by AlcoholThe International Agency for Research on Cancer of the World Health Organization has classified alcohol as a Group 1 carcinogen. Its evaluation states, "There is sufficient evidence for the carcinogenicity of alcoholic beverages in humans. …Alcoholic beverages are carcinogenic to humans.A 2011 study found that one in 10 of all cancers in men and one in 33 in women were caused by past or current alcohol intake. Data from 2009 indicated 3.5 percent of cancer deaths in the U.S. were due to consumption of alcohol.Individuals who both smoke and drink are at a much higher risk of developing mouth, tracheal, and esophageal cancer. Research has shown their risk of developing these cancers is 35 times higher than in individuals who neither smoke nor drink. This evidence suggests that there is a co-carcinogenic interaction between alcohol and tobacco-related carcinogens.Alcohol is a risk factor for cancers of the mouth, esophagus, pharynx, and larynx. The U.S. National Cancer Institute states "Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, and liver in men and women, … In general, these risks increase after about one daily drink for women and two daily drinks for men. (A drink is defined as 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor.) … Also, using alcohol with tobacco is riskier than using either one alone, because it further increases the chances of getting cancers of the mouth, throat, and esophagus.A WCRF (World Cancer Research Fund) panel report finds the evidence "convincing" that alcoholic drinks increase the risk of colorectal cancer in men at consumption levels above 30?grams of absolute alcohol daily. In the United States, a standard drink contains about 14 grams of alcohol. The National Cancer Institute states, "Heavy alcohol use may also increase the risk of colorectal cancer."Alcohol is a risk factor for liver cancer, through cirrhosis as presented in the Global Burden of Disease Study 2013. "Cirrhosis results from scar formation within the liver, most commonly due to chronic alcohol use." "Approximately 5 percent of people with cirrhosis develop liver cancer.”Alcohol increases the risk of breast cancer. The more alcohol consumed on a regular basis, the greater the risk, says Wendy Y. Chen, MD, PhD, a cancer specialist at the Dana-Farber Cancer Institute in Boston. The study was presented at the annual meeting of the American Society of Clinical Oncology. Chen notes that women thinking about having a few glasses of wine a day for their heart-healthy effects need to figure in the new findings when weighing the risks and benefits. She stresses that "it’s only regular, repeated use that increases the chance of breast cancer. For most women, having a glass of wine or beer on occasion is not a problem."Approximately 6% (between 3.2% and 8.8%) of breast cancers reported in the UK each year could be prevented if drinking was reduced to a very low level (i.e. less than 1 unit/week). One unit of alcohol (UK) is defined as 10 ml. (8 grams) of pure alcohol. A large (250?ml) glass of 12%?ABV red wine has about three units of alcohol. A medium (175?ml) glass has about two units. Moderate to heavy consumption of alcoholic beverages (at least three to four drinks per week) is associated with a 1.3-fold increased risk of the recurrence of breast cancer. WithdrawalAcute withdrawal takes 3 to 5 days but can last as long as 7 to 10 days if the drinker has been drinking for 20+ years. It has to do with the amount of alcohol consumed each day plus the years of drinking. Age is a factor in that the older the addict, the harder the withdrawal symptoms and the more lethal. Those individuals that are physically debilitated are more at risk medically. Detoxification has to be done inpatient because of the risk of a cardiovascular injury from elevated blood pressure and pulse though the vital signs can be normal and there can still be a cardiovascular event. In 34 years of practice I had 5 patients have either a stroke or a heart attack and the vital signs were normal. None of these patients were debilitated physically and they were on appropriate detoxification regimens. The standard of care is a Tranxene, Klonopin, or more rarely, phenobarbital taper over 3 to 5 days. Any benzodiazepine can be used as well as Depakote. If there is a history of withdrawal seizures, loading with Depakote may be a must to prevent a withdrawal seizure especially if there is also a history of a head injury. Nausea, vomiting, disturbed sleep and mood swings are common especially during the first couple of days. Patients can have a complete personality change and be very difficult to manage with rage and sometimes physical violence. PAWSAfter detoxification, the patient may feel good physically and believe that they can go directly back to work and get back to their life. This is a relapse in action and will occur quickly. The patient is still physically debilitated nutritionally, physically, and has sleep deprivation. Judgment is not the best or is outright impaired. Without having alcohol to help, the joy of life and the relief of stress is not there. The addict usually falls off what is called a “pink cloud” into the reality of life. Soon many things will not feel right. Relapse is a very high probability. Aggressive medical treatment of insomnia, anxiety, mood swings, and cravings will allow the sober alcoholic a better potential to stay sober. The PAWS will not last forever but the alcoholic post detox does not know this. If the alcoholic has been drinking a fifth of liquor a day for 10 years, the PAWS will last a year though each day these symptoms slowly get better. If there is also a co-occuring psychiatric disorder, this has to be treated or it may be the addict’s number one relapse risk factor. Anxiety disorders are the number one psychiatric disorder in alcoholics. Unfortunately, the treatment of these disorders usually takes several weeks to a month to start feeling significant relief. The standard of care is an antidepressant but the addition of Buspar will start giving relief sooner. Vistaril and Neurontin are also medications that can give relief of the anxiety of PAWS.Campral and naltrexone are medications that are part of the standard of care to deal with those who have more severe PAWS. Campral seems to calm the anxiety and irritability of the PAWS. Naltrexone has been shown to decrease heavy drinking and to decrease the desire to need to drink. Its mechanism of action in alcohol dependence is not fully understood, but as an opioid receptor antagonist, it is likely to be due to the modulation of the dopaminergic-mesolimbic pathway which is one of the primary centers for risk-reward analysis in the brain and a tertiary "pleasure center". A naltrexone treatment study released by the National Institutes of Health in 2008 has shown that alcoholics having a certain variant of the opioid receptor gene demonstrated strong positive response to naltrexone and were far more likely to experience success at cutting back or discontinuing their alcohol intake altogether, while for those lacking the gene variant, naltrexone appeared to be no different from placebo. Many African American alcoholics do not have this gene variant. Possibly one day, we will be able to quickly test for this gene variant and make a more objective decision as to who would benefit from naltrexone. Antabuse does not deal with PAWS but for those alcoholics who want recovery but keep relapsing, this medication may save their life. If they drink alcohol while taking daily Antabuse, they will have nausea and vomiting so severe that they have to go to the hospital and have IV’s to keep from having severe life threatening dehydration. The mechanism here is that the addict takes the Antabuse in the morning when they do not have much desire to drink. In the afternoon and evening when impulsive relapses occur, the thoughts of having nausea and vomiting prevent the relapse.Any alcoholic who has tried to get into recovery and relapsed should be started on one or all of these medications. Since it takes a year to teach your limbic system alternatives to having relief instead of using alcohol, it is recommended that the alcoholic stay on these medications for at least a year. Some alcoholics may need to stay on these medications longer. Cannabis Use Disorder Marijuana heightens certain senses (appetite, sexual desire, etc.) and dulls others. It attaches to special endocannabinoid receptors in our brain that ordinarily react to natural THC-like chemicals in the brain. These natural chemicals play a role in normal brain development and function. Marijuana over-activates parts of the brain that contain the highest number of these receptors. This causes the "high" that users feel. Marijuana may initially “chill you out” and relax you so that you can sleep and not be overwhelmed by certain emotions, but the next day, your response time and your motivation to do work that you do not like to do is not the best. To begin with, you are still stoned though you rationalize that you are not. The following list explain some of the adverse effects of Marijuana Intoxication:Short-term Cannabis intoxication can hinder the mental processes of organizing and collecting thoughts. This condition is known as temporal disintegration. Difficulty thinking and problem solving.Frustration tolerance is poor especially when you are pressed to get things done that you do not want to do. Short term memory is poor. Motor skills are impaired in that your response time is slow. Some have feelings or paranoia or anxiety.Most have the “munchies” resulting in some gaining a great deal of weight Impulsively do strange or inappropriate activities such as having unprotected sex with someone that you would never have sex with.Have loose associations (inability to stay focused on one subject)Have an altered sense of time such that an hour may feel like 20 minutes or 2 hoursHave disinhibition of other emotions at inappropriate times and places such as constant laughter with your boss or with your grandmother Unfortunately, marijuana also comes with a few other problems. Marijuana stays in your body for weeks after just a little use of marijuana. It binds with your adipose tissue (fat) so it accumulates if you are using marijuana once or twice a week. Unless you only smoke marijuana once a month, it accumulates as a result of that one use of marijuana every Saturday night. More marijuana in the body means more severity of the problems stated above.When someone is in intensive psychiatric treatment, the use of marijuana, even once, may be the factor that tips that person over the edge emotionally or prevents them from resolving the conflicts that need emotional work. If someone uses marijuana several times during the week to deal with stress or to be able to go to sleep, then, after the high wears off, the individual realizes that whatever was not dealt with emotionally before they smoked is still not resolved. They then realize they are even more behind (homework, chores, going to see their probation officer, etc.) and feel that they have to smoke more marijuana to deal with that stress. The cycle continues resulting in more anxiety.Studies have been done with pilots on flight simulators the day after smoking a marijuana cigarette. Those who smoked were clear that they did not believe that it affected their functioning, but when tested concerning how they remembered a situation and how they performed on hand-eye coordination, their performance was worse than the control group not using marijuana. Longer Term Adverse Effects from Consistent use of MarijuanaMarijuana can also give you a “do not care” attitude. It does not do this in the early stages of smoking but, over time, the occasional apathy becomes a daily attitude and affects being able to accomplish anything productive. This is called an Amotivational Syndrome. The problem is that the marijuana user does not realize this has happened because they are busy doing a number of things, all of which are not productive in terms of working a job, preparing for midterms or taking care of chores in the house. In fact, the user may believe that their ability to think and to produce is better. The problem is that they are thinking of esoteric issues and not what they need to be thinking of in order to take care of business. Many projects may be started but most are not finished.About 9% of those who experiment with marijuana eventually develop a Use Disorder. The rate goes up to 1 in 6 among those who begin use as adolescents, and one quarter to one-half of those adolescents who use it daily according to a NIDA (National Institute on Drug Abuse) review. The highest risk of cannabis dependence is found in those with a history of poor academic achievement, deviant behavior in childhood and adolescence, rebelliousness, poor parental relationships, or a parental history of drug and alcohol problems.Long-term use of marijuana can affect brain development. When marijuana users begin using as teenagers, the drug may reduce thinking, memory, and learning functions and affect how the brain builds connections between those areas necessary for these functions. Marijuana’s effect on these abilities may last a long time or even be permanent. A study showed that people who started smoking marijuana heavily in their teens and had an ongoing Cannabis Use Disorder lost an average of eight IQ points between ages 13 and 38. The lost mental abilities did not fully return in those who quit marijuana as adults. Those who started smoking marijuana as adults did not show notable IQ declines.In the past five years there have been two good studies that point out that marijuana is not a cause of Schizophrenia. If someone is genetically going to have Schizophrenia, marijuana will bring out the first psychotic episode of Schizophrenia one and a half to two years earlier than it would have come out naturally. Marijuana smoke irritates the lungs, and frequent marijuana smokers can have the same breathing problems that tobacco smokers have. These problems include daily cough and phlegm, more frequent lung illness, and a higher risk of lung infections.Marijuana Extracts - Smoking THC-rich resins extracted from the marijuana plant is on the rise. Users call this practice dabbing. These extracts can deliver extremely large amounts of THC to users, and their use has sent some people to the emergency room. People are using various forms of these extracts, such as:hash oil or honey oil—a gooey liquidwax or budder—a soft solid with a texture like lip balmshatter—a hard, amber-colored solid03422650Opioid Use DisorderAccording to the American Society of Addiction Medicine (ASAM) 21.5 million Americans had a substance use disorder in 2014. 1.9 million had a substance use disorder involving prescription pain relievers. This means that one in ten addicts have an Opioid Use Disorder. 586,000 had a substance use disorder involving heroin. 23% of individuals who try heroin develop opioid addiction because it is so addicting.Drug overdose is now the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014. Young adults trying to get high and those around 60 years old and older who are trying to manage their pain are the main groups of people involved. By the end of 2017, the total number of deaths in 2017 because of opioids may reach 60,000.About half of these individuals have an Opioid Use Disorder because of a genetic predisposition. Those who are “genetically prewired” can remember the first opiate that they did. That Lortab or Percocet gave them mental clarity, motivation to do things that were boring, relief from worry, and a sense of wellbeing. They were able to be with other people without being anxious though they may have an anxiety disorder. If they had been suffering with constant depression, the feelings of depression may have been completely relieved for about six hours. Of course, anyone having these benefits from just one opioid pill would have to take the next one when the effects of the first one wore off. Someone with a genetic predisposition to be an opioid addict has a paradoxical reaction to opioids as compared to the rest of the population. The rest of the population do not feel these positive things. In fact, most of the general population actually have a dysphoric feeling from opioids including nausea, sedation, mental clouding, and lack of motivation. They might consider having a little pain better than using an opioid.The problem with using opioids for depression and anxiety in those people who are “genetically prewired” is that opioids always with time develop a tolerance to the above benefits. In order to get the same feeling, the dose has to be increased. Usually after 6 months, the dose needed to feel good is too expensive unless you are rich. A 30 mg Roxicodone cost $30 on the street so a habit of 90 mg a day cost $90 per day. Heroin is more potent and is much less expensive. At this crossroads in the progression of the addict’s use disorder, a decision must be made. Many addicts have a great deal of ambivalence about switching from a known, standardized pharmaceutical (e.g. Percocet) to a drug that can be totally unpredictable in terms of potency and makeup. Their hesitation to start using IV heroin may cause them to shop lift, pawn family property, or to steal other things. In this process they may be caught and this is when the first wave of opioid addicts come into treatment. These are the lucky ones.The second wave of addicts come into treatment because they are arrested and charged with a felony for possession of heroin or they are found out by their employer, family or significant other. Another group comes in because of Hepatitis C or other medical problems. There are multiple reasons that help the addict to realize that they need treatment. Each reason is a blessing because without the addict fully recognizing the unmanageability in their life because of their active addiction, they are not able to make a decision to stop using the substance that makes them feel so good until one day they take a lethal overdose.Pregnancy is a special problem with a mother who is actively using opioids. These women cannot be withdrawn from their opioid during the pregnancy because the risk of miscarriage is too high. They have to stay on opioids and the paradox is that the OB-GYN has to prescribe these medications as part of their management of the pregnant patient. Opioid Withdrawal Within 24 to 36 hours of the last use of an opioid, those individuals who have been taking opioids daily for at least a month will go into withdrawal. The potency of the opioid (i.e. heroin vs. 40 mg hydrocodone) and the length of time the opioid has been used on a daily basis will determine the severity and length of time of the opioid withdrawal. Withdrawal symptoms will start with irritability, dysphoria, anxiety, sometimes anger, and severe insomnia. Then there will be abdominal cramping with lose stool, diarrhea, nausea and vomiting, body aches, nose running, and a strange sensation of being too hot with diaphoresis, then a shaking chill. Sometimes the addict feels that their ‘skin is crawling”. Most of the time, there will be a strong desire to use the opioid to stop the misery of the withdrawal. This desire can be more of an essential drive similar to the need to drink water when you have not had any water for several days. Some patients are convinced they are dying. Most addicts cannot tolerate withdrawal without relapsing on an opioid. The acute withdrawal averages 3 to 5 days. During this time the addict is not able to eat or drink and potassium drops because of vomiting and diarrhea. The dehydration and nutritional depletion can be severe so that someone who is already physically debilitated or elderly could die or have a heart block from low potassium.Those individuals that have been on Methadone, Suboxone, Duragesic (fentanyl) and kratom for 3 to 6 months will have acute withdrawal symptoms for 7 to 12 days. Please do not minimize the patient by telling them that they are drug seeking when they are coming off of these particular opioid drugs. They are still in an acute physiologic withdrawal state long after the more traditional 3 to 5 days of withdrawal from less potent opioids like hydrocodone and oxycodone.The standard of care for opioid withdrawal is Subutex in tapering doses. Clonidine (Catapres) is also used especially in the extended detoxification which helps to decrease the “hot and cold” and the “skin crawling” sensations and can give the patient significant relief. An anti-inflammatory drug also is needed for the body aches in joints and muscles which can be severe. All of this allows the patient to decrease the withdrawal symptoms so that they can eat, hydrate, sleep, and resist a relapse.Mood stabilizers are also necessary at times because of the irritability and anxiety. Both Neurontin and Seroquel are two drugs that are frequently used but 2 to 3% of addicts can get a high from these drugs and they may be abused. Discretion must be used especially with those addicts that are polysubstance abusers and being detoxed as an outpatient. Other ConsiderationsAfter withdrawal from opioids, the addict is at a very high risk for relapse unless the patient is in agreement to go into a residential addiction program or is placed on harm reduction medication. This is a potentially life threatening situation if the patient is discharged to just an IOP (3 hours three days a week) or outpatient 12 meetings and counseling. The cravings will be high and if the addict relapses, they will use a large amount of opioid in the initial relapse which can cause an overdose. After the addict is off of opioids for 2 to 3 weeks, the tolerance of the opioid will have dissipated. If they use their usual daily dose of opioid when their tolerance was high, they will be in an overdose situation and will die. The moral to this story is to not withdraw an opioid addict who does not plan to go into the next level of structured, safe treatment.Also, during the first 2 to 3 weeks post withdrawal, the patient will be cognitively impaired because of PAWS. The addict’s judgment will be an issue in terms of making decisions. Usually it is not so severe that you would hold the patient against their will but their judgment is definitely an issue and will affect their ability to comprehend, remember what you have said to them, and cause them to be more impulsive. Harm ReductionRecovery from Opioid Use Disorder is not easy and takes at least a year to make the changes in life that are necessary to replace the reward system developed in the limbic system around opioids. Recovery occurs through a process of biological conditioning that takes practice, a desire to change, and time. Those addicts who have been using for years may take 2 years to feel comfortable with life without opioids. Because most opioid addicts will not have the resources for a long-term addiction treatment, harm reduction medication and counseling is essential to prevent regression back to using their drug of choice. Methadone was originally invented in the 30’s as a long acting synthetic opioid for pain management. Methadone was the first harm reduction medication. It covers the cravings and the PAWS with 98% of the opioid addicts not feeling “high”. This gets them off the heroin. The addict goes to a methadone clinic daily and receives their methadone in a liquid form so they do not cheek it and sell it. Methadone can have some sedation and constipation which can be a real medical problem. Buprenorphine injectable came out about 30 years ago for the treatment of pain. Suboxone is buprenorphine plus naloxone and became the second harm reduction medication about 20 years ago. It is a class III drug so it can be called in to a pharmacy over the phone with refills. Most patients feel more “natural” on this medication than on the methadone but it must be taken several times a day. Most opioid addicts do feel a “high” on Suboxone. Also, most young adult addicts end up abusing this drug by taking higher doses of the Suboxone or using other opioids other than Suboxone on the weekend. Once the patient can make some changes in their life towards a path of recovery, then they can begin to taper down the Methadone or Suboxone until they can stop the opioid and begin the process of total abstinence and complete recovery. Withdrawals from these two extremely potent opioids are the most miserable as well as some of the longest. The opioid withdrawal has to be done slowly over a longer period of time. Naloxone/Naltrexone Naltrexone is the oral form of naloxone. One pill lasts 24 hours. Naloxone (Narcan) is the IM (injectable) and sublingual (under the tongue) forms of naltrexone. Vivitrol is the depo (injection in an oil base) form of naloxone that lasts 28 days. Naloxone binds the opiate receptors in the brain. Once the receptors are bound, most alcoholics and opioid addicts have a significant decrease in cravings. Some have no cravings and rarely, some addicts do not feel any benefit. Cravings are biological and emotional. If the addict’s substance was also used to deal with a depression, an anxiety disorder, or to deal with the symptoms of PTSD, the naloxone will not help these problems and the cravings for their old opioid that relieved these symptoms will still be there even on the naloxone/naltrexone.The added benefit of naloxone is that if the addict relapses on their alcohol or opioid, they will not get the usual pleasure or relief because the opiate receptor is bound leaving no place for alcohol or opioid to bind. This gives the addict, who has impulsively relapsed, the rest of the day to decide if they want to stay in their relapse or if they want to call their sponsor and stop the relapse. Naloxone should be a part of any opioid or alcoholic’s regimen to deal with the PAWS. The danger is that if an addict is not ready to stop using and a parent or a spouse makes the addict take naltrexone, then when the addict must use, they will try to override the opiate binding by taking a large dose of opioid trying to get high that will also cause respirations to be too low and the addict will suffocate and die.A relapse of an opioid can be a lethal event. If the addict has a series of loses or stresses that feel overwhelming, the limbic system will demand that the addict use an opioid. Usually, the first dose is not that large but the second or third dose will be the addict’s routine dose before they stopped. This dose will cause an overdose because there is no longer tolerance to the opioid. This is when many opioid addicts die. If the addict has a medical emergency such as a car accident with a broken leg or a ruptured appendix, the effects of the naloxone can be overridden by an anesthesiologist. Opioid can be given to the addict at a dose of opioid that will give analgesia (pain relief) but may cause life threatening decreased respirations that may require assisted breathing which can be done in the hospital. Also, the anesthesiologist can do nerve blocks that will give pain relief minimizing the use of an opioid. If the addict is found unresponsive after an overdose, the family needs to be prepared for this by having available intranasal or injectable naloxone. This can be obtained from an MD through a prescription or just bought at your pharmacy without a prescription. The intranasal comes as a nose spray (Narcan Nasal Spray). The injectable comes in a devise (Evzio) that talks to you and tells you exactly what to do. Seconds count, so once you realize that there has been an overdose, the naloxone has to be administered and 911 has to be called along with initiating CPR if the addict is not responding. Chronic Pain and OpioidsOver the past 20 years there has been a dramatic increase in the use of opioids to treat pain. The introduction of OxyContin provided an analgesic that starts working within 30 to 45 minutes and lasts from 6 to 8 hours (it does not last 12 hours as stated by the pharmaceutical company). Side effects are less as compared to morphine. Also, during this same time Opioid Use Disorder increased dramatically. The number of young adults and 65 and over dying from overdose has at least tripled from 2001 to 2013 according to the National Institute on Drug Abuse (NIH). The largest cause of deaths for young adults (18 – 26) is from overdose on opioids.In light of all of this lethality, Thomas Friedan, the Director of the Centers for Disease Control and Prevention has taken on Opioid Use Disorder as a major medical problem that deserves more intensive assessment. In 2014 the CDC added opioid overdose prevention to its list of the top 5 public health challenges. He has presented guidelines that include that doctors should limit prescriptions to a 3-day supply for acute pain then seek alternative treatments for chronic pain such that narcotics should be the last resort. All of this is based on evidence that suggests that long-term prescriptions of opioids for chronic, noncancerous pain is: not efficacious for pain reliefactually causes increased reported pain symptomsare inherently pharmacologically addictive and disablingthat the inherent nature of opioids is that they cause depression and anxietydoctors, in general, do not understand the problems with prescribing opioids and prescribe opioids too frequently and at too large of an amountOpioid-induced hyperalgesia (OHI) is a state of nociceptive sensitization caused by exposure to opioids. Hyperalgesia is a paradoxical response whereby a patient receiving opioids for pain becomes more sensitive to painful stimuli and has pain induced or caused by opioids. Also, since there has been a dramatic availability of opioids in the community, teenagers and young adults are taking these medications from their parents and grandparents to use recreationally and to sell since they have a high street value. Opioids are most often prescribed by primary care physicians and opioids are the most frequently prescribed medication in the United States. The United States prescribe the most opioids of any other country.The United States Department of Health and Human Services (HHS) made a formal announcement targeting the increase in deaths by opioid overdose:Aiding doctors in opioid prescription training and monitoringIncreasing use of naloxone (IV Narcan, IM Evzio, Naloxone nasal spray, Naloxone Prefilled Syringe, Naltrexone, Vivitrol)Expanding the use of medication-assisted treatments (Harm reduction medications)My ExperienceI have worked heavily with chronic pain patients for the past 25 years. I have watched the increase in the use of opioids for the treatment of noncancerous, medical conditions such as Osteoarthritis and Rheumatoid Arthritis, severe vehicle accidents, and a multitude of other medical conditions and accidents. 80% of the chronic pain patients that I have treated have been involved with the Gwinnett Medical Center Pain Program and had a degenerative disease such as osteoarthritis. Once the patient had the appropriate surgery to correct what could be done surgically and once the anesthesiologist had done the appropriate epidurals and other procedures such as spinal cord stimulators to give pain relief, then we would use opioids. Since surgeons and anesthesiologists have limited desire to manage a patient chronically, the patient ended up in my care for pharmacologic management, supportive therapy, and overall education of better life styles.99% of these chronic pain patients had either a diagnosis of Major Depression or Generalized Anxiety Disorder. Most of the time these disorders were a product of the chronic medical condition. Very rarely, did I believe that the opioids were the cause of the psychiatric condition. 99% of the time I did not see an Opioid-Induced Hyperalgesia. I know that this exist but in reality it is rare with the true chronic pain patient. All of my chronic pain patients are on a long acting opioid such as Methadone or Duragesic and a short acting opioid usually Percocet. Attempts would be made to use Cymbalta, amitriptyline, and the gabapentins to provide analgesia. The best that these patients could hope for was to have enough pain relief that they could have some quality of life. If I could get them at least 50% pain relief, they were then able to take care of themselves physically, be able to go to the grocery store, go to doctor visits, and to do some minor things around the house. This population of patients are different than those who go to multiple emergency rooms and doctor shop. My type of chronic pain patients had been filtered through many providers before they were eligible to come to the pain center and then to me. These patients have received the surgical intervention they need as well as the pain relieving procedures that were appropriate. As in every medical pathology, these are those patients that the medical profession is unable to resolve their problem. They need medical management to give them as much relief that is medically necessary without doing them harm (the Hippocratic Oath).It is true that those patients with chronic pain who have psychiatric problems and certain personality disorders before they began their chronic pain condition are a challenge. Many want higher doses of medication than what is necessary to manage their chronic pain condition. This is where the physician has to set limits and to be sure that the team approach is used to manage the patient. Ideally, a psychiatrist should be part of the team but unfortunately, this is rarely the case.Patients with an Opioid Use Disorder are not candidates for maintenance opioids for chronic pain. Most alcoholics are not candidates but I have had several alcoholics that did not stop drinking until they got pain relief on Methadone. One patient in particular had a horrible pain condition from a broken neck and was paraplegic. She could not stop drinking alcohol. Once she was place on Methadone, she was able to get into recovery from her Alcoholism and became a leader in the recovering community.The bottom line is that if a chronic pain patient is managed appropriately, maintenance opioids can be used effectively. Just as in any new epidemic such as the increase in Opioid Use Disorder, we do not want to throw the baby out with the bathwater as we try to “clean-up” the problems that as a medical community we have created while trying to take care of the patient. KratomKratom is a substance that is grown in southeast Asia. At small doses, it is a stimulant and used by Thai and Malaysian laborers and farmers to overcome the burdens of long days and hard work. At higher doses, it has many qualities of an opioid and can be used when opioids are not available. It can be used to manage opioid withdrawal symptoms. This can be bought over the internet and is not illegal though it is as addictive as an opioid.Sedative/Hypnotic Use DisorderThis addiction usually results from the use of a benzodiazepine drug either to get relief from anxiety or insomnia. Most addicts prefer a sedative/hypnotic that works fast such as Xanax or Ambien. If this is not available then the other ones will do the same job such as Klonopin, Ativan, and Valium. The first problem with this class of drugs is that they require multiple doses a day to cover anxiety 24 hours. This creates mood swings and more anxiety around whether they will be able to get the next dose of the drug in time to cover their anxiety or insomnia. The urgency around obtaining enough drug becomes the most important thing in their life. The second problem is over time you develop a tolerance to the benefits of the drug necessitating increasing the amount of drug used to get the same original relief. This cycle of tolerance and increasing the dose continues until the person is on a large amount of drug. The higher the dose, the more dangerous the side effects. Disinhibition of emotions becomes worse on the higher doses such that acting out of primitive desires and rage are more likely and cause that person to be dangerous to themselves and others. This class of drugs have several other adverse complications such as:Sedation,Disinhibition as well as flattening of emotions making the person unpredictable, enhancing the respiratory depressant effects of alcohol and opioids, creating a blackout of time, slowing of movements causing slurred speech, and slowed response time (driving), balance problems (falls). Triggering the desire to use the drug (or alcohol) of another primary addiction.More times than not, those individuals who have a Sedative Use Disorder have an untreated Anxiety Disorder. The standard of care for an Anxiety Disorder is an antidepressant. Unfortunately, it takes 2 to 4 weeks on a dose of an antidepressant to see if that antidepressant will be effective to treat the anxiety. Other “antianxiety medications” such as Buspar and Vistaril can be used to cover some of the symptoms not covered by the antidepressant until the benefits of the antidepressant can kick in. WithdrawalThere are two stages to a sedative withdrawal. First, the acute stage which is very much like that of alcohol withdrawal. What is deceiving is that sometimes the vital signs can be relatively normal and the patient can have a withdrawal seizure. Tranxene is the standard of care in tapering doses. If the vital signs are elevated and there is no history of untreated hypertension, use extra doses of Tranxene to keep the vital signs normal to prevent a cardiovascular even (heart attack or stroke). The second stage of withdrawal begins after the vital signs are normal off of the Tranxene. This is the second through the fourth week after stopping the use of the sedative. Without warning the addict can have a violent seizure. The danger here is if the addict is driving a car, walking on steps, or in the bathroom with a tile floor. Any sedative addict that has been on a daily sedative for at least a month, should be placed on Depakote for a month at a dose that is therapeutic to prevent seizures. I have never had a withdrawal seizure using this approach. Benzodiazepines are the most notable drug for inducing prolonged PAWS with symptoms sometimes persisting for years after cessation. Symptoms can sometimes come and go with wave-like reoccurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse. The protracted withdrawal syndrome from benzodiazepines can produce symptoms identical to Major Depression or Generalized Anxiety Disorder as well as Panic Disorder. Due to the sometimes prolonged nature and severity of benzodiazepine withdrawal, abrupt withdrawal is not advised.In my experience when I begin to work with someone who has been taking a benzodiazepine medication for 10 or more years and who does not have an addiction, I will try to taper off the benzodiazepine over a month or longer. If there is a significant PAWS after a couple of months, I do not continue to try to stop the benzodiazepine because the PAWS may last for years. In the case of someone who has an addiction such as an alcoholic or someone abusing prescribed benzodiazepines, I have to take this addict off of the benzodiazepine. Also, I have not been successful keeping an addict sober from their alcoholism if they stay on the benzodiazepine. Benzodiazepines share a similar mechanism of action with various sedative compounds that act by enhancing the GABA receptor. Although benzodiazepines can be very useful in the acute detoxification of alcoholics, benzodiazepines in themselves act as positive reinforcers in alcoholics, by increasing the desire for alcohol. Low doses of benzodiazepines were found to significantly increase the level of alcohol consumed in alcoholics. There is cross tolerance between alcohol, barbiturates, and corticosteroids, which all act by enhancing the GABAA receptor's function. Neuroactive steroids (e.g., progesterone) are positive modulators of the GABAA receptor and are cross tolerant with benzodiazepines. The active metabolite of progesterone has been found to enhance the binding of benzodiazepines to the benzodiazepine binding sites on the GABAA receptor. Abrupt withdrawal from any of these compounds (e.g., barbiturates, benzodiazepines, alcohol, corticosteroids, and neuroactive steroids) precipitate similar withdrawal effects characterized by central nervous system hyper-excitability, resulting in symptoms such as increased seizure susceptibility and anxiety. Alterations of levels of neuroactive steroids in the body during the menstrual cycle, menopause, pregnancy, and stressful circumstances can lead to a reduction in the effectiveness of benzodiazepines and a reduced therapeutic effect. During withdrawal of neuroactive steroids, benzodiazepines become less effective.PAWSPAWS from sedatives can be difficult to manage. The longer the patient has been on a daily dose of a sedative, the potency, and amount of the sedative used affect the severity of the PAWS. The main symptoms are usually either irritability or depression with disturbed sleep. Nothing gives the individual joy or contentment. Several studies using Neurontin have supported a longer time without a relapse. Both Neurontin and Seroquel are two medications that help the anxiety, sleep, and mood swings, but a small percentage (3% to 5%) of addicts will abuse these medications. Several studies have supported the use of Celexa which has improved the PAWS symptoms. Many times, trazadone will help the sleep. If PAWS is not treated aggressively, the patient will relapse on their addictive drug. Stimulants (Cocaine and Amphetamines)The stimulants “squeeze out” dopamine in the brain multiple times what is released normally. This release of large amounts of dopamine gives the user a sense of wellbeing and motivation (as well as prevents sleep). Until the dopamine is replenished, that person is emotionally flat, feels exhausted, and sleeps which is called being “spun out”. Each stimulant has its own personality in terms of the nuances of how someone is stimulated. Each subsequent use of the stimulant will require higher and higher amounts to give the same effect. This is caused tolerance. Once the dopamine receptor is “upregulated” from each use, it takes time for the receptor to “down regulate” so that natural brain stimulation of the dopamine receptors can give the baseline sense of wellbeing and normal motivation. The longer the addict uses and the more potent the stimulant, the longer it takes to normalize. During the time needed for the dopamine receptor to normalize, craving will occur. Craving is the limbic systems demand that the addict use more stimulant. The effects of the stimulant are so successful in giving the addict energy and motivation during times of boredom, depression, or a heavy work load that the limbic system cannot see how anything else will give as good of a relief. Crack cocaine and methamphetamine release dopamine at dramatically higher levels than normal. These drugs do it so efficiently that when the effect wears off, the craving is extreme. Methamphetamine in particular causes the worse cravings. This drug upregulates the dopamine receptor so high that with repeated use, the dopamine receptor actually dies creating dots on an MRI scan. These dots are dead brain tissue that will not regenerate. This graph visually shows the how much dopamine is released with each stimulus/substanceCrack cocaine is cheap but only gives a high for 20 to 30 min when smoked. Methamphetamine is cheap compared to powder cocaine but it lasts 8 hours. The problem is that with both of these stimulants, the addict will use the drug over and over until they have “spun out”. They will stay in a meth house or crack house spending all the money they have and/or giving sexual favors to someone for the next “hit” of the drug. They do this until they physically cannot function and will literally crawl out of the house. Somehow they get home and sleep for a day or two until they can physically function. They may try to work for the rest of the week then they will have to go back to the “house”.Crack cocaine and methamphetamine (and sometimes heroin) are the only two substances that can cause anyone to develop a use disorder. You do not have to be genetically prewired to become addicted to these substances. Once you use these drugs the release of dopamine is so dramatically higher than the normal release and resultant sense of wellbeing and motivation is so wonderful, that when the effects of the drug wear off, you are in a deficit of dopamine to just be normal. The emptiness and lack of drive can be painful and the cravings become strong. The limbic system knows what will give you immediate relief. PAWS for StimulantsThe post-acute withdrawal syndrome for stimulants is at least as severe as opiates and alcohol. Again, it all depends on the potency of the drug used and the length of time it has been used on a regular basis. The first couple of weeks of abstinence is very hard because of the cravings which are the worst of any addictive substance. It takes months to years for the cravings to decrease enough that they are not constant. Sometimes a therapeutic dose of Wellbutrin can help decrease the more severe cravings but this will take 2 to 3 weeks to start working. Sleep, irritability, depression, anger and mood swings are also a problem. Many meth and crack addicts are not able to function in a treatment program for at least a month because of PAWS. The nutritional and physical disability can be severe. Ideally, they need to be involuntarily confined for a month or two before attempting the recovery process. This is the heart break of treating these addicts who need so much love, understanding, physical, psychological, and spiritual care during the first month. They probably do not get this in jail and many are not stable enough to stay in an outpatient or residential treatment without relapsing because of their cravings.Hallucinogens/ DissociativesThe most commonly used hallucinogens are “shrooms” (mushrooms) and a variety of psychedelic drugs called “LSD”. True LSD used in the 60’s is hard to find but many dealers mix up concoctions that can cause hallucinations as well as a sense of wellbeing. “LSD” causes distortions of senses. You see music or hear colors. A “bad trip” is when these sensations take on a dangerous quality and you believe they are going to harm you. This can be a horrifying experience because it feels so real. Days, weeks, months, or even years later, you can re-experience this bad trip (a flashback) for no particular reason. This can be a bad situation when you are driving at night in heavy traffic and it is raining. What people order over the internet as “Spice” is rarely synthetic marijuana. It is something mixed up in someone’s bathroom sink. There is no accrediting agency to be sure that the formula is standardized. Many individuals use “Spice” and become paranoid or have auditory hallucinations. They have to be hospitalized and usually after 3 to 5 days of heavy antipsychotics they come out of their psychosis. Cathinones (“Bath Salts”) is an “amphetamine want-to-be” that is purchased at “head shops” or over the internet. There is also no standardization of the formula. They usually act like a weak amphetamine. The user believes that higher and higher doses will give them the same effect as an Adderall but it never does. Eventually, they take the drug IV and many times they will have auditory hallucinations or paranoid delusions. This user of “bath salts” will have to go through the same hospitalization as the above user of “Spice”.Dissociatives include ketamine (Special K) and phencyclidine (PCP or Angel Dust). These drugs give you a sense of wellbeing and can cause you to dissociate from your normal state of consciousness. The term dissociation describes a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a loss of reality as in psychosis. Dissociation describes common events such as daydreaming while driving a vehicle. Further along the continuum are non-pathological altered states of consciousness or depersonalization experiences. Dextromethorphan (DXM) is an opiate-like substance. When used in large quantities it will cause a dissociative experience. It will give the user a sense of wellbeing similar to a mild opioid such as Lortab though the experience is more unique to DXM. The user will go through a withdrawal with some qualities to that of opioids but the use of Subutex to detox the patient does not help that much. Some opioid users who run out of their opioid of choice and who are desperate, will use DXM (Robitussin DM or Mucinex DM) until they can obtain their opioid though it does not prevent the withdrawal. Coricidin (Head cold medication) is sometimes used in high doses as a recreational drug because it contains the dissociative drug dextromethorphan. In this context, Coricidin is referred to as C's, Red Devils (Red D's), Skittles, Trips, or Triple C's. As an aside comment. In the late 1960s, blues-rock guitarist Duane Allman of The Allman Brothers Band began using an empty glass Coricidin bottle as a guitar slide, finding it to be just the right size and shape for this purpose. Duane, obviously, was an addict.Young teenagers (11 to 14) inhale (huffing) the fumes from glue, gasoline, and other volatile substances to get a sense of wellbeing and can have a dissociative experience. This is dangerous because repeated huffing destroys that part of the midbrain that is necessary to coordinate movements. That person is unable to do any fine motor skills like writing and will have a tremor for the rest of their life. 3,4-methylenedioxy-methamphetamine (MDMA) or “ecstasy” is a synthetic drug that alters mood and perception (awareness of surrounding objects and conditions). It is chemically similar to both stimulants and mild hallucinogens, producing feelings of increased energy, pleasure, emotional warmth, and distorted sensory and time perception. People who use MDMA usually take it as a capsule or tablet, though some swallow it in liquid form or snort the powder. The popular nickname Molly (slang for "molecular") often refers to the supposedly "pure" crystalline powder form of MDMA, usually sold in capsules. However, people who purchase powder or capsules sold as Molly often actually get other drugs such as synthetic “bath salts” instead.MDMA increases the activity of three brain chemicals:Dopamine—causes a surge in euphoria and increased energy/activity and motivation.Norepinephrine—increases heart rate and blood pressure, which are particularly risky for people with heart and other cardiovascular problems.Serotonin—affects mood, appetite, sleep, and other functions. It also triggers hormones that affect sexual arousal and trust. The release of large amounts of serotonin likely causes the?emotional closeness, elevated mood, and empathy felt by MDMA users.Just like most other drugs of abuse, a tolerance develops with repeated use. Higher doses are required to give the same effect. When this drug is used heavily and consistently, it upregulates the dopamine receptor in a similar fashion to its brother “crystal meth” such that the receptor dies and leaves holes in the brain seen on a MRI.Addiction TreatmentIn order for the addict to get into treatment they have to experience repeated unmanageability in their life because of the consequences of being intoxicated. This causes a noxious, unpleasant feeling that outweighs the benefits of using the substance. You cannot treat an addict who does not want to stop their addiction.AbstinenceThe first attempt to stop the addiction is through abstinence. The addict soon finds that just abstinence will cause them to be miserable. Nothing will satisfy the limbic system’s demands for the addictive substance. Besides this, there will be a medical withdrawal syndrome that will occur which makes the addict physically sick and can be life threatening if withdrawing from alcohol, sedatives, or some hypnotics. This withdrawal requires that the addict is medically detoxed in a hospital to prevent a cardiovascular accident or a seizure. Once this is done then the addict will move into a post-acute-withdrawal syndrome (PAWS).A “dry drunk” is an alcoholic who is abstinent but has not found other coping skills and pleasure to replace what the alcohol gave them. This term is used for all addicts that are just abstinent. They are usually miserable, angry, depressed, and anxious. Their misery can be so bad that you may wish that they would just go on and use. Nothing can be right in the dry drunk’s life. The addict is constantly complaining about everything.RecoveryRecovery is a process by which an addict:Recognizes the unmanageability in their life that is caused by their addiction.Is ready to make the changes that will be necessary to find a better way to cope with life.Will follow through with what it will take to make these changes while abstinent from the addictive substance.There are multiple frameworks that can be used to guide an addict to recovery but the most common treatment approach is the 12 Steps presented through the book Alcoholics Anonymous written by Bill W. and Dr. Bob. This treatment evolved out of the understanding that once addicted, the addict is self-centered in order to sustain the daily use of their substance. This along with the limbic system’s demand that the addict use their drug separates the addict from society (except for their using friends). This separation creates an emptiness and a fear of others such that the end result is that the addiction becomes the main relationship in the addict’s life. This separateness is the basis for the fact that addiction is a “spiritual disease” where spirituality is defined as recognizing something greater than just themselves. A concern for others and an understanding that asking for help will connect them with a Power greater than themselves is the core of this energy that will ultimately give recovery from addiction. The first step of the 12 Steps is admitting powerlessness over the ability to just use the addictive substance in moderation. Recognizing that there is something other than themselves and the addiction is the second step of the 12 Steps. This is when the addict begins to see how separate they have become from everyone and everything else in life. The third step is when the addict starts to put into action their new life style. They do not try to deal with life by themselves but in a community of others also dealing with their addiction.Since the limbic system believes it has found the only source to stop all stress and boredom and fear through the addict’s substance, these new coping skills cannot just be learned in one lesson. The changes in life that will be necessary require practice every day through an in-depth process that makes the addict look at their whole life history and how this has affected how they get their needs met as well as who and what they can trust.After learning the basics of the 12 Steps of recovery (which will take 4 to 8 weeks), then the next 10 months involves working these steps with other people in recovery in a sober living environment. There is a structural change in the brain that takes about a year. During this time, the addict will transition back into the world through working or going to school. All of this is a “one day at a time” process.RelapseMany will relapse at least once during the first year of treatment. In the Young Adult Addiction Program at Ridgeview Institute, there is a 43% relapse rate the first year. In light of the PAWS, along with the fact that the addict has not had time to substitute healthy coping responses for the limbic system, relapse is a very real event. This is not a statement that the addict is just not trying hard enough. Because of the high likelihood of relapse, the addict and the family of the addict has to be prepared to respond to a relapse. The addict will respond to a relapse with shame, guilt, and hopelessness. The number one relapse risk factor is the feeling of worthlessness. If the addict feels hopeless and worthless enough then the addict will rationalize staying in the relapse: “Since recovery is hopeless, at least I can feel good by using.” The family will respond with anger and judgment that the addict was not trying hard enough. Obviously, this just makes the addict feel more worthless and helpless to change. The family will need as much education and treatment as the addict so that the family matures in how they are taking care of themselves. After the relapse of using the addictive substance, the issue is not the fact that there has been a relapse but how is the addict going to get out of the relapse. Time is of the essence in that every moment that goes by after a relapse takes the addict deeper back into their active addiction. As soon as the addict can get themselves together and realize that they do not want to return to the original unmanageability they had, they need to call their sponsor, get to a meeting, and tell the secret that they relapsed. Keeping the relapse a secret will only perpetuate the relapse and throws the addict deep into their addiction that could be life threatening. After the addict is safe with others in recovery, then exploring how this relapsed occurred is in order. The addict will realize that the relapse started a long time before the use of the substance. “There are at least a thousand relapses before there is use of the substance.” What this means is that every time the addict acts the same way that they did before they started the process of recovery, this is considered a relapse. Any lie, any time they are in the wrong place (bar) at the wrong time with the wrong people (old using buddies), are all relapses even if they do not use their substance. Whenever they miss a 12 Step meeting or do not work with their sponsor on a regular basis, these are all relapses. Eventually the addict will use their substance if they keep this up.AgeThe approach of the treatment of an addiction has to be based on the age of the addict. There is a big difference in how you would approach an adolescent versus an individual over 65 years old. In the same way, there is a big difference in how you approach a 20-year-old versus a 40-year-old. Even though the addiction may be the same (i.e. Alcoholism), the way the treatment is presented and how it is received can be very different. Some obvious issues have to be recognized.In the adolescent the major issue is that they are in what Ericson calls the “Stage of Separation and Individuation”. This means that the adolescent’s purpose in life is to prove that authority figures are too old and do not know what they are talking about concerning the present and the future. This makes them inherently oppositional and defiant. They require constant structure so they do not act out their frustrations and anger. They also expect to be respected as an individual who does not want to be treated like a child. The other major issue is that there are not very many if any 12 Step groups that are for adolescents. Adolescents grow up and move on every 4 to 5 years which does not support the growth of a 12 Step adolescent group. The newcomers need more senior members to direct them so most adolescent groups end up made mainly of newcomers.The young adults (18 to 26) are legally adults though they are usually developmentally delayed as “professional adolescents”. This is a product of our western, abundant culture. This generation of young adults are self-centered, entitled, well-educated, single, not spiritual, and unemployed. They may have a master’s degree but since they do not have any work experience in anything, they have to live in their parent’s home and are bored out of their minds without a purpose.Adults (27 to 65) have a mortgage, a job, children, a marriage (or two), and though they may have resources, do not have time to stop long enough for treatment because of their obligations. Seniors are dealing with life stage changes such as retirement, loss of purpose, loss of children and parents, and loss of health. They need other seniors in recovery that they will respect to give them direction.Final CommentsAddiction is a medical disease that requires medical treatment. Unfortunately, because of the continued ignorance of the general public, this illness is considered a weakness of character. It has not been too many years since epilepsy was considered an evil spirit that entered someone because they were cursed because of something they had done because they were bad people. Just two generations ago being left handed was something that needed to be corrected as a child. A child was forced to write with their right hand or they were punished. We have continued to progress in our medical understanding of addiction and more of the general population are seeing this as a medical illness. Unfortunately, many health care professionals say that they believe that this is a medical illness but in practice they put the burden on the patient to stop their addiction while not giving the patient adequate resources and direction as to how to do it. The reality of the medical profession is that if the professional has an addiction themselves or has someone who is addicted in their immediate family, then that professional may want to understand this medical disease and have compassion for the addict. If this is not the case, that professional will just be irritated with an addict because of how their addiction adversely affects the ability of the professional to treat the illness that the professional wants to treat. In fact, the majority of medical professionals have no real interest in understanding addiction as a medical illness. This is not just a problem for health care professionals. It is a problem for our society. This greatly affects how addicts are able to get the care that they need. According to “Defining the Addiction Treatment Gap”, a CATG review of the annual National Survey on Drug Use and Health released by the Substance Abuse and Mental Health Services Administration (SAMHSA) and other national data sources, addiction continues to impact every segment of American society.?“Drug use is on the rise in this country and 23.5 million Americans are addicted to alcohol and drugs. That’s approximately one in every 10 Americans over the age of 12 – roughly equal to the entire population of Texas.? But only 11 percent of those with an addiction receive treatment for addiction.”Many insurance companies believe that a 21-year-old heroin addict can detox at home, get on Suboxone, go to some 12 step meetings, and maybe go to an IOP (3 hours, 3 days per week) and they will stay sober. The majority of the time this inadequate approach is a waste of time. This is not enough structure to prevent the limbic system from taking control and the addict will relapse back on heroin on the weekends and eventually be kicked out of the program. Some adults over 30 years old may be able to do this if they have a good support system. The point is that trying to put every addict into one mold of treatment for convenience and economic reasons, is as doomed to failure in the same way as trying to treat every cancer patient with the same approach.Continued education of health care professionals and of our society of how addiction is a medical disease is essential if we are ever to treat this illness. Breaking through the prejudice around this illness will require more than just education. ................
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