#15 Genetics

Genes are part of our DNA and are needed to give instructions for how to make and operate all parts and functions of our bodies. It is estimated there are over 40,000 different genes, and about one half of these affect the human brain. The knowledge that living things inherit traits has been used all through history to improve crops and domestic animals through selective breeding.

With the advent of genetic testing, this science exploded in the early 70's and researchers began to profess that genes determined our destiny. This began to raise many ethical questions. For example there were fears were that if someone's genetic code revealed a predisposition to a disease, an insurance company with this information would refuse medical coverage. The conventional view was that  since DNA carries all our inheritable information, nothing an individual could do in their lifetime could change what was inherited.

Family, twin and adoption studies have shown that alcoholism does have a genetic component. Scientist's initially looked for a particular gene to explain addiction, but now we know that multi-genes are involved.

Although genetics plays a large role in the appearance and behavior of all living things, it is the combination of genetics with the life experiences of an organism that determines the ultimate outcome. For example, while genes play a role in determining an organism's physical size, the nutrition and overall health it experiences after inception also has a large effect. 

This means that every person's life experiences re-design and affect the genes we inherited. We know now the reality of our inherited genetic makeup is not deterministic, but more likely demonstrates predisposition. About one half of addiction has some roots in a genetic predisposition. This doesn't mean that addiction is already determined for someone who inherited these genes and one is destined to be an addict. But they are more at risk. It does mean someone with the probability of inheriting these genes must use caution and be vigilant as they evaluate their use of mind altering chemicals.

One of the most exciting recent developments in understanding our brain and its relationship to behavior is something known as epigenetics. It is the study of changes in gene activity that do not involve alterations to the genetic code, and still get passed down to at least one successive generation. But they tell your genes to switch on or off, to speak loudly or whisper although thery do not alter them in any way.The effects can be good or bad depending on many factors:

          POSITIVELY: diet and nutrition (essential minerals and vitamins),

          meditation, exercise (running particularly) and enhancing our

          sense of belonging and identity in cultural - social - spiritual spaces

          (Posts #4, #5, #6).

  NEGATIVELY: smoking and other addictions, trauma,
  starvation, toxic chemical exposure, and dislocation (Post #7).

This means that the impact of our genetic predispositions can be modified or even shut down with healthy and balanced lifestyles.

This has all kinds of implications in recovery and helping prevent relapse. For example it has recently been shown that those that quit smoking at the same time they quit their drug of choice have a better chance of getting and staying clean and sober. Historically it was maintained that quitting one addiction at a time was stressful enough. In early recovery most recovering addicts report doubling the amount they smoked while using.

On a positive note, seeking a balanced and healthy lifestyle in addition to abstinence enhances a life of sobriety and the pursuit of emotional sobriety for those in recovery.

In my next post we will discuss children with addicted parents.

#14 Harm Reduction

It is necessary to have read last week's Post #13 Stages of Addiction and Homelessness to put my views about Harm Reduction in context. I think it is a valuable strategy to help those in 4th stage addiction. They are without homes, living lives of oblivion and not really caring if they live or die. They don't seem to have the moments of clarity we commonly call a bottom. I was initially resistant to Harm Reduction until being exposed to the levels of addiction in Vancouver's DTES and the inability to help with traditional methods.

Harm Reduction aims to meet substance abusers “where they are at” as opposed to immediately imposing abstinence. It helps prevent unnecessary hospitalizations due to preventable infections and diseases. It is trying to keep people alive and healthy while working to engage them in treatment for their addiction. It is doing things for the addict they are unable to do for themselves which is different than enabling. Criticism of harm reduction typically centers on concerns that tolerating risky or illegal behavior sends a  message to the community that these behaviors are acceptable. Again, I am recommending Harm Reduction strategies only for 4th stage addiction.

To be effective Harm Reduction needs to be part of a "Four Pillars" approach which includes Prevention, Treatment, and Enforcement (Protection over Prosecution). Decriminalization for using drugs and limiting prosecution to drug related crimes (including manufacturing and sales) would drastically lower prison populations where sadly there are few treatment programs. There are many who abuse drugs but do not break other laws. The National Institute of Health estimates that only 9% of alcoholics end up in prison or homeless.

The Housing First model is simple: provide housing first, and then combine housing with supportive services in the areas of mental and physical health, substance abuse treatment, education, and employment. Housing is provided in apartments scattered throughout a community. This "scattered site" model fosters a sense of home and self-determination, and it helps speed the reintegration of clients into the community. 

Providing housing and support services for homeless addicts costs less than leaving them on the street, where taxpayer money goes towards police, shelter and emergency health care. Residents are required to pay about 30% of their income including welfare towards rental. Housing First restores dignity and offers space and encouragement for change to take place. Imagine the addict thinking, "why should I go through treatment when I have no place to live but the street and its drug culture when I leave!"

Research in major cities shows lifting the ban on alcohol use in homeless projects lowered consumption 40%. The Pennsylvania Hotel experiment in Vancouver provides 8 ounces of alcohol per day which keeps residents from going into the Delirium Tremens of withdrawal and the associated risks of drinking Illicit alcohol (any alcohol not bought in a liquor store like rubbing alcohol, mouthwash, hand cleaner etc). Last year their research showed a 62% decrease in the consumption of alcohol.

What is encouraging, is that many 4th stage addicts who participate in these Harm Reduction programs go into remission to 3rd stage addiction where moments of clarity are possible and opens the possibility of recovery. With the Housing First initiatives, they become part of a social - cultural  community necessary for recovery (blogs #5 and #6: Proxemics).

Probably the most controversial Harm Reduction approach in Vancouver's DTES is InSite, the only legal supervised injection site in North America. It provides a safe and health-focused location for drug injection. The clinic does not supply any drugs but registered nurses supervise the injection and are prepared to handle any emergencies. In1996 there were 2,100 cases of HIV reported in the DTES. After the formation of InSite, in 2006 there were only 30 new cases of HIV. There have been 2,492 clinical medical treatment interventions, and 6,242 referrals to other social and health facilities (mostly for detox and addiction treatment). Of the referrals, 40% began treatment and it has been shown that InSite users are 2X as likely to engage in treatment than non-Insite IV users. 

In 2009 484 overdoses occurred with no fatalities, due to intervention by the medical staff.  There is also a government sponsored Detox center called OnSite upstairs. Of 411 admissions last year, 55% completed detoxification which is a remarkable statistic.

Much resistance to InSite has come from the evangelical church. This was addressed in a lecture last year by Dr John Stackhouse and Nurse Meera Bai from Regent College Seminary in Vancouver. I think understanding addiction in 4 stages and restricting Harm Reduction to the 4th stage would lower resistance from the evangelical community. 

Methadone clinics were started in the 60's primarily to address the crime rate associated with the heroin epidemic. It did reduce the crime rate however the federal government did not follow up with recovery programs that were supposed be included. Without integration with other harm reduction programs I feel methadone clinics mostly fail 4th stage addicts. Methadone is harder to withdraw from than heroin. Many 4th stage addicts take their oral methadone daily at clinics or pharmacies to prevent opiate withdrawal, but then pursue other drugs including alcohol through the day. 

Methadone is currently being prescribed as a common pain killer for its benefits as a pain killer and its low cost. For many, this adds to the current opiate addiction epidemic when not regulated closely. In its pill form it can be powdered and injected making it valuable on the street. The cost of today's China White heroin (very pure) today is cheaper on the streets than scripts of methadone and heroin becomes attractive with prescription addicts.

What has been helpful and encouraging is the advent of Suboxone in pill form for opiate addiction. It stops the horrible withdrawal as an agonist and if opiates are taken they have no effect as Suboxone blocks the receptors as an antagonist. It requires monthly involvement with a specially licensed physician, and the good ones insist the person be involved in some type of recovery. The treatment ideally is limited from 3-6 months as the Suboxone dosage is gradually titrated.

My next blog will explore the role of genetics in addiction.

#13 Stages of Addiction and Homelessness

It is important to put my following comments in context. The number one cause of homelessness today is poverty, and more social services aren't needed, it's about needing  jobs!  Vancouver's 12 block DTES area is an exception -- most are addicted or have mental health issues. It has the highest concentration of IV users in North America.

My compassion for the homeless in Vancouver's DTES was initially stirred reading In the Realm of Hungry Ghosts: Close Encounters with Addiction by Gabor Mate. My previous experience with the homeless was limited to occasional visits to shelters. I did know some folks in AA who had been homeless for brief times and now had functional lives, but few long timers at the missions really showed any interest in AA or what churches had to offer. 

As a counselor I was effective with those who had been abused as I had been helped so much in my own treatment and therapy. I knew many of the long term homeless were horribly psycho-socially-spiritually damaged. They rarely recovered and I didn't understand why. Traditional thinking was they haven't reached a bottom but when someone has almost died a number of times, lost everything, and only staying alive due to shelters, I was puzzled what would a bottom look like?
 

The following diagram by Ric Matthews (Executive Minister of New Way Community) helped  to clarify my understanding of homelessness. 

The first circle outside MAINSTREAM are the MARGINALIZED, or those not fitting in due to addiction and mental health issues. Even though poverty is the number one cause of homelessness but I often question which came first...poverty or addiction? Society attempts to repair or contain these folks in institutions (recovery groups, church, treatment, hospitals and prisons). Those we can't seem to help, slip out to the next circle or the HOMELESS. One of the errors we make is expecting them to be rational but addiction and mental illness are not rational conditions. The most damaged often don't fit the barriers of many shelters and become PREMATURE DEATHS from drug overdosing, related medical conditions and inclement weather. 

Generally addiction in seen in four stages: Experimentation, Misuse, Abuse, and Dependency. My problem is by these criteria, my diagnosis when practicing my addiction was the same as the homeless in DTES. For a number of reasons, I wasn't as damaged and had so many more opportunities in life compared to so many who are homeless. With help I was able to recover and be restored to the MAINSTREAM at the center of the diagram without slipping into homelessness.

So many I meet and spend time with in Vancouver's DTES have not responded to traditional treatment and other assistance. I think first of all we need to rethink how we discuss and understand stages of addiction. 

It is multi causal but addiction can be seen as a brain disease. Other diseases are seen in four stages. The fourth stage is so critical in cancer that patients are told it has metastasized to other regions of the body and is rarely considered curable. Patients with fourth stage heart disease, cirrhosis, and kidney disease must have transplants to live.

To understand the marginalized homeless I am proposing understanding addiction in four stages. 

     Stage 1: Initial  

                      Motivation is pleasure...

                       “They Abuse and Live”

    Stage 2: Chronic

                      Motivation is relief...

                     "They Live to Abuse”

    Stage 3: Acute

                      Motivation is maintenance...

                      “They Abuse to Live”

    Stage 4: Terminal

                       Motivation is escape to oblivion...

                       “They Abuse and Die”

Stage 4 addicts do not seem to have moments of clarity or respond to a bottom. They are not currently criminal enough to end up in prison or considered mentally ill enough to end up in psychiatric care. So what would be involved for them to recover? 

My next post will focus on the Harm Reduction controversy and its impact in the context of Stage 4 addiction.

#12 Willpower

The role of willpower is probably the most controversial issue in discussions of addiction, its roots, and recovery. Initially some views seem contradictory. On one hand are those that see addiction as merely another disease and feel the individual is no more responsible than having  any other disease. On the other hand are those who talk about free will and choice, and that addiction is simply a choice.The discussion often polarizes into "either or" options. I would like to suggest that another option might follow a "both and" discussion as there are contradictions in both schools of thought.

Some diseases do involve choice. For example heart disease and cancer can be influenced by smoking or diet. On the other hand there is no choice involved in diseases like cystic fibrosis, muscular dystrophy or babies born addicted. Addiction is progressive and in its advanced stages it becomes impossible to recover by the unaided will. I meet folks who are so damaged by life and addiction that even after losing everything and almost dying a number of times from overdosing, they still continue to use.

I have also heard the discussion that addicts lack willpower or they would straighten up. The reality is that generally addicts have more than an abundance of willpower. In early addiction this can be evidenced by drinking all night and still showing up at work the next day. Addicts generally attempt to exercise control in all their relationships. However as the addiction progresses (part of the disease concept) the will becomes hijacked by what the chemicals are doing in the brain. (posts #10 and #11).

Post #3 discussed the "Spirituality of Addiction." Dallas Willard writing in the Journal of Spiritual Formation and Soul Care adds: The spirit is the will of the heart, which, lives mainly in our bodies. One of the ironies of spiritual formation is that every "spiritual" discipline involves bodily behavior. We have to involve the body  because that is where we live and what we live from. Spiritual formation is formation of the "inner" dimensions of the human being, resulting in transformation of the whole person, including the body in its social context.

Will operates in the physical body as well as the spirit in this sense of will being part of heart, spirit, character and choice. Addiction is a condition that originates initially in the pleasure / pain location of the primitive brain. Pleasure and avoidance of pain is experienced in the body leading eventually to craving. Progressively, individual will and choice are surrendered and overpowered by the addiction.

Dallas Willard discusses the issue of will in three categories: The impulsive, reflective and embodied.

·       Impulsive: This exercise of will generally originates in the instinctive part of the primitive brain and moves towards things that are attractive or trigger curiosity. It generates exploration but requires little forethought (which originates in the neo-cortex). For example we safe guard electric sockets knowing that small children impulsively stick a fork or their fingers in them. In adults it is simply choosing what is desired without using reason (eg. impulse buying).

·       Reflective: Experiencing either negative or positive experience from an impulsive act, we reflect on the consequences or rewards of an impulsive act and evaluate if the activity is in our best interests before acting on it.

·       Embodied: Desires have enslaved the will and

     bypass reflection or moments of clarity as now

     their body is running their life in terms of desire

     and the pursuit of pleasure.     

For some, impulsively experimenting with addictive substances leads to addiction characterized by the absence of reflection or moments of clarity about their use of addictive substances or behaviors.

I think another error in our thinking can be generalizing the role of will in addiction and not understanding that the role of will is distinctive in different stages of addiction. These stages will be discussed in the next blog.