#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.

#11 Neurotransmitters

A neuron (nerve cell) is an electrically excitable cell that processes and transmits information through electrical and chemical signals. Neurotransmitters are the brain chemicals that communicate information throughout our brain and body by relaying signals between neurons. The brain uses neurotransmitters to tell your heart to beat, your lungs to breathe and your stomach to digest.  Most importantly for our consideration, they affect mood. They are the parts of the central nervous system most affected by psychoactive drugs and other addictive behaviors like gambling, pornography, binge eating etc. Addiction triggers and magnifies the sensations or feelings that have a natural counterpart (neurotransmitters) in the body.

Dopamine is often known as the reward neurotransmitter as it triggers feelings of pleasure. If something feels good, dopamine is involved. All psychoactive drugs increase the levels of dopamine which is experienced initially as mood elevation and euphoria. Dopamine also helps regulate fine motor muscular activity and blocks pain. For example, it is exciting to win a race but with a stimulant drug like methamphetamine it would be ecstatic or 8 times as pleasurable.  In the early times of the Civil War, drinking alcohol was the only anesthetic for amputations and other painful surgeries. When someone ingests too much alcohol their muscular movements are affected by the flood of dopamine. The neo-cortex and sound judgement gets hijacked and numbed. (see Post #10, Addiction and the Brain)

Norepinephrine and Epinephrine (adrenaline) are strongly associated with bringing our nervous systems into "high alert." They increase our heart rate and our blood pressure. Our adrenal glands naturally release them into the blood stream. Stimulants like methamphetamine trigger these two neurotransmitters as well as dopamine. With large doses of meth, addicts can become so "over alert" they hallucinate visually and hear noises that don't exist. They can exhibit classic symptoms of paranoia. Rapid movements and nonsensical speech are also symptoms. All the basic instincts that reside in the primitive brain are exaggerated (particularly aggression and the sexual drive).

Endorphin is short for endogenous morphine. It is structurally very similar to the opioids (opium, morphine, heroin, oxycontin, codeine, percodan etc.) and works by attaching to the endorphin receptor sites. It creates pain reduction as well as pleasure. Endorphins are produced by the pituitary gland and the hypothalamus which are part of the neo-cortex as opposed to the other potential addictive neurotransmitters being part of the primitive brain. (see Post #10, Addiction and the Brain). This is one reason why it is so difficult to diagnose opiate addiction, as there is little loss of motor control as there is with dopamine (staggering, slurred speech and impaired vision etc.) An exception would be an overdose of opiates characterized by nodding off. Dilation of the pupils is about the only visible symptom, and often opiate abusers wear sun glasses as their visual perceptions appear so bright. 

Serotonin is an inhibitory neurotransmitter that is intimately involved with emotion and mood. Depletion of serotonin is related to depression, problems with anger control, and obsessive-compulsive disorders. Hallucinogens such as LSD, mescaline, psilocybin and ecstasy attach to serotonin receptor sites and block transmissions in perceptual pathways distorting perception of reality. 

Anandamide is has an affinity for receptor sites that accommodate THC (Tetrahydrocannabinol) the main ingredient in marijuana. It is found in the limbic system of the primitive brain and the areas responsible for integration of sensory experiences with emotions.  Long term studies continue to show that marijuana can become addictive and long term use affects learning, motor coordination, and memory.

In summary, drugs and other addictive behaviors imitate the brain's natural chemical messengers and over stimulate the reward circuit of the brain. With our understandable concerns about addiction the rates of addiction must be put in perspective. Addiction takes considerable time to develop. 1% of first-time users of inhalants and tranquilizers were addicted a year later. For hallucinogens and sedatives the figure was 2%, pain relievers and alcohol 3%, powder cocaine 4%, uppers 5%, marijuana 6%, crack cocaine 9%  and the most addictive was heroin at 13%. The greatest predictor of addiction is the age of first use.

Addicts are searching for a means of dealing with psychosocial stress associated with developmental psychological stress and social dislocation. (See blog # 7, Dislocation) The addict is drawn to a culture which promises to complete these unfinished tasks and this influences their drug of choice. Opiate users are drawn to themes of nurturing and support. Stimulant users are drawn to themes of autonomy. Hallucinogen users are drawn to themes of inclusion and belonging. Alcohol users are drawn to themes of will and power. The cultures of technology are sufficiently broad as to offer the psychological rewards of all the cultures of substance abuse combined. Ross Laird.com

My next post will explore the role of willpower in addiction.

#10 Addiction & the Brain

The brain is a 3 pound mass of interwoven nerve cells and one of the most magnificent and mysterious wonders of creation. It is the supervisory center of the nervous system serving as the site of thought, emotions, memory, and self-awareness. By means of electrochemical impulses, the brain controls our conscious, voluntary behavior and the autonomic nervous system through its feedback circuitry regulating the physiological functions of the body. The blood-brain barrier provides protection against toxins, bacteria, and other pathogens, but all psychoactive drugs are able to pass through.

The advent of eleven different brain measuring scans allow neuroscientists to explore the structure and workings of the living brain. There are a variety of ways to describe the different parts and functions of the brain. In the interests of simplicity in understanding addiction, we will use the terms "primitive" and "neo-cortex." The primitive brain controls the autonomic system but also equips the experiencing of our basic instinctive emotions such as fear, hunger, anger, pleasure and lust. The neo-cortex processes information from the primitive brain as well as conscious voluntary behavior, cognition, and memory. It tries to make sense of the feelings and instinctive drives coming from the primitive brain. Imagine someone craving a drink of water which originates in the primitive brain. In response, the neo-cortex will organize a way to get it. 

The primitive brain is located at the base of the skull including the brain stem and is much smaller than the neo-cortex. One might reason because of the major difference in size, the neo-cortex would be in control. This is not the case. During stress we try to resist impulses to resort to instinctive or primitive behavior often characterized by the flight/fight syndrome. A balanced life requires healthy interaction  between these two parts of the brain. 

The role of the nucleus accumbens, generally described as the pleasure / reward center, is our last consideration of the primitive brain and is key to understanding the impact of alcohol and other drugs on the whole brain. Although it has traditionally been studied for its role in drug addiction, it plays an equal role in processing many other rewards such as food, sex, gambling, and other compulsive behaviors which are now recognized as  addictions. (See current definition of addiction in Post #1)

Neurotransmitters are chemicals in the central nervous system that transmit messages between nerve cells. Over a hundred of them help regulate the body’s natural stimulants, painkillers, mood stabilizers, muscle relaxants, arousal, sleep, aggression, and all other functions of the central nervous system. Drugs increase or block the release of these naturally occurring neurotransmitters. 

Alcohol and other drugs create sensations or effects that have a natural counterpart in the nervous system. They trick and over stimulate the release of the body’s natural chemicals, which then “flood” and "hijack" the central nervous system. Drugs don’t get one intoxicated; they trigger the release of a surplus of the body’s own chemicals at levels which are intoxicating. 

With this background, in my next post we will begin to explore drugs of choice and what part of the brain they take hostage.