Lessons from Philip Seymour Hoffman

Is it that some of the most talented among us are drawn to opiates, or that we only hear about the famous, admired figures?  Before Philip Seymour Hoffman, who was certainly among my handful of favorite actors, there were others like Health Ledger, Chris Farley, River Phoenix, and Jim Morrison (to turn back time further), and Robert Pastorelli (whom we remember best as “Eldin,” Murphy Brown’s painter who never quite finished the job).

According to the Center for Disease Control, the rates of fatal opiate overdose have more than tripled in the past 2 and a half decades.  Of course, the incidence of death reflects an increase in the number of individuals using these substances.  As I’ve seen in clinical settings during that time, initial exposure to painkillers like Oxycodone (Percocet) or Hydrocodone (Vicodin) too often leads quickly to addiction, characterized by powerful cravings and painful withdrawal symptoms relieved by repeated use.  People who thought they were just following a surgeon’s orders or having fun with drugs in college or neighborhood settings fail to recognize their addictions until they become severe.  Many proceed from pills to heroin, which is much less costly though also more likely to cause overdose (because of unpredictable variations in purity).

If you are concerned about your drug use or that of someone you care about, there are a number of treatment approaches that can help in the very difficult path to sustained recovery.  The process starts with a clinical overview, either with someone in private practice like myself or at an appropriate clinic.  Not every clinician knows much about addictions, which does not prevent them from saying that they do.  Look for either experience working in an alcohol/drug-focused setting or a certification (CADAC or CAS) or alcohol/drug counseling license (in Massachusetts, called LADC).  

If only we had reason to hope that Philip Hoffman’s tragic death would be a turning point for our society, just as the death of Len Bias in 1986 seemed to puncture the myth that anyone was immune to the dangers of cocaine.

Is Procrastination Addictive?

Well, let’s not go quite that far – we are probably already applying the term “addiction” to too many phenomena that really are not equivalent. But, in my view, there is an important aspect of procrastination that overlaps with addictive behaviors.

A key type of procrastination involves a chronic pattern of avoidance at the moment when it is “time to get something done.” The individual says to him- or hersself (as I myself have done countless times), “I’m too [tired, drained, sick, etc] to do this right now. Instead, I’ll [take a nap, watch TV, play a video game, etc] and I’ll do this task at a later time.”

The three central elements here are (1) anxiety [something about this project that gets you nervous], (2) rationalization [as described above] (3) avoidance [the decision to walk away from the assignment].

More than one of my recovering patients has told me that the moment of rationalization when avoiding a task feels very similar to the moment of rationalization (e.g., “This time will be different,” or “I deserve this”) preceding the decision to drink or drug.

These behaviors happen repeatedly (and typically with increasing frequency) because they are highly reinforcing. It is well known in the field of behavioral psychology that immediate reward is much more reinforcing than delayed reward. In this case, in the split-second when the individual decides “I’ll skip this for now,” there is an immediate reduction in anxiety, just as with the first drink, even though the result is likely to be an increase in later stress (just as drinking tends to generate more negative consequences that must be faced later).

That is part of what makes the temptation to avoid so potent. What, then, is to be done? There are too many aspects of the situation to address here, but some key components of working one’s way out of severe procrastination and facing overwhelming tasks are: (1) breaking big projects down, by stages, into smaller and smaller pieces, so small that they are manageable even when one is very anxious; (2) doing one piece at a time; (3) self-rewarding each accomplishment (e.g., making that nap or video game conditional on completing the small task).

Needed: More Sober Settings for the Non-Wealthy

Even for those with health insurance (made possible for more people, though certainly not all, by RomneyCare and hopefully to be enhanced by ObamaCare), when it comes to substantial help for the newly sober, available help is quite limited. 

Health insurance will usually cover something like weekly sessions with someone like myself. But more many, that’s not much more than a drop in the bucket.  Covered inpatient services generally consist of a few nights in detox (just until observable withdrawal symptoms have diminished).  After that, one may be able to access an “intensive outpatient program” (IOP, often 3 or 4 evening groups a week) and, if they have “flunked” IOP recently maybe 2 weeks in a Partial Hospital (Day) program.  Generally speaking, residential options are self-pay, and the options for low to moderate income people are very limited and typically unappealing.  For well-maintained and staffed residential sobriety programs, expect to pay multiple thousands per month.  These are, of course, usually profit making enterprises.  (For less money, there are so-called sober houses, which often are little more than rooming houses.) 

Yet for many, it will be very hard to sustain recovery without a structured sober environment, where they can get more consistent support and avoid the plethora of stimuli that are powerfully conditioned to alcohol or drug use.  Obviously, neither premium payers nor tax payers will feel inclined to foot the bill to subsidize such resources for all who need them.  But the fact is that people who are able to stay sober won’t be committing alcohol/drug related crimes, injuring themselves or others, showing up in emergency rooms (or destroying their organs and generating more medical costs), etc. – my guess is that this is a net savings,  but we tend not to see the big picture.

Thank goodness that at least there are self/mutual help groups like AA and SMART Recovery, driven not by profit but by actual humanistic motives, that to some extent can fill in the gaping holes in funded/covered care to those struggling to overcome addictions.

Bigger than Molly

News of recent deaths linked to the use of “Molly” (a variant of ecstasy)  has generated increased attention to the use and dangers of so-called “club drugs,” frequently used by young adults in music/dance club settings.  The use of these substances has accelerated in prevalence in the past several years.  Deaths may result largely from dehydration and also, importantly, from adulteration with unknown and potentially lethal compounds. 

A 2012 study of university students found that 12.5% had at least tried club drugs at some point in their lives.  But about 20% had used opiate painkillers (such as Oxycontin), representing a much greater danger of serious, life-shattering addiction (and potential overdose).  Not surprisingly, about 25% had at some point taken stimulant pills (ADHD medicine, widely misused by college and graduate students) and 58% had used marijuana.  But another study found (again, to no one’s surprise) that 88% of college students had consumed alcohol in the previous year. 

Alcohol and prescription drugs (when prescribed) are legal, but they destroy many more lives than club drugs or even methamphetamines.  Alcohol, while used safely by most drinkers, has the potential to harm almost every bodily system, and kills people regularly via overdose, impulsive/dangerous and often violent behavior, intoxicated driving, etc.  So yes, we worry about “Molly” and her friends at the club, but some greater dangers lurk closer to home.

Suboxone -- A Tool for Persistent Opiate Addiction, Useful but Imperfect

As always, let me begin by reiterating that I am a clinical psychologist and not a medical doctor, biochemist, or active scientist/researcher; most of my perspectives are derived from 30+ years meeting with actual patients. 

Both heroin and painkillers (like Oxycontin, Percocet, Dilaudid, Vicodin, etc) are opiates or opioids (the 2^nd term coined to include drugs synthesized rather than derived directly from the poppy plant).  All of these drugs are highly addictive, though they are also powerful agents in reducing pain.  Along with pain reduction, especially when used in larger dosages than necessary, many people experience a kind of euphoria and cushion from the world’s slings and arrows that keeps them coming back for more.  Some physicians perhaps don’t worry enough about the addiction risk when prescribing pain medications.  (Lighter pain meds like Tylenol and ibuprofen are not in this category.)  It is often extremely difficult for people who have become addicted to opiates (some of them originally interested only in pain relief when they began), and the rate of relapse is very high. 

In light of that problem, the notion of a kind of controlled addiction came along years ago in the form of methadone, and in recent years in the form of Suboxone (in which the main ingredient is buprenorphine).  Most individuals I have run across strongly prefer Suboxone, which is administered by prescription in the offices of specially certified physicians, rather than at methadone clinics, which are environments that I’ve never heard described in favorable terms.  The idea is that the Suboxone, which is an opioid, quells cravings for opiates while producing little or no “high,” so a person is in a reasonable frame of mind to go about his or her work and family life.  The whole concept of this kind of controlled addiction falls under the broader category known as Harm Reduction, essentially meaning, “if we can’t get the most desirable outcome, in this case total abstinence, let’s settle for an achievable level of improvement.”   

Since I generally favor whatever helps and doesn’t hurt, I have found Suboxone to be a useful tool.  (I am not a prescriber, but a number of people who have seen me for “talk therapy” have also been on Suboxone.)  I have seen it truly help stabilize their lives of people who are motivated to sustain stable lives which, if not free of drugs, are at least free of drug abuse.  There are also some real problems with Suboxone, and this is far from a complete list: 

(1)  Many individuals find it difficult to ultimately taper and discontinue Suboxone without relapsing.  One hears increasingly of recommendations to remain on Suboxone perpetually.  That may still be the best option for many people, but perhaps not what they had in mind.

(2)  Part of the reason for (1) may possibly be that people are relying on Suboxone as their sole treatment and, in particular, not connecting with sober support networks such as 12-step or other supportive networks and life environments.

(3)  There are way too few certified Suboxone prescribers (under 3% of physicians), and the number of patients that each can treat at a time is limited by law.  As a result, it can be very difficult to find a provider when you’re seeking one, and you can anticipate being placed on a waiting list.  But not if you’re wealthy (see #4).

(4)  For a number of physicians who might be viewed as either entrepreneurial or exploitive, Suboxone provision is a gold mine.  They can decide that each (relatively brief) visit costs hundreds of dollars, and to require self-payment rather than use of health insurance.  (The medication itself may still be covered by insurance.)  If you can afford these kinds of fees, you can get Suboxone in very short order.  Of course, this is only one of many, many examples of the fact that the wealthy get greater access to care (and housing, and lawyers, etc.)  But it can be particularly frustrating to the addict who has reached a threshold of motivation to get off drugs and can’t get a kind of service that might help a lot.

New Insights on Old Observations about Addiction

I have yet another media link to recommend. Charlie Rose, on his PBS program, has commenced a second series designed to provide new insights on the brain and its connection to human experience, and the first installment provides a great overview, led by neuropsychiatrist and Nobel laureate Eric Kandel. The panelists are Gerald Fischbach (neurology), Thomas Insel (of NIMH, on psychiatric disorders), and – most relevantly to this blog – Nora Volkow, director of the National Institute on Drug Abuse. With her unmistakable accent (the outgrowth of growing up in a Russian family while living in Mexico), she is a remarkably articulate explainer of addiction from a neurobiological standpoint.

What often strikes me is that new brain-based descriptions of how addictions develop and operate often dovetail with old observations. Those of us who have been working with alcoholics/addicts for a long time have tended to develop conclusions based on our collected observations. Now, we have some possible ways to understand the neurobiological mechanisms that may underlie these observations. For example:

[Observation] Even people who express a sincere wish to abstain from substances, or who think they should be able to exert enough “willpower,” usually find that they return to the kind of behavior that they have sworn off. [Neurobio Explanation] The process of developing an addiction includes developing a linkage between drug- or alcohol-related stimuli and a drive toward addictive behavior, co-opting the same reward circuit that drives us toward doing things we need to survive (such as eating and procreating). In addition, the repeated intrusion of drugs into our brains injures the prefrontal cortex, the part of our brains that helps us exert appropriate caution before acting.

At first, individuals enjoy getting high when they choose to use alcohol or addictive drugs. For those who become addicted or alcoholic, however, substance use has the primary function not of feeling good so much as feeling normal or OK. Neural reward circuits “light up” in real-time brain scans of non-addicts when they use the substance, but those who have developed addictions show little or no change. This fact, however, does not extinguish their urge to use, which is now driven by other factors.

With rare exceptions, addicts/alcoholics do not “rewind” and return to an earlier, more normal pattern of use. A purely learning/unlearning model does not seem to apply. Although learning and memory clearly play a role in the development of addiction, changes in brain circuits persist. Even in the absence of active substance use, the disorder is typically chronic.

A 30-day rehab alone is rarely successful if not followed by frequent and consistent follow-up, in some combination of support groups, professional contacts, and safer living environments. Brain changes resulting from months or years of addictive drug use endure for months or years; short-term treatment is far short of what’s necessary to reverse or compensate for those changes.

Addiction and Neuroscience

One of the treasures of radio (nowadays expanded to include podcasts), even within the wonderful world of NPR, is Terry Gross’ daily Fresh Air program. To my mind, she’s the best interviewer in broadcasting. I recently listened to a podcast of her June 23 interview with Dr. David Linden, professor of neuroscience at Johns Hopkins University School of Medicine, and author of The Compass of Pleasure. He does a nice of job pulling together the exploding body of scientific research that reconfirms that addiction is a largely genetic and neurobiological condition rather than simply a matter of choice and self-control, as some opponents to the so-called “disease model” have argued for years.

There has been evidence for decades, from a large number of studies of identical twins, adoptees, etc., that addictions (most studies focusing on alcoholism) are largely genetic. (Dr. Linden quotes a figure of 40%; almost all the recent research references I have found say 50%.) Thus, a number of people, usually with genetic family histories of alcoholism/addiction, appear to be born with a predisposition to addiction. However, environment (including stress level), personality, and learning also play large roles. People who do have this predisposition but who barely use alcohol or drugs will still not become addicted to these substances. On the other hand, people without these genes (and there seem to be many genes involved, not just one) will have a lower chance of developing addictions despite heavy exposure to substance use.

Even the process of learning to drink or drug in progressively greater amounts, and increasing frequency, is heavily influenced by biology, which, for example, determines how good or relieving it feels to use a given drug and how much of the substance is needed to get an effect.

What is kind of exciting is how many of the characteristics of addictive behavior that we have observed for generations are now understood to be paralleled by neurobiological processes that can, at this point, be identified rather than merely inferred.

Anyone who took an introductory psychology course heard about both Operant (or Instrumental) and Classical (or Pavlovian) Conditioning, both of which are hugely important in the development of addictions. In operant conditioning, when a particular action of an animal (such as yourself) is followed repeatedly by a reinforcement/reward, the individual is likely to engage in more of that behavior. In classical conditioning, when a particular stimulus (e.g., a pub; white powder) becomes associated with a response (e.g., drinking, drug use), exposure to the first tends to trigger the body to prepare for the second (e.g., craving).

What neuroscientists have clarified is that underlying these behavioral experiences are chain reactions in the brain’s reward system (located in the medial forebrain and involving structures you may have heard of, such as the ventral tegmental area and nucleus accumbens, as well as chemicals, neurotransmitters, especially one called dopamine that is increased in reaction to addictive drugs). This reward system evolved because it promoted the survival of our species; it is turned on by food, water, sex, and also by exercise, altruism, and the experience of learning – all essential and all pleasurable to most humans. (And Linden notes that non-substance related behaviors, such as eating and sex, can also become addictive for predisposed individuals.)

One kind of genetic predisposition, according to Linden, is that people born with a “blunted pleasure circuit” are driven to put more energy into risk, and seeking pleasure and novelty. Clinicians have noticed for years that some people seem unusually drawn to seek excitement/sensation and that they are more prone toward substance abuse – now we have a way to understand why that may be.

As Linden also notes, the heavy and repetitive substance use of addicts seems to actually change the cellular structure of their brains, in a way that tends to be irreversible. Over time, the addictive behavior actually comes to have less to do with pleasure/reward than with simply feeling OK and functioning adequately. He calls this a transformation from “liking” to “wanting.” I think “wanting” is too weak a word, and that in the addict’s experience it is closer to “needing.”

None of this is to say that addicts are without any level of choice or responsibility. Obviously, the only way anyone moves in the direction of recovery is by acknowledging and taking responsibility for his or her addiction, and making choices, developing new behaviors, etc., in an effort to get around these established but ultimately self-defeating patterns. But let’s recognize that when we advise people to give up addictive behavior, we are typically asking them to take on a herculean task, to use their intelligence and consciousness to override what has become their natural mode of brain functioning. That’s why so often they need strong support, frequent reminders and motivators, etc. And, since changed brains don’t revert to their pre-addictive structure, it is for good reason that the term “recovering” has replaced the term “recovered.”