Sunday, March 8, 2009

Drug addiction and Alcoholism

The DSMIV (Diagnostic and Statistical Manual of the American Psychiatric Association) the principal psychiatric diagnostic reference in North America, is cross referenced with the International Classification for Disease used elsewhere. This text begins with a generic heading 'substance related disorders' which includes alcohol and all other substances of abuse. The principal division is 'substance abuse' and 'substance dependence' with the latter usually indicating greater severity, the disease being seen as a continuum. This reflects the tendency to group alcoholism and drug addiction under the same umbrella and to treat all alike. This has an appeal in many ways to 'programs' and counteracts the rationalization and denial in individuals in both groups which results in so called 'terminal uniqueness' because of the inherrent selfishness of addiction. Self absorption in this regard is commonly adaptive and defensive for the individual but nonetheless remains fundamentally selfish and self centred in the community sense. The programs of Alcoholics Anonymous and Narcotics Anonymous and indeed all the 12 step programs, because of the divisive nature of the disease and the tendency to isolate and have greatest difficulty with novel and unstructured community situations ,encourage individuals to 'look for the similiarities, not the differences."
This said, there are differences within the groups and in individuals which give rise to some confusion and persist as controversies. This is not new. Medically speaking it is indeed normal for a collection of related conditions to be treated under one heading by specialists in that 'field'. There are significant differences in the various arthritis conditions but they are commonly treated by rheumatologists and there is a lot of similiarity in the diagnosis and treatment of these conditions. In contrast to the psychiatric disorders where there always seems to be alot more personality it seems those with more physically dominant conditions aren't on campaigns to be 'different' and 'special'.
The disease of alcoholism per se is however different from the diseases of drug addiction in certain specific ways. One is genetically. The genetic contribution to alcoholism is more significant and more clearly defined than it is for drug addiction. The addiction to cocaine appears to occur more rapidly and not require any significant family history. Jaenneck early described the deterioration in character associated with long term alcoholism and this general pattern can be seen with the different addictions. However with alcoholism the common deterioration was seen over decades whereas with some drugs this same deterioration can occur in months. On the streets addicts and alcoholics clearly group themselves around those who like 'uppers' and those who like "downers' as opposed to those who liked 'hallucinogens'. Clearly the groups overlap as in Venn diagrams but research will eventually deliniate what it is that creates so called 'drugs of choice' and associated behaviour and possibly explain why over time the groups tend to coalesce. How much of this is a product of brain chemistry, psychology or sociology.
Whereas marijuania which has a profile similiar to alcohol in north america was commonly associated with non violence in the white population, in Africa it is more commonly a drug associated with violence. The origin of the name, Assassins, comes from the hashish using group of killers. Robert Graves showed that mushroom cults were at the basis of ancient European 'berserk' warfare strategy. This would come as great surprise to the normal British Columbian psychedelic mushroom user lethargically face planted in a cow paddy.
In the farming community of Rosedale there was once an older AA meeting which was specific for alcoholics alone, attended by many leading members of society, which refused to discuss "outside issues' such as drugs. This was an 'exclusive' AA meeting and offended mostly younger "newcomers" whose own history had more drug abuse along with alcoholism. Asking a long term sober member of that group what this was about I was told, "We're alcoholics here. We want to talk about our alcoholism and can't relate to alot of the kids with drug addiction. All of us believe in the law and are good citizens when we're sober and we didn't break the law except when we were drunk. But we found alot of the addicts were disrupting our meetings and trying to take them over because they'd never learned the basic community values and their addiction began with breaking the law when they were sober." The stirling examples of recovery at that meeting were remarkable but only the most 'willing' from the start were likely to benefit from the wisdom and success of that group where long term recovery was the norm and the majority of members had rapidly returned to being useful competent and caring members of their greater society, highly regarded and respected throughout the region.
Indeed it was alcoholics and such AA members whose success individually and collectively changed the whole world's attitudes to addiction. In 1935 when AA began it was the societal norm to consider addiction a moral issue and demonstration of lack of character. Freud said alcoholics were untreatable and the general consensus was that addiction in many ways was worse than any other mental illness both for the individuals and for the community. The consequences were jails, institutions or death and the morbidity and mortality of those afflicted with addiction was profoundly greater than normals. Today outside of those countries influenced by the examples of Alcoholics Anonymous this is pretty much the way that addiction is still treated.
Growing up I remember my father working in the north and telling us that alcoholics were some of the best workers that he hired but that he could never pay them before the job was done because they could not be depended on to complete any work once they had enough money to drink with. It was standard advise when I was growing up to avoid friends or marriage to those with family history of alcoholism. The ripple effect of the disease is seen in the organization of Al Anon and Adult Children of Alcoholics. One of the books whose title I unfortunately forget did an historical analysis of the great reversals of history and the alcohol and drug addiction of leaders showing the profound negative consequences of alcoholism historically on society. As a progressive illness alcoholism was commonly associated with a high early success phase and later a decline in decision making. With drugs this is also commonly seen but the reversal can occur much more rapidly.
It was the success of alcoholics in recovery, those anonymous early members of AA, who changed societal attitudes and community beliefs profoundly. The pilots, doctors, judges, mechanics, farmers, parents in recovery demonstrated that they could not only maintain their abstinence and thus stop the progressive disease but further could be trusted in positions of highest responsibility. Their extraordinary performance and high acts of character and selflessness gave rise to alcoholics collectively getting a second and many times more chances at work, marriage and membership in the civilized society of gentleman and gentlewomen. Indeed the famous psychiatrist Rabbi Twerski who has written and worked for decades with alcoholics and addicts, says that he would rather have a recovered alcoholic as his pilot because then he can trust that the individual is sober and safe.
Honesty was seen as the key characteristic necessary for being able to grasp and follow the program of Alcoholics Anonymous. Jaenneck's curve shows that the deterioration of character associated with alcoholism involves increasing society deception and self deception. First there is the minimization of how much is drunk, then the lies to family about where one has been, the excuses, missing work, and increasing self deception about how one is able to 'handle the alcohol". The program of AA states that if one is able to be honest with oneself they can have hope.
Not ironically there is a joke that circulates AA and NA meetings which goes like this: an alcoholic might steal your wallet but an addict will steal your wallet and then help you look for it.
The organization of Narcotics Anonymous was developped along the lines of Alcoholics Anonymous and has had increasing success in helping addicts recover from lives of addiction and become useful contributing sober and clean members of society. Much of it's success has come from the pioneering work and trust and experience gained from the parent organization of Alcoholics Anonymous. Cocaine Anonymous and Marijuania Anonymous have followed these earlier examples. More and more there is overlap between those who attend Alcoholics Anonymous and the other anonymous programs because collectively these addictions are seen in the light of these programs as all being a Spiritual Disease. In this regard, churches collectively cater to sinners and welcome pedophiles and presidents alike.This inclusivity is admirable.
Yet I continue to advocate for the police to accept a recovered addict who for 20 years has been a model citizen who now wants to serve his community as a police officer. He continues to be refused whereas my recovered alcoholic patients are certainly welcome to join the police force after 5 years of abstinence. Collectively addicts in recovery have not as yet convinced society at large in the way alcoholics have, that they can be trusted.
Part of this problem has arisen from the earlier ages of many addicts. Commonly alcoholics especially those in the early years of AA had completed schools, attended churches and held down responsible jobs while caring for families well before their alcoholism caused them increasing social and occupational dysfunction. Occupational functioning is the last to go in addiction because it's what pays for the substances and also assists the denial which says "I'm okay, I can hold down a job." More and more addicts are cycling through their addiction in adolescence and arrive in recovery in their late teens and 20's going on 11 and 13 years old emotionally, having never learned any forms of self control, emotional self soothing, societal expectation and the reasons for community. As one old timer said, "more and more of these addicts are downright feral." The programs are therefore being given the task of literally parenting these people, teaching them right from wrong and helping them understand for the very first time that they have to clothes and feed themselves and that everyone else should not be expected to be their mommy. Further, many of these younger addicts come with a burden of trauma including sexual abuse and physical abuse from the early age lives of crime, drug dealing, violence and prostitution.
Now there's a new trend coming out of the harm reduction traditions which says that "only cocaine" was my problem and since I've stopped cocaine I can handle alcohol and pot and the occasional heroin chaser. Whereas in most AA meetings there are the old timers with 20 to 50 years of sobriety and societal contribution, not uncommonly today there are some meetings of NA where the longest sobriety is 5 years. More commonly too is the idea that I've done my part by being clean and sober and now only have to take care of myself. Hence the essential self absorption remains whereas the program of AA was a 'we' program and 'service' and contribution to the community at large were the best evidence of recovery. Recovery was not solely about not drinking or drugging but rather addressed the overall disease of thinking and behaviour that separated the individual from God and community. The axiom commonly used is that one can 'sober up a horse thief' but then all one has is a much more dangerous and effective 'sober horse thief." The programs of recovery were indeed directed at addressing the character flaws as well as the addiction. Harm reduction programs have often lacked a coherent agreement around issues of community and individual responsibility.
Addicts collectively while riding on the shirt tails of Alcoholics need to recognise that they themselves must now demonstrate to society at large that they too can be honest responsible citizens who will benefit society. The previous 'honour system' that worked for alcoholics is increasingly in the job situations being replaced by urine drug testing because of the issues of dishonesty which persist today in the addiction population in general.
To this end alcoholics whose drug of choice was alcohol are encouraged to attend AA even if they used other substances but as members of Alcoholics Anonymous identify as alcoholics. One individual amusingly states, I drank alcohol, I smoked alcohol, I snorted alcohol and if there had been an alcohol to inject when I was drinking alcohol I'd probably have injected alcohol as well." This was the understanding of the original alcoholics when they accepted their first addict and recognised that AA would work for addiction as well. However, those who do not consider alcohol their drug of choice are advised to attend Narcotics Anonymous because the old timers there are perhaps firmer and have a better understanding of addiction specifically. Generally speaking it's okay for individuals to straddle programs and this works where the individuals have sufficient sobriety and clean time and socialization to be respectful of the group they are in and recognise that they are there to learn rather than teach the group.
This said, there are significant medical and psychiatric differences within the overall disease of addiction. The lessons learned from tobacco addiction and gambling addiction can indeed help us to understand alcoholism and vice versa much in the way the study of the DNA of fruit flies has helped eludicidate the human genome. There are more similiarities within the group than differences but the field is increasingly developping to a state where more individualization of therapy can be expected. The once universal 28 day prescription for in patient treatment is now being modified on an individual basis. This was first done sadly based on the insurance and bank accounts of individuals with those having more money getting more treatment whether or not it was beneficial. Increasingly though there's a new trend to looking at what is specifically needed for each individual and developing programs specific to those needs while at the same time keeping the overall notion of recovery in tact.
A recent joke regarding this trend to claiming recovery from one drug at a time went, "I've been recovered from heroin for several months now but I'm still doing cocaine. I was recovered in Texas from cocaine and got my AA one year medallion there because I was only drinking in Mexico. I never had a problem with pot so I'm still doing that and I think now that I've quit heroin completely I can probably have a social drink." Probably the old timers were right about the need for honesty. In many cases today it's the NA program where a fellow addict in recovery can better assess honesty and help multiply addicted people with their Steps. Interestingly though some of the old time low bottom alcoholics described different alcohols causing similiar effects to different drugs today ie 'scotch made me racy and wanting to fight', 'tequilla made me hallucinate', 'gin made me mello'. One wonders if the psychosocial factors associated with 'context of use' and 'expectation' are not as relevant as the factors of neurochemistry. Increasingly MRI's and PET scans are adding to our understanding of the contributions of different disciplines to our understanding of the whole.
Dr. Nady el Guebaly former president of the International Society of Addiction Medicine and foremost researcher today in gambling addiction has begun to establish occupational standards to assist physicians in saying when and what jobs a recovered person can be trusted with. International Doctors in Alcoholics Anonymous has however demonstrated that the Addicted doctors there can be as successful in their recovery as the purely alcoholic doctors. In that population the use of drug testing in the first 3 to 5 years of recovery appeared to assist the alcoholics and addicts and the the community collectively.
In time it is likely that the examples established by the original AA members will spread throughout the recovery programs as a whole and individuals will consider and care that their own recovery affects how others will be treated who follow them. This altruism which was so much a part of the original alcoholics anonymous program is likely then to replace the essential narcissism which dominates addiction itself but is not a part of the recovery process originally envisioned by the founders. With that in mind I'm hopeful that in time enough addicts will demonstrate their value to society that I can get the police to accept a recovered addict as easily as I now see them accepting recovered alcoholics. I believe it's the same disease essentially but the devil still remains in the details.

1 comment:

Blogking said...

Alcoholism is the new death wish…..thats all I have to say. we need to offer a hand to those in need of help. Help by helping others, not by ignoring the pain…