Saturday, May 26, 2012

Progressive Nature of Alcoholism and Addiction

In meetings of Alcoholics Anonymous people who relapse describe their descent into the abyss of addiction by saying "when I was in the rooms of AA, my disease was in the parking lot doing push ups."  Returning to the struggle with alcohol they went from the plan of 'drinking like a gentleman" or 'drinking like a lady" to the all consuming animalistic life of serving the god of the bottle.
Millions of people come to AA but don't stay, simply using the success of AA to initiate their recovery in some other form.  AA showed the world in the 1930's that Alcoholism and Addiction could be 'cured' through abstinence and 'one drunk helping another'.  The 'self help movement of 12 step programs with the essential spirituality of a 'god of your understanding' ie no longer making yourself and your own desire God but rather joining group and community for a consensus reality, has served countless others with compulsions of wide variety. The recognition was the Aristotelian idea that one couldn't 'think themselves into new action but rather needed to act themselves into new thinking".  The cognitive behavioural therapy of the 12 step program as opposed to the 12 step fellowship showed individuals through action that their belief in the benefits of alcohol were cognitive distortions induced by the insaniety of addiction.
Untreated alcoholism progressed to institutions or death.  Once a person passed a certain point the so called up elevator or down elevator place, the future was either a slow or fast descent depending on how one 'controlled' the drinking, all paths downward being at best 'harm reduction' .  The only cure to date in chemical addictions remains the abstinence which causes so many addicts to say "I don't like AA because......."  Those who themselves achieve abstinence by any means see the value of AA and don't disparage it. Those who don't achieve abstinence will likely condemn all programs which come between them and their drug of choice with the passion which most recognise when we say, "the lady protesteth too much."
A tenet of AA is that once an alcoholic, always an alcoholic.  This is certainly evidenced by scienttfic research which to date has not be able to identify those who won't relapse to previous levels and worse.  Vaillant's research showed that relative to the general population, an alcoholic 5 years sober was 'statistically' no greater risk of drinking dangerously than a person who never drank. This is important in the work place but on an individual basis no one sober knows if he or she could pick up a drink "safely".  A Montreal study of 'controlled drinking' showed that despite 5 years of abstinence of those who returned to drinking 50% within the year drank alcoholically.  I believe it was a Dutch study that showed that 30% of those 15 years abstinent returned to drinking alcoholically.
The research suggests that there is a decreasing risk after 3 years of abstinence of people returning to their previous behaviour but that the risk of this even at 15 years sobriety is that a third risk death or institutions for the sake of a drink.  The World Health Organization designates only 'abstinence' as a cure and requires all other programs be called 'harm reduction".  Further it recommends that 'harm reduction' programs only be used in the context of a stepping stone towards abstinence not as an 'end in themselves' .
This suggests that the insaniety itself persists.  People with simple 'allergies' don't decide I'll try taking something that once caused a horrible rash, again.  Yet people who broke out in police and divorces seem to somehow figure 15 years of good living later that picking up alcohol is again a good thing.
The progressive nature of alcoholism has been the principle reason for people explaining that with relapse a person returns to previous level of abuse much more quickly than the first time. People who drank 'normally' for 20 years then drank abusively for 2 abstain only to relapse and find themselves drinking abusively either immediately or a year or so later.
Personally I remember smoking an occasional pipe or cigar for 10 years before becoming a pack a day cigarette smoker for a year.  Quitting somking on 2 separate occasions with the intent of just having a weekend smoke or at most one or two a day I was back to smoking a pack a day within six months.  Quitting again then I found the next time at six months in the week before I quit I was smoking 2 packs a day, a truly exponential increase. It's almost 15 years since my last smoke and still I occasionally 'romanticize' an 'occasional' cigarette.
Functional MRI studies of gamblers have shown that the addiction is not driven by reward associated with the 'win' but rather by the 'dice' being in the air 'just before the 'decision' of 'win or lose'.  The 'thrill' for the brain is that moment of uncertainty.  Psychoanalytically the addict has been seen as having failure in primary relationships and seeking to re enact that 'moment of abandonment'. Melanie Klein described this as the 'good breast, bad breast' moment for the infant.  The infant wants food and the 'good breast' is the one that delivers it. The 'bad breast' is the breast that doesn't appear 'on time'. The longer the delay in a child having basic needs met, ie the period of neglect, the greater the division between the good breast and bad breast.'  This explains to some extent those who are at greater risk for addiction though to date no one appears to be immune to addiction. As one cocaine researcher said "some of us might not sell our grandmother's for crack in the first week of addiction but all of us would after a few years." Addiction itself causes reversible or permanent brain injury with increasingly loss of the more human motivational structures seen in Maslow's research with the devolution over time to the 'animal' and finally 'lizard' brain of the McLean triune brain model.
All research to date on persons who develop alcoholism or addiction shows them as being inherrently 'immature' psychologically especaily around the issue of  'gratification'.  Despite this the head of the Supreme Court of Canada's alcoholism was a serious concern for the high court only decades past.  No doubt some of the early work of Beverly McLaughlin, present supreme court head of Canada was undoing that 'wreckage of the past'.
The more 'instant' a substance has for providing 'gratification' the greater the risk of addiction. This is shown in the 'addictive' potential of crack which smoked or injected has greater addictive potential than coke which is 'snorted'.  The addictive potential of injected and inhaled substance is greater than that which is ingested. This is one of the distinctions which separate the marihaua or cannibis addict from those who want cannibis for 'medicinal' purposes. The addict must smoke the cannibis whereas the healing benefits of cannibis are equal and more medicinal if taken as a tea.  Those wanting it for medicinal purposes, a highly significant minority, despite the eupheminism of "medical marijuana' the precurser of 'medical prostitution', are therefore not those who insist it only 'works' for them if it is 'smoked'.
Following on this progressive disease of addiction it's been said that the sex addict who has made a life of orgies,   doesn't truly thereafter, want to hold just hands with a nun.
The brain of the addict is demonstrably changed on a whole range of neurochemical measures. Dopamine pathways associated with the nucleus accumbens, the pleasure centre of the brain, are changed and the change persists.  Frontal lobe utilization of sugars, the food of the brain, is altered on MRI studies for 3 months after the last use of cocaine.  Marijuana remains detectable and active in the system for 6 weeks and possibly 3 months.  Alcohol influence on the liver is detectable days and weeks later.  The minimum true test of abstinence and once a diagnostic test of addiction was the abstinence from a substance or behaviour for 4 seasons or one year.  If a person couldn't stop gambling despite negative consequences, or drinking despite dui's, this was pathognomic of inherrent addiction.  Marijuana smokers who say they can go a days or weeks without a 'toke' are akin to alcoholics or  who say they can go a few hours without a drink.
There is permanent organ damage with addiction as well.  Women are much more susceptible to the physical deterioration of addiction which is a kind of poisoning of the system physically and obviously spiritually.  Spirituality is likened to Freud's 'eros' or life drive as opposed to his 'thanatos' or death wish.  The dice in the air or really 'playing with death' seen in the 'adrenaline junkie' and 'compulsive risk taker'.
The definition of addiction is that it is unhealthy and hastens risk of death whereas a behaviour such as AA attendance, normal work or church or sports or any recreation moderately followed is by definition not an 'addiction'.  The term addiction is used for 'unhealthy' substances and endeavours.
The other factor which obviously plays a role in the apparent progressive nature of alocoholism is the aging of the host.  A person will drink to a steady state they may maintain at a younger age but this drinking behaviour is 'hard' on the 'body'.  When a person abstains or takes a break it's a bit like an athlete who leaves and returns to the sport.  The alcoholic now has an older liver, older lungs, and older brain.  Addiction is a burden at the best of times.  A common time for 'relapse' is with early retirement when one has means, loss of life  structure and there's just so much golf one can play. These executives who stopped drinking often 20 years earlier begin to drink excessively in their late 60's. Alcoholism is a principal cause then for the heart disease and illness and death seen specifically in this population.  It's not so much that the 'disease' is 'stronger' it's that the 'host' is older.
The neurochemical explanation for the apparent 'progressive' nature of the disease and the high risk of return to previous level then worse for addiction is that the addiction has established an information 'highway' in the brain.  Not using the highway results in the development of other 'tracks' for neurochemical communication. However the 'highway' remains and can quickly be brought back into use. Much like we say about learning to 'ride a bicycle' .  Once one 'learns to be a drunk or addict' it's like 'riding a bicycle', the learning is always there to return to and build on.
Further if the 'thrill' or 'adrenaline rush' is of the 'dice in the air' then the death wish of addiction is to go further than one's worst last drunk.  So if a person crashed a motorcycle drunk at 70 mph  and lived maybe this time one's unconscious wish would be to 'crash a motorcycle drunker at 80 mph" and see if one lives..
Certainly that's the picture that the sex addicts give in their simply 'pleasure' driven experience so well described in  the snuff movie 9mm starring Nicholas Cage.   Only increasing risk and degradation gives the same 'high' so more and more of a thing is sought in the ancient adage of heroin addiction when one is forever 'chasing the tail of the dragon.'
Thankfully abstinence resolves this issue if the alcoholic or addict can 'surrender' to the notion that this is not their 'war' and there are countless alternatives in life worthy of such intense endeavour.  Addicts and alcoholics not surprisingly when they change their focus from death resulting activities to life enhancing ones commonly go on to great contribution and amazing success and altruism.
 It's well recognised  today that one doesn't need to take the elevator to very bottom of society but rather can get off any at any basement floor.   That then can  become one's'personal bottom' and  the basis for the springboard into a life that has been called for may 'the 4th dimension'.  Peace, bliss,  joy, happiness,  love and meaning  are  far different from the frenzied withdrawal and driven  pleasure lust of addiction.

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