12.2 Safer Drug Use: What is Addiction?

[00:00:00] In this episode, Dr. Love and I talk about what addiction is. We talk about some historical experiments in addiction, including an experiment revolving around something called rat park, as well as retro-spective reviews of Vietnam war veterans' addictions to heroin

[00:00:19] and how they change from being in a wartime environment to being back home in the United States. As with most things on this podcast, we try to appreciate the nuance about the quote unquote cause of addiction and illuminate the fact that it is not just a biological

[00:00:35] and not just an environmental basis, which leads to a discussion of why addiction is so much worse in the United States related to massive availability or societal obsession with an instant fix as well as other foreign entities targeting the United States, including the fact that

[00:00:56] almost all of the produced fentanyl, at least historically came from China as well as most if not all of the heroin and fentanyl traffic across the border comes from Mexico and is run

[00:01:11] by the major Mexican cartels. We discuss how the lack of nuance and appreciation for the differences amongst drugs created a governmental monolithic outlook on drugs that something like marijuana is equally as dangerous as something like methamphetamine or heroin or fentanyl.

[00:01:34] This quote unquote war on drugs not only insinuated that every drug was equal in its detrimental effects, but really turned into a war on drug users and did not appreciate or provide support for

[00:01:50] the reasons why people use drugs. Lastly, Steven and I talk about the academic war within addiction between the AA or alcoholics anonymous, now narcotics anonymous, etc. entity as well as the medication assisted treatment entity and again, emphasize the fact that medication assisted

[00:02:14] treatment especially something like buprenorphine or suboxone is a very important tool in the fight against addiction. We outline the need for diversified drug addiction treatments, emphasizing the need to meet people where they're at and also the importance of helping persons facilitate increased

[00:02:35] human connection when possible because the impact of a supportive 30 day treatment environment and then going right back to the same oftentimes unsupportive environment afterwards may not be very helpful in the long term. I do want to apologize for any sort of terminology that may be offensive.

[00:03:00] I try my best not to refer to people as addicts because again, I know it's just semantics. I know it's just words and some people who struggle with addiction and drug use refer to themselves as addicts but it can be very stigmatizing in that it lacks appreciation for

[00:03:21] the entirety of that person. They are not just in addict. There are a lot more complex factors that go into who they are and give context to why they have struggled with addiction.

[00:03:35] There's absolutely no offense meant by any terminology and Dr. Love and I have an absolute passion for working with this population and understand the importance of it but I did think it was

[00:03:49] important to point that out in advance of listening to our discussion. Hope you enjoy and thanks for listening. Somebody get this guy some help! So in 1978 Bruce Alexander designed a novel type of experiment around addiction prior to that most experiments and animals on addiction

[00:04:21] would put the animal in this case a rat into an isolated environment and give them options of opiate water versus regular water and many of the rats would drink the opiate water until

[00:04:37] they essentially died. And this was a prevailing theory that led to the war on drugs that it drugs are available people will become addicted to them and let us to criminalize both drug use behavior as well as any in every drug being placed on the same toxicity level

[00:04:59] not having nuance and appreciation of the danger profile of each different drug. So what Bruce Alexander did was he wanted to show that the community around the individual or the rat in this

[00:05:14] case was also very important. He designed a very similar experiment where the rats were able to choose between opiate water and regular water but they were amongst a lot of other rats in an environment

[00:05:30] that was not isolated that had activities male and female rats mixed together and he found in his experiments the rats did not become addicted when they had alternatives socially of other things to do.

[00:05:45] In a world with a choice between neutral and euphoria you're going to choose you for it. I mean it's just water versus opiate water these rats are low in the cage right? Yeah so there's nothing else for the rats to do except either drink regular water or drink

[00:06:02] heroin water. The rat park experiments showed that rats that were pre-addicted to opiate water were less likely to continue to drink the opiate water when they were thrown into a non-isolative environment with a community of rats aka a park with activities and social interactions

[00:06:25] taking some creeds away from the idea that some people are just going to be addicted no matter what. Now when there are another study by Godbore Matai, he studied Vietnam War veterans right?

[00:06:42] I don't know if he's actually the one who did that study but I believe in his book and the realm of hungry ghosts about addiction it might be one of those other ones. He basically

[00:06:50] just said the heroin issue and the Vietnam vets was sort of a real world rat park experiments in humans. So the rate of heroin use in addiction while soldiers were overseas in combat environment

[00:07:09] was insanely high and then the proportion of people who remained addicted when they came back to the USA addicted I mean continuing to use the drug at their health expense and engaging in addictive behaviors when they came back to the states it was no longer an issue for 90

[00:07:28] percent of them. Yeah they were like 20 times more likely to use in Vietnam than they weren't home. So up to 20% of American troops used heroin regularly during their tours in Vietnam

[00:07:42] and the concern was that they were going to bring that addiction problem back to the states but by the time they came back home the vast majority of soldiers stop using heroin so when they were out of

[00:07:55] dangerous environments with all the stress and chaos of combat and they were back home in their desired social milieu and had other things to engage in and when not actively about to die all the time rates plummeted. So the quote unquote isolated environment in this case is Vietnam

[00:08:12] in the fact that they are isolated from their families, from their communities etc etc and insanely stressful environments which that can be literal and concrete combat it can also just be stressful internal. I think both of those studies there's so many potential flaws that I could think

[00:08:31] of how available was heroin to them when they came home heroin is widely available now but I know it wasn't as available in the 70s so we've obviously seen a resurgence in opioid use in general

[00:08:43] in the states but it did peak back then too. It was pretty widely available. It kind of went by the wayside relative to how it was in the 60s and 70s in the 80s and 90s and that has come back

[00:08:55] but I do believe that it was way more widely available too. A lot of people were bringing it back too so I mean it was available but I think just the larger broad strokes impression is that

[00:09:07] should the environment is going to lead to more addictive behaviors and rampage of use. It would be really interesting to know of the veterans that came back and continued to use heroin both the availability of that heroin to them at home but also their sense of community or

[00:09:26] their environment at home if they were in a co-bore that did not have a very healthier supportive family or friends or community. Yeah there's a lot of questions that obviously I answered by just a real-world observational data collection study. I think it's just hard to break it down

[00:09:46] and say that there's one cause of addiction or one thing that pushes people to become addicted or to remain addicted we've talked about availability of something is very important for the potential for addiction adverse childhood experiences carry a higher risk of addiction and

[00:10:03] addicted behaviors obviously any sort of stress like being in a wartime environment we know that genetics play role and that some people are predisposed to be addicted but I think it launches into a bigger discussion of the fact that there are both genetic and environmental causes of addiction

[00:10:25] and just stigmatizing the user as we did with the war on drugs and criminalizing that behavior obviously has not led us to winning quote unquote the war on drugs. Yeah I also just

[00:10:42] holy misses the point it's a punitive system and it's driven people further and further away from their communities probably given them less incentive or less drive to combat the addiction because then they're back in a shitty situation and what else do they have with those moments of

[00:11:02] positive experience with drugs. Bruce Alexander actually said about a decade ago that he doesn't actually think that genetics play any role in addiction. It's an interesting take I don't know I mean you look at something like bipolar illness bipolar illness is so strongly

[00:11:20] comorbid with alcohol use disorder and there's reasons for that right like self medication all that but in the same families where bipolar illness runs alcoholism runs and I believe that there are family members that do not have bipolar illness that also just have their baseline predisposition to

[00:11:39] becoming alcoholic is way higher than it is in general population. But then again is that a genetic predisposition sort of a scapeysome is that genetic predisposition to getting a certain response when one drinks alcohol something along lines of somebody who will eventually become an addict. There were

[00:11:56] how they feel when they have their first beer versus how somebody who will not go on to become an addict feels when they have their first beer the degree of euphoria that they felt when they first

[00:12:06] got intoxicated and then how far down below their baseline they fell and then the new baseline that they established people who have a biological predisposition to addiction they have higher highs with drugs of abuse or alcohol and lower lows in the aftermath and that it ultimately

[00:12:26] ulcers their baseline almost after the first use whereas people who do not have genetic predisposition you know they get you for it with the substance and they come down afterwards but then they go back

[00:12:37] to their regular baseline. The point being that the people who did have a biological predisposition were more likely to end up chasing their tail based off of their subjective experience than the people who did not have a biological predisposition with all that being said I don't know if

[00:12:53] that was a legitimate study but I do think they were counting on subjective experiences of first time use to try to track out and then retroactively looked at like that these people have addiction

[00:13:06] that runs in the family that they not have addiction that runs in the family and seeing if there was a correlation. The common sense point that if your dad is an alcoholic then you're much more

[00:13:15] likely to have alcohol in the home, right it's much more likely to be normalized to be drinking on a Tuesday night what percent of addiction is genetic versus environmental. That's a complicated

[00:13:27] question because I don't know if I believe in that dichotomy in the same way that it might sound I'm a pluralist and I think we're misguided in our field and everybody is too eager to take monolithic takes on certain aspects of the field. The people who believe that

[00:13:44] addiction is a biological disease, the people who think addiction is purely environmental purely behavioral like the truth for this one is almost certainly somewhere in the middle with some subtypes that are biological and some subtypes that are purely environmental and

[00:14:00] the genetic component I think is probably so layered and related to personality traits more so than like a quote unquote predisposition to addiction in addictive behavior. So I probably would err on the side of saying that if you're in a sufficiently shitty environment and have a sufficiently

[00:14:21] shitty childhood and drugs are around then you're going to have bad time. Why are drug use and overdose fatalities so much higher in the United States compared to worldwide? I think we have a fractured society maybe more so than other places. So think we have high availability of

[00:14:43] lot of things right America is the entertainment capital of the world probably by some metrics the drug capital of the world to or at least the markets. So things are way more available

[00:14:54] I believe in least certain parts of America than they are and lots of other parts of the world. But I also think it is a reflection of some aspect of our culture and our society which

[00:15:06] is dislocated and in some places lacking sufficient community and we want it and we want it now whatever it is that we want we want it now the American mindset. I think American exceptionalism

[00:15:22] also that misguided mindset that we're better than other people I think that same thing applies to certain aspects of our drug culture. It's interesting I was listening to a psychologist on a podcast talking about parenting actually and talking about how and I noticed immediately when they made this

[00:15:42] common I was like oh yeah I do that and that was my experience growing up when we experience a negative mood state or a negative event in life especially with young children get they fall down

[00:15:56] start crying there is this immediate urge to correct or change the behavior. Hey you're okay you're okay you're fine as opposed to just allowing them to experience the negative event without feeling a need to correct it that idea translates also into why we have such a hard

[00:16:18] time with drugs we feel bad because let's face it like fucking sucks sometimes there's really hard things that come with being a human and if we are programmed to internally say I've got

[00:16:34] to get away from this negative state as opposed to say now right now right now. I live in the world of convenience stores you've reeds in fast food we want the same thing to happen to our

[00:16:45] opposed to saying let me sit back and think wow I dealt with some difficult things today and I should feel bad for a period of time I should process this and then I can move beyond it

[00:16:57] there is this rapid desire to escape negative emotions therapy helps you to process things and tendencies that you have so that you can not learn to avoid negative states but learn to be more

[00:17:12] resilient to negative states and by association learn to continue to progress or move your life towards the things that matter to you. In the slow and steady manner as opposed to an injectable

[00:17:27] manner so almost all of the fentanyl comes from China it used to come from a father and son manufacturer in China the Chinese government eventually cracked down on allowing them to export

[00:17:40] fentanyl so they just went to a precursor of fentanyl so now the flow and this is according to the DEA the flow of fentanyl goes from China primarily to Mexico and then into the United States

[00:17:58] from Mexico and there are feedbacks with the cartels in Chinese banks but you don't see the same rates of addiction in Mexico you don't see the same rates of addiction in other South American countries

[00:18:14] that may be a product of economics and the financial ability to purchase drugs but we outnumber every other countries foreign military bases we have a presence everywhere across the world

[00:18:30] we are if you will the alphas in terms of our military which spends way more money than anybody else has way larger availability of planes and tanks and equipment in the event that there was a war

[00:18:48] we also have way more guns than any other country in the world so I think there's also an anti-America stance that contributes you think they're targeting us with drugs yes that

[00:19:04] is that yes ultimately what I'm trying to get is I think there is a degree of the United States being targeted we buy him yeah we buy him but other places have the capability of buying drugs

[00:19:18] I mean I'd get it it's not one issue but I think it is a factor like fuck them we'll give them that exactly we know that the fentanyl comes from China and doesn't make a whole lot of inherent sense from a drug dealer perspective to kill your

[00:19:34] users but I don't know I think that the military industrial is a complex plays a role that's interesting take I was wondering about the data collection validity of other places having significantly lower its addiction we monitor everything or at least we do it better than

[00:19:51] other people we don't do as good as the scant nadeans and them but I don't know how closely they track cocaine addiction in Bolivia our relationship with drugs is more binary it is more

[00:20:04] all or nothing you read or abstinence or using heavily type of things that seems to be the cultural consensus perception at least whereas there are certain parts of the world where

[00:20:14] more people are more casual users but American mindset of go big and go home you just struck a I've always thought about the way that our society and our government approaches drugs as having

[00:20:27] the same ideas about every drug right a drug is a drug there's not any nuance there but from the consumers perspective if that is a message that is being driven into your brain into your mind then

[00:20:42] yes you may start with marijuana but a drug is a drug so why wouldn't I if I'm already being stigmatized for my marijuana use then why wouldn't I go ahead and use cocaine and then why wouldn't

[00:20:58] I go ahead and use a X or heroin or you think that mindset the mindset that describes gateway drugs is probably more susceptible to it than maybe another thing is just because there's not a lot

[00:21:12] of nuance and I'm thinking about it it's obviously a multi-factorial issue I think those are factors I think the way that we've always provided treatment for addiction in this country which

[00:21:23] were not primarily was to throw people in jail and demonize them for what they've done I think that's a big factor but definitely marketing in America led us to be susceptible to desire

[00:21:38] things that we can purchase that make us feel good and also drugs are cool right like in the entertainment industry and movies and all that and since we are the I don't know for actually

[00:21:48] like the culture capital of the world but we think we are we do export a lot of films and music there's other places that rival us for sure but we do a lot of that and but this is the home of it

[00:21:59] right yeah we do sensationalize drugs quite a bit you're right in movies and TV and considering media constantly we are just always bombarded with advertising yeah but that probably does play real

[00:22:14] we were in medical school at least it seemed to be a hard divide between the AA based recovery community which was more abstinence based and the MAT or medication assisted treatment community which was more suboxone methadone biologically based you had this problem we're going

[00:22:37] to treat it with this medicine and you're going to be able to stay off your addiction but you're going to have to take this medicine forever because there's something biologically or fundamentally wrong

[00:22:48] with you I don't think everybody approaches MAT that way no I'm trying to draw the extremes though and on one end you've got the potential for well I mean let's be real a lot of profit right if I tell

[00:23:02] you that you have to take suboxone in safe lives yeah absolutely absolutely but I think we're trying to guide towards a more unified or combinatorial approach where we can use these lifesaving treatments like suboxone which by the way binds so strongly to the opiate receptor that even when

[00:23:24] the person uses something like fentanyl if they're not using large amounts of it that fentanyl isn't doing anything they're not getting a high but more importantly they're not running the risk of dying from respiratory depression or not breathing when they have that suboxone in their system so

[00:23:44] yes buprenorphine is an opiate it does give people a certain quote unquote high but it's nothing like the hide that they would get from an opiate like oxycodone or heroin or fentanyl and therefore

[00:23:59] it's not nearly as rewarding and the benefit is that it prevents them from overdosing there definitely has to be a nuanced approach the flip side of that the more extreme aayers would say well you're

[00:24:13] replacing one addiction with another and there is some credence to that but if you're addicted to eating and you replace an addiction to McDonald's with addiction to apples and bananas one of them

[00:24:28] is going to be a hell of a lot healthier and yeah you can eat too many apples and bananas hit fruits to where you're causing problems for yourself but you're not going to cause the same types of

[00:24:37] problems that you would buy eating big max a 10 piece McDonald's every day a parallel just for the sake of the point you're always replacing it with something else in some cases this methadone

[00:24:47] or suboxone and in some cases it's going to meetings in some cases it's exercise there's more nuance to it than that it's not just like everybody's addicted just got to find something else to be addicted to

[00:24:58] but there's some truth to it and on the relative scale of what is preferable to be quote unquote addicted to there are things better for your health than methadone and fentanyl there's a misguided side to both of these arguments i think we're all familiar with recovery programs

[00:25:18] that try to get people onto MAT which is a very important first step don't get me wrong but then basically keep people hostage on MAT saying that they're never comfortable taking them off of it

[00:25:32] and for that facility that means that they see that person once a month forever and they continue to build their patient population and so they make a lot of profit off of it but also to tell an

[00:25:44] addict that is freshly in the throws of heroin or fentanyl withdrawal the only way for them to truly get sober is to not use any opiate at all well then you could absolutely be killing people with

[00:25:59] that advice i was working at one of the local psychiatric hospitals and gotten to an argument with one of the AIDS who was in recovery in an AA-based recovery program and she had been sober for a

[00:26:13] couple of years from methamphetamine heroin prior to that was employed was doing really well but she was on this side of you're not actually sober if you're on suboxone i proceeded to watch her

[00:26:28] take at least 15 smoke breaks during the day i watched her down several cups of coffee several mountain dudes in Coca-Cola and I'm sitting there thinking well why is this not addiction but suboxone is addiction you forgot the best the most appealing thing she engaged into her which

[00:26:51] is the thrill of moral judgment on better than this person because i am not on a replacement opioid if you want to make that argument like you're just replacing one addiction with another like sure

[00:27:06] fine but through live right we can now we can deal with the rest of it right now we can talk about do we want to take her into the one to stay on it for a while how are you feeling in

[00:27:16] these other voids in your life how can we get you to more completely engaged with your recovery program whether it's a a cbt based act based or whatever it is infuriating to hear some of the

[00:27:29] culture aspects of the 12 step groups be categorically against mait in the same vein it's infuriating to hear people be categorically against 12 step groups because of the notion of the Christian God being central to it or the fact that they don't allow empirical data it works for the

[00:27:46] people it works for just mait works for a lot of the people it works for yeah why don't we offer all sides of the treatment we know that people need community we know that people need

[00:27:57] meaning in life and yes some people need a replacement to me if they need to be on that forever and they make that decision that I would rather be on this medicine that I take every morning

[00:28:12] or every night as opposed to using a drug when I'm having a bad time or when I'm bored then that is absolutely a suitable option they should also have the option to

[00:28:25] wean off of it to replace it with something like the vitral once they're weaned off of it the vitral is a now trick zone it's available in a once a month injection it can throw an opiate user into immediate withdrawal because it is a total opiate blocker

[00:28:42] it's a great tool that we have an addiction that is likely underutilized because you take it for a few months and then when you feel comfortable in in your recovery and your desire to stay away from illicit drugs then at some point you can stop taking it

[00:28:59] when I love to have nuance in psychiatry anymore yes to opinions and you have to know what they are and they can't ever be broken it sounds tried different strokes for different folks like some

[00:29:09] people they are 12 steppers and that is what works for them and that is what they need other people need different things we should not take categorical approaches to these things when we're dealing with this from a public health perspective abroad perspective if it seems like we are

[00:29:25] airing on the side of everybody should be on MAT forever right now it's probably because we previously aired on the side of MAT is the devil hopefully we get better empirical data to support

[00:29:39] the timeframe after which the risk of relapse plum its if you're on methadone for this period time and you engage in this type of therapy keep bringing at this point is much safer than

[00:29:51] tapering at this earlier point if we ask those questions more clearly we could probably get a little bit more empirical guidance in this but for now paying attention to the individual is always the best approach unfortunately I don't think it's just this evil profit driven MAT side

[00:30:07] that once people be on MAT forever there is also a medical legal component to that yes because if you're a had be heroine user and I take you off of suboxone then all the sudden you have

[00:30:21] some bad outcome there's the threat of being sued especially because I do technically think that the data right now says that long-term treatment is what leads to the best outcomes but that's also

[00:30:31] how long we've been studying suboxone this extensively I don't know the answer but I do think that's where the data points are medically yeah for sure you're not covered as well as you might be

[00:30:41] if you support somebody tapering off in a hub from a theoretical standpoint it seems like having a community focused addiction treatment will have better outcomes higher rates of remission if you can help people find a community find meaning in their life outside of the temporary

[00:31:06] meaning that they may get from illicit drug use maybe this is splitting here as maybe this is what you meant but I think there's a difference between a community focused recovery center and finding

[00:31:18] community in one's own world in one's own environment community focus recovery center you know that could be some 12 step program where you go stay for 30 days and there's a crew there versus like facilitating human connection in an increasingly disconnected society like the one that we live in

[00:31:41] because you get somebody better because of their community connections and their stay not a farm out in the bunnies and everything's hunky dory and then they go back to their disjointed world in the city and then all of a sudden that's kind of lost so

[00:31:57] that's where my argument for larger societal changes to help counteract the things that lead people to seek out drugs in the first place is warranted from what I've seen in friends and acquaintances

[00:32:10] from high school and college who got addicted to opiates and went into treatment the ones who remained local and did the 30-day structured addiction program it was very difficult for them to find sobriety going right back to the same environment but others that have been very successful in

[00:32:32] their recovery had to get out of the environment completely maybe come back to the environment years later but certainly not 30 days later people places and things. Somebody get this guy some help. Thanks for listening for more social media content check us out

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