The Thirteenth Step

Addiction in the Age of Brain Science

Markus Heilig

• Publisher: Columbia University Press
• Year: 2015
• ISBN:
  9780231539029
• Topic: Medizin
• Subtopic: Psychiatrie & geistige Gesundheit

The past thirty years have witnessed a revolution in the science of addiction, yet we still rely on outdated methods of treatment. Expensive new programs for managing addiction are also flourishing, but since they are not based in science, they offer little benefit to people who cannot afford to lose money or faith in their recovery.

Clarifying the cutting-edge science of addiction for both practitioners and general readers, The Thirteenth Step pairs stories of real patients with explanations of key concepts relating to their illness. A police chief who disappears on the job illustrates the process through which a drug can trigger the brain circuits mediating relapse. One person's effort to find a burrito shack in a foreign city illuminates the reward prediction error signaled by the brain chemical dopamine. With these examples and more, this volume paints a vivid, readable portrait of drug seeking, escalation, and other aspects of addiction and suggests science-based treatments that promise to improve troubling relapse rates. Merging science and human experience, The Thirteenth Step offers compassionate, valuable answers to anyone who hopes for a better handle on a confounding disease.

1

US AND THEM

AS THE NURSE on the floor picked up the chart to read the transfer note, she thought there must have been a mix-up. She sighed. It was a Friday afternoon, and, like her colleagues, she was getting ready to get off her shift and go home. She was a good nurse, one of many in the underappreciated army who keep hospitals going by juggling a job and family. On any other day, she did not mind unexpected work. In fact she enjoyed it, thriving on getting things right, offering comfort to patients, and keeping physicians in line. After fifteen years in the profession, much of it had become routine. For the most part that was a good thing, relieving her of the anxieties of the early years and allowing her to spend more time with patients, the most gratifying part of the job. But this once she was not really into it. She had expected to reclaim some hard-earned comp time and for once leave early so she could get to the grocery store before it was invaded by hordes of other suburbanites. Instead here it was: a last-minute transfer from the medical floor in anticipation of a busy weekend.

In the rush, something seemed to have become mixed up. The label on the chart identified the patient as a fifty-two-year-old woman. Instead the patient in front of the nurse looked like she was closer to eighty and dying. Yellow as a canary, she looked shrunken and could not have weighed over eighty pounds, yet her belly floated out into the bed like a balloon half filled with water. Her body was covered with sores and bruises, making her look like she had been badly beaten. To an experienced eye, however, it was one of the unmistakable signs of advanced liver failure—when platelet counts are so low they cannot plug little holes in broken blood vessels, and coagulation factors that could start the repair process are also largely absent because the liver cannot make enough of them. The nurse greeted the patient and tried to get the usual admission talk going, but after a polite initial response, the patient excused herself, saying that she felt terribly tired, and asked the nurse to please read the chart for her history so she could rest. She then turned toward the wall and became quiet, maybe falling back into a shallow sleep, maybe just resting. As she breathed, a sickeningly sweet smell filled the room.

The chart offered an equally conflicting story. The patient was a married homemaker who lived in a single-family home in a well-to-do suburb, not too far from where the nurse herself lived. Two children, both boys, now studying at the city’s prestigious Institute of Technology and living in the college dorms, were mentioned. The history of prior contacts with the health care system was very limited. There was reference to some old prescriptions for insomnia from the family doctor. There was mention of a round of referrals over the past couple of years to evaluate possible causes of an accelerating weight loss. A routine workup to rule out cancer showed no significant findings. And then there were a couple of admissions for abdominal pain, which were written off as the result of emotional distress caused by the departure of the grown children.

But just over two weeks ago, the patient’s husband had found her unconscious when he returned from a business trip. She was brought to the emergency room, and the admission exam showed life-threatening liver failure. Her urine output had rapidly decreased and there was fluid in her abdomen and blood in her stools. An ultrasound of the liver had shown an organ that was shrunk and nodular, like a cluster of grapes, rather than the normal healthy smoothness. Only the miracles of modern medicine, including a stint in the intensive care unit, had kept her alive. After the ICU she had been stabilized on the medical floor, with continued intravenous fluids, platelet transfusions, and fresh frozen plasma. Yet for all the advances of medicine, and all the scientifically derived algorithms that spit out prognostic numbers, no one knew whether she would make it. It seemed from the progress notes that both staff and family had written her off. Her sons had been contacted, came to visit in disbelief, and left hours later with ashen faces, to return a couple more times before they dropped off the radar screen. Her husband, though, had stayed night after night until things seemed to slowly start turning around, and he returned daily during visiting hours, a quiet shadow.

It was only in the transfer note from the medical unit that heavy use of alcohol was mentioned, for the first time, as the reason this otherwise healthy, affluent mother of two had been so close to dying of liver failure.

The nurse closed the chart, quietly shaking her head in disbelief. She worked in a psychiatric addiction unit. The doctors and nurses prided themselves on being unfazed by almost any human behavior or predicament. The drugs, the addictions, the withdrawals were just the beginning, and staff had the routines for managing those down to the tiniest detail. And they had pretty much seen it all. One patient could be an unruly 250pound port worker who had gone into a classic delirium tremens after having been admitted for chest pain and having his alcohol supply cut off. Another could be an old lady with quiet delusions signifying the onset of a late delirium from Valium overuse. Or perhaps, hiding under the use of tranquilizers, a true delusional syndrome lurked, the vast labyrinths of which suddenly opened in response to a single trigger word, which unleashed paranoid stories. The staff were acutely aware that seemingly strange behavior could occasionally be the result of or mask a serious medical condition. While trying to help and comfort people, they had to make sure no drugs entered the unit and that no medical condition was missed. In short, the psychiatric addiction unit was a challenging but fascinating place to work.

Whether a patient came in from the emergency room or from another unit in the hospital, or was a scheduled admission from the outside, there was a strict admission policy. It included thoroughly searching anything that was brought into the unit and strip searching the patient. Newcomers on staff sometimes rebelled against this. They brought up patients’ rights, autonomy, and respect. The most experienced nurses sighed and then tried to explain. A few of the new staff never got it and moved on to other units. The vast majority noticed that patients had no problem with the routines if they were done right and quickly absorbed the healthy “tough love” culture of the unit. Like their more seasoned colleagues, most newcomers ultimately learned to set boundaries with care, making it clear that allowing patients opportunities to overdose in the hospital or sell drugs to other patients was impermissible.

But this case was different. The prematurely aged woman lay there, turned away from the nurse in the still and peaceful room. It was as if death had entered the hospital and then decided it was not yet time to claim the patient. It felt out of place—in fact, inappropriate—to disturb the patient and start searching her and her belongings. The nurse sighed again, completed the transfer sheet, and started rolling the bed from the admission room onto the unit, with the patient’s neatly packed bag underneath it. As she was rolling the bed down the corridor, she saw the young psychiatry resident who would have to complete the admission. She waved, pointed to the room where the patient was going to be placed, and moved on. Poor guy, she thought. He would have to stay even longer than she did. Then she reconsidered. After all, he didn’t have any kids to feed tonight. And besides, those guys all went on to make twice the money she did, or more. There was really no reason to pity him. She pushed the bed to the wall, secured the wheels, and quietly left the ward for the world outside.

By Monday morning the patient was dead. Hidden in her bag had been a quart of vodka. She had consumed almost all of it before anyone had noticed. After that she had become unconscious and, despite efforts to revive her, died within a few hours.

Addictive disorders kill and debilitate countless people, most of whom are in the prime of their lives. Alcohol alone ranks as the third most common preventable cause of death in the United States and is estimated by the Centers for Disease Control and Prevention (CDC) to kill an astounding eighty to ninety thousand people each year.¹ On average, the lives of these people are shortened by about thirty years. Among preventable causes of death, alcohol is topped only by smoking and a lifestyle of physical inactivity and unhealthy diet. In an increasingly health-conscious society, not a week goes by without reminders of public health and personal consequences caused by such factors. The pharmaceutical industry invests billions of dollars in developing antismoking as well as antiobesity drugs. In contrast, rarely does alcohol or other drug addiction receive similar attention. When it does, it is often in the guise of other issues. Car crashes and other accidents cause about forty thousand alcohol-related deaths. Liver cirrhosis, cancer, and other medical conditions caused by excessive alcohol use result in thirty-five thousand more. Frequently those conditions receive more attention and sympathy than the underlying addiction. It is a bit like being concerned that patients die because their heart stops beating but neglecting to consider the hypertension that caused that to happen. Beyond the deaths, the CDC has estimated the annual economic cost of damage inflicted by alcohol and other drugs as over a quarter trillion dollars in the United States alone. No numbers, however, can properly capture the emotional toll of addictive disorders.

All too often people have little sympathy for the plight of alcohol or drug addicts. “It is self-inflicted.” “They should just get their act together.” “Just say no.” “Lock them up.” This phenomenon is as interesting as it is disturbing. Don’t people generally hold that if you have a home, an income, a family, and perhaps even a sense of meaning to your life, then you are obliged to give some thought to those less fortunate than yourself? Yet people persist in a lack of compassion for those suffering from addictive disorders. What allows for this apparent contradiction to continue is a split that is as basic as it is false. Even otherwise caring people routinely make a distinction between “us,” the good citizens who deserve a helping hand when we fall on hard times, and “them,” the fundamentally different people on the margin who may smell bad, stagger, scream, behave in bizarre ways in the metro, or stop breathing on the floor of a public restroom.

If you, too, hold this belief, I have a surprise for you. Your brain is not wired much differently from that of your fellow human on that floor. Understanding the neurobiology of addictive behavior, if only to the degree possible at present, is a good vaccine against drawing lines between “us” and “them.” Drugs hook into brain circuitry we all rely on to obtain what we desire, avoid dangers, and make sensible decisions. Once you have realized that, it is impossible to look at a person with an addiction and escape the thought, “There, but for the grace of God, go I.”

Had it not been for some unexpected turns of life, I might never have learned these lessons. Born into the protected environment of an academic family, I had as a child only once seen anyone intoxicated, when a colonel in the Polish Army got down on the floor during a dinner party my parents hosted, held his pistol in his teeth by the trigger guard, and ran around barking like a dog. But at the age of eleven, I was thrown into a world I had until then not known existed. Our family became refugees from the latest persecutions of Polish Jews and ended up in a small town in the south of Sweden, by way of first an Italian and then a Swedish refugee camp. We left behind virtually all we had owned and settled down in an area to which others who owned little or nothing also gravitated. Drugs and violence were commonplace. In memory, this period of my life lies between two landmarks. The first was an early bike trip to the grocery store for my mother, interrupted by a knife threat from a guy who, I now realize, must have been high on amphetamine. The second was an encounter, many years later, at an outdoor café across the street from the eleventh-century Romanesque cathedral that towers over the city of my alma mater. My parents and I were quietly celebrating my graduation from medical school at the oldest coffee shop in town, now gone. I can still see my former classmate from grade school, Ante, crossing the street and heading toward us, smiling, waving his hand, happy to see me, but already visibly intoxicated at the noon hour. He quickly dismissed our unspoken reaction. He was just out of jail, he told us, did not expect to stay on the outside long, and intended to make the best of the time available to him. In between those two memory landmarks, kids I knew succumbed to drugs. One died from a heroin overdose. Another was killed when he drove his motorcycle while intoxicated and was hit by a truck.

I have since spent more than twenty years working with psychiatric and addictive disorders. As a young physician I had patients who made it and those who did not. I was vomited on, given flowers, lied to, told heart-wrenching life stories, threatened, or hugged, in a kaleidoscopic stream of experience. I felt hopeful at times but powerless much more often. I saw how the medical model, helpful though I found it, was also painfully insufficient in dealing with addictions. Recognizing the limitations of a hospital, my colleagues and I worked hard to establish mobile services and reach out to those whose addiction had made them homeless, whose homelessness had made them addicted, or for whom one simply could not tease out what might have caused what. As “treatment” we would listen, talk, and give behavioral therapies and medicines, but we would just as often help our patients get dental work done, land a lease on an apartment, or practice for a job interview. We worked with a women’s safe house because once I had seen the wounds of a battered female patient, the thought of sending her back for more of the same made me sick to my stomach. It was, of course, the same sickening feeling that hit me when I realized heroin-addicted patients died because some politicians would not allow provision of methadone treatment, for ideological or populist reasons.

Yet this gut-wrenching feeling is only a starting point for dealing with the difficult issues of addiction. From the beginning it has been clear to me that we also need to work hard on gaining a scientific understanding of this condition. Clearly a better mechanistic understanding of addiction can be expected to offer increasingly effective treatment approaches. But another reason is almost as important. The behaviors of people who compulsively use drugs or alcohol are not only incredibly destructive and self-defeating but also seemingly incomprehensible and scary. Therein lies a big part of the reason the average person so easily distances himself or herself from those with addictive disorders. A better scientific understanding of what makes people become addicted, explained in a way the average person can understand, will help reduce the stigma of addiction. For these reasons, addiction science and addiction medicine offer opportunities to do something that is as practical as it is challenging, important, and gratifying. Yet for all its practicality, the science of addiction is also a window on the fascinating brain functions that make us who we are. This is truly the last frontier of medicine, and a field to consider for every talented medical student, psychologist, or neuroscientist who wants to accomplish something as meaningful as it is interesting.

In this book I will share some of the amazing advances the neuroscience of addiction has made over the years I have been in the field. I will offer a personal take on what addiction is: a malfunction of some of the most fundamental brain circuits that make us tick, and a disease that is not much different from other chronic, relapsing medical conditions. I trust it will be clear what addiction is not: a moral failing, a simple inability to say no, or a condition that can be cured by mystic incantations. As we move between clinical and basic science, it will be clear that there has, finally, been a striking convergence of the two, including an understanding of the major triggers that make people relapse to drug seeking, and the brain mechanisms those triggers engage. We will see that the scientific advances we have already achieved are able to improve, in major ways, the lives of people with addiction, and that they hold out considerable hope for further progress.

It will also be clear, however, that there is a major need to bring together the emerging science of addiction and the world of treatment. I will describe how people with addictive disorders continue to be offered, with great certitude and frequently at great cost, “treatments” that are unsubstantiated by data or already known to be without beneficial effects. Meanwhile, advances that may be modest but have solid scientific support are arrogantly rejected by treatment providers in ways that would cause uproar in other areas of medicine.

A striking example that I will discuss is the medication naltrexone, approved by the Food and Drug Administration (FDA) for alcoholism treatment and supported by extensive evidence but provided only to a tiny fraction of patients who would benefit from it. A broadcast of Larry King Live from 2007 illustrates the problem that needs fixing. In the broadcast Susan Ford, at the time chair of the Betty Ford Center in Arizona, debated with my then colleague at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Mark Willenbring. Ignoring Mark’s thorough digest of research data, Ford simply dismissed naltrexone and other anticraving medications as something she and her institution just do not “believe in.” In recent years, attitudes at the Betty Ford Center may have come closer in line with the scientific evidence, but similar attitudes continue to prevent patients from access to life-saving, scientifically well-understood and documented treatments such as methadone and buprenorphine maintenance for heroin addiction.

These attitudes are obviously very troubling for a number of reasons. One is that resources for addiction treatment are scarce. That being the case, it is tragic that the majority of resources are largely wasted on interventions that do not improve meaningful clinical outcomes.

The reasons are not only ideological, but also financial. It is trivial to mention that a criminal hunger for profit fuels the supply of illicit drugs that kill people, and that tremendous efforts are devoted to a “war on drugs” that is aimed at reducing the supply of these drugs to the market. But alcohol is in the aggregate a much greater cause of death and disability than cocaine, heroin, and cannabis are together. Because alcohol is a legal substance, little attention is paid to the fact that the alcohol beverage industry works as hard to maximize profit at the expense of public health as any street-corner drug dealer. For instance, it consistently opposes efforts that have been proven effective at limiting harm from alcohol, such as higher taxes, a monopoly on sales, and limited store hours. Instead the industry favors measures such as education directed at schools and college students—things that may look good but are known to be ineffective.²

But the industries that provide people with addictive substances are only one part of the financial ecosystem of addiction. People who develop alcohol and drug problems frequently are taken advantage of twice—first by those who sell them the drugs, then by others who sell them a “cure.” There is a whole addiction treatment industry that generates some $34 billion in annual revenue in the United States alone. Much of this industry preys on people made vulnerable by their addiction by peddling exotic interventions with no scientific basis whatsoever as treatments. Even when more reasonable treatment approaches are offered, they may be extremely costly, while outpatient treatments offered at a fraction of the cost would do just as well.

The time has come to bring together the everyday realities of addictive disorders and the emerging science and available evidence. The science is fascinating; the evidence is modestly encouraging. As important as advancing evidence-based treatments, however, is asking the hard questions about the disconnect between what we know and what we do with and for people with addictive disorders. I hope to have triggered enough curiosity for readers to join me on a journey through patient encounters, neural circuits, and price tags. Let’s begin.

2

A GROCERY STORE THAT CLOSED

FRIDAY NIGHT TO Saturday was the most unattractive tour of duty in the psychiatric emergency room of the old mental hospital, keeping doctors and nurses cloistered while everyone else was enjoying weekend pleasures. Weekday shifts did not mess up weekends, so they were more desirable. From noon Saturday through the rest of the weekend, comp time was offered at twice the hours worked, so it quickly accumulated and offset some of the pain of missing out on weekend fun. But the Friday night tours really had no redeeming features. So it should come as no surprise that, being the youngest doctor on staff, I found myself assigned to quite a few of them.

It was one of those Friday nights. The night shift had just taken charge of the small psychiatric emergency room. They were a hardened crew, used to managing not only the patients, who could range from psychotic and violent to depressed and suicidal, but also the young physicians. The shift manager,...