COVID-19: Potential Implications for Individuals with Substance Use Disorders

From National Institute on Drug Abuse
March 24, 2020

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As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have Opioid Use Disorder (OUD) face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

Vulnerable Populations

The most vulnerable to Covid-19 among substance abuses is going to be the crack-smoking homeless. The homeless are vulnerable just by being homeless, but add to that the lung damage from smoking crack and the risk is compounded. As Dr. Volkow points out, tobacco and marijuana smoking are also more prevalent among those who are homeless. This is going to be an important area of research.

 

Connections between Sleep and Substance Use Disorders

From the Monthly Blog of Dr. Nora Volkow,
Executive Director, National Institute on Drug Abuse

Original Date March 9, 2020

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Most common mental disorders, from depression and anxiety to PTSD, are associated with disturbed sleep, and substance use disorders are no exception. The relationship may be complex and bidirectional: Substance use causes sleep problems; but insomnia and insufficient sleep may also be a factor raising the risk of drug use and addiction. Recognizing the importance of this once-overlooked factor, addiction researchers are paying increased attention to sleep and sleep disturbances, and even thinking about ways to target sleep disruption in substance use disorder treatment and prevention.

We now know that most kinds of substance use acutely disrupt sleep-regulatory systems in the brain, affecting the time it takes to fall asleep (latency), duration of sleep, and sleep quality. People who use drugs also experience insomnia during withdrawal, which fuels drug cravings and can be a major factor leading to relapse. Additionally, because of the central role of sleep in consolidating new memories, poor quality sleep may make it harder to learn new coping and self-regulation skills necessary for recovery.

The neurobiological mechanisms linking many forms of drug use and sleep disturbances are increasingly well understood. Dopamine is a neurochemical crucial for understanding the relationship between substance use disorders and sleep, for example. Drugs’ direct or indirect stimulation of dopamine reward pathways accounts for their addictive properties; but dopamine also modulates alertness and is implicated in the sleep-wake cycle. Dopaminergic drugs are used to treat disorders of alertness and arousal such as narcolepsy. Cocaine and amphetamine-like drugs (such as methamphetamine) are among the most potent dopamine-increasing drugs, and their repeated misuse can lead to severe sleep deprivation. Sleep deprivation in turn downregulates dopamine receptors, which makes people more impulsive and vulnerable to drug taking.

In addition to their effects on dopamine, drugs also affect sleep through their main pharmacological targets. For instance, marijuana interacts with the body’s endocannabinoid system by binding to cannabinoid receptors; this system is involved in regulating the sleep-wake cycle (among many other roles). Trouble sleeping is a very common symptom of marijuana withdrawal, reported by over 40 percent of those trying to quit the drug; and sleep difficulty is reported as the most distressing symptom. (Nightmares and strange dreams are also reported.) One in ten individuals who relapsed to cannabis use cited sleep difficulty as the reason.

Opioid drugs such as heroin interact with the body’s endogenous opioid system by binding to mu-opioid receptors; this system also plays a role in regulating sleep. Morpheus, the Greek god of sleep and dreams, gave his name to morphia or morphine, the medicinal derivative of opium. Natural and synthetic opioid drugs can produce profound sleepiness, but they also can disrupt sleep by increasing transitions between different stages of sleep (known as disruptions in sleep architecture), and people undergoing withdrawal can experience terrible insomnia. Opioids in brainstem regions also control respiration, and when they are taken at high doses they can dangerously inhibit breathing during sleep.

Addiction and sleep problems are intertwined in other, unexpected and complex ways. In a particularly fascinating finding published in Science Translational Medicine in 2018, a team of UCLA researchers studying the role of the wakefulness-regulating neuropeptide orexin in narcolepsy were examining human postmortem brain samples and found a brain with significantly more orexin-producing cells; this individual, they then learned, had been addicted to heroin. This serendipitous discovery led the team to analyze a larger sample of brain hypothalamic tissue from individuals with heroin addiction; these individuals had 54 percent more orexin-producing cells in their brains than non-heroin users. Administering morphine produced similar effects in rodents.

Further research on the overlaps between the brain circuits and signaling systems responsible for reward and those regulating sleep may help us understand individual differences in susceptibility to addiction and sleep disorders. I believe that the future of addiction treatment lies in approaches that are more personalized and multidimensional, and this includes using combinations of medications and other interventions that target specific symptoms of the disorder. It could prove very useful to target an individual’s sleep problems as one of the dimensions of treatment. For example, NIDA is currently funding research to test the efficacy of suvorexant, an FDA-approved insomnia medication that acts as an antagonist at orexin receptors, in people with opioid use disorder.

The causal relationship between impaired sleep and drug misuse/addiction can also go in the other direction. People who suffer insomnia may be at increased risk for substance use, because sufferers may self-medicate their sleep problems using alcohol or other drugs such as benzodiazepines that they may perceive as relaxing. Or, they may use stimulant drugs to compensate for daytime fatigue caused by lost sleep. Impaired sleep may also increase risk of drug use through other avenues, for instance by impairing cognition. Consequently, sleep disorders and other barriers to getting sufficient sleep are important factors to target in prevention.

Early school start times, for instance, have been the focus of considerable debate in recent years, as teenagers may be particularly vulnerable to the many health and behavioral effects of short sleep duration. Fewer hours of sleep correlate with increased risk of substance use and other behavior problems in teens. In this age group, tobacco, alcohol, and marijuana use are all associated with poorer sleep health, including lower sleep duration, again with possible bidirectionality of causation.

Longitudinal research is needed to better clarify the complex causal links between sleep, brain development, and mental health outcomes including substance use. The Adolescent Brain and Cognitive Development (ABCD) study is examining these relationships in a large cohort of children who were recruited at age 9-10. This longitudinal study, now in its third year, is already beginning to produce valuable findings. A team of Chinese researchers using ABCD data recently published in Molecular Psychiatry their finding that kids with depressive problems had shorter sleep duration 1 year later, as well as lower volume of brain areas associated with cognitive functions like memory. We will learn much more as the ABCD study progresses.

Despite all we are learning, more research is needed on the relationship(s) between drug use, addiction, and sleep, in adults as well as young people. NIDA is currently funding several projects to study various substance use disorders and sleep, as well as the neurobiology of reward and its relation to circadian rhythms. It is an area with great potential to prevent substance use as well as to treat one of the most debilitating side effects associated with substance use disorders.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org.

You can also find help through Narcotics Anonymous at 844-335-2408.

Children Suffer in Families of Addicted Parents or Siblings

Kids of Addicted Parents

One group that doesn’t get the robust advocacy it needs is young children experiencing the impact of addiction in their family. Kids can be profoundly impacted by a parent’s or sibling’s addiction, and they grow up at greater risk of developing addiction themselves. And yet, insurance doesn’t cover care and prevention efforts for such children or the family, and children and families generally get scant mention in policy plans like the 2020 National Drug Control Strategy or relevant federal budgets (see here and here). That’s why advocates like our Jerry Moe and Sis Wenger, the CEO of the National Association for Children of Addiction, say children are the first hurt and the last helped.

National Children of Addiction Week just wrapped up, and we spent the week advocating for “kiddos,” as some of our Children’s Program counselors like to say. Jerry spoke in Ohio and did interviews with media from nearby West Virginia, two states hit hard by the addiction crisis. Lindsey Chadwick and our Children’s Program in Colorado hosted an art show featuring the drawings and paintings of young children growing up in families affected by addiction, and discussed it on a Denver TV station. And, Jerry fielded online, anonymous questions in real-time during a Reddit AMA (Ask Me Anything) hosted by NPR. That Q&A lives on—please help advocate for children by sharing it with others who may have questions about how to support kids affected by addiction in their family. Jerry will continue to answer questions over the next couple of weeks.

Find Help Near You

The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. Also, a step by step guide on what to do to help yourself, a friend or a family member on our Treatment page.

 

Narcotics Anonymous National Hotline: 1(877) 276-6883
Alcoholics Anonymous Website: https://www.aa.org
You can also visit https://www.allaboutcounseling.com/crisis_hotlines.htm

NIDA 2019 Achievements

From the Blog of Dr. Nora Volkow,
Executive Director, National Institute on Drug Abuse

NIDA Banner Science of Abuse and Addiction

Original Date January 24, 2020

As NIDA sets its sights on new goals and objectives for 2020 and beyond, I like to reflect on how far we have come in our research efforts, especially as they concern the opioid crisis, one of the biggest public health issues of our era. Although deaths from synthetic opioids like fentanyl continue to rise, glimmers of hope are starting to appear. Provisional numbers show that overall overdose deaths have held steady rather than increasing since 2018, and a massive federal investment toward finding scientific solutions to the crisis promises to further turn the tide against opioid and other drug use disorders.

The biggest news of the past year is the grant awards in the Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM. In Fiscal Year 2019, 375 grants, contracts, supplements, and cooperative agreements totaling $945 million were awarded in 41 states. As part of this aggressive, trans-agency effort, NIDA is funding research on prevention and treatment of opioid use disorder, including developing new treatments and expanding access to those that already exist.

The HEALing Communities Study led by NIDA in close partnership with the Substance Abuse and Mental Health Services Administration is testing the implementation of an integrated array of evidence-based practices in various healthcare, behavioral health, justice, and community settings in 67 hard-hit communities across four states. Objectives of the study include increasing the number of people with OUD receiving medications for their disorder, increasing naloxone distribution to help reverse opioid overdoses, and reducing high-risk opioid prescribing, with the goal of reducing opioid overdose deaths by 40 percent in those communities over of the next three years. Effective strategies learned from this project can then be exported to other communities.

Other HEAL projects are aimed at finding ways to address the prevention and treatment needs of the most at-risk populations. Grants to 12 institutions as part of the Justice Community Opioid Innovation Network (JCOIN) will create a network of researchers in 15 states and Puerto Rico to study ways to scale up and disseminate evidence-based interventions in a population with extremely high rates of OUD and overdoses, including evaluating the use of the different medications for OUD in jails and prisons as well as in parolees suffering from OUD. In a separate set of projects, NIDA is funding research aimed at preventing the transition from opioid use to OUD in young adults, including projects targeting rural and American/Indian communities.

NIH HEAL money has also allowed NIDA to greatly expand our Clinical Trials Network and, in partnership with other Institutes, is additionally partially supporting pilot studies in preparation for a large-scale study of brain health and development across the first decade of life. The HEALthy Brain and Child Development (hBCD) study, along with the already-underway Adolescent Brain and Cognitive Development (ABCD) study (not funded through HEAL), will contribute in innumerable ways to our understanding of brain development and the many factors influencing risk and resilience for substance use during childhood and adolescence.

Science Highlights

In 2019, researchers at NIDA-funded Yale University made significant strides toward understanding biological predictors of addiction and relapse. Using functional magnetic resonance imaging and machine learning, Sarah W. Yip and colleagues found that functional connectivity among a number of brain regions predicted chances of achieving abstinence in patients receiving treatment for cocaine use disorder. Their results, published in the American Journal of Psychiatry last February, could lead to new approaches to treating cocaine addiction by intervening directly in those pathways.

Genetic approaches are also yielding important insights in this area. An analysis of genome-wide association studies (GWAS) published in Nature Genetics last January identified hundreds of gene loci associated with tobacco and alcohol use and related health conditions. Genes involved in dopaminergic, nicotinic, and glutamatergic signaling were among those identified. Another partially NIDA-supported GWAS study published in Nature Neuroscience in July identified an association between expression of the gene for the cholinergic receptor nicotinic α2 subunit with cannabis use disorder in brain tissue from a large Icelandic sample.

NIDA-supported basic science is also shedding important light on opioids and the brain’s opioid signaling systems. Research published in June in ACS Central Science provided new insights while raising new questions about the drug kratom. Its active ingredient mitragynine acts as a weak partial agonist at the mu-opioid receptor (MOR), but new findings by a team that included researchers at Columbia and Memorial Sloan-Kettering found that the drug’s analgesic properties are significantly mediated by a metabolite produced when mitragynine is consumed orally, called 7-hydroxymitragynine. In mice, at least, this compound seems to provide analgesia but with fewer respiratory-depressing and reward-associated side effects than other opioids such as morphine. These findings point toward the potential of this drug in pain research as well as the need for further research on the pharmacology of kratom’s constituents, their toxicity and potential value in the treatment of OUD.

Although the MOR system is most commonly associated with pain and pain relief, other receptors are also involved.  One important dimension of pain is the negative affect commonly associated with it, and NIDA-supported research published in Neuron in March found that the kappa-opioid signaling system, specifically in cells located in the shell of the nucleus accumbens, are involved in processing pain-associated negative affect. This discovery could perhaps provide new targets for treating the emotional distress associated with many pain-associated syndromes.

Other Developments

Translating addiction science into new treatments and treatment tools is another area where NIDA is having an impact. For example, in the past few years, NIDA has been extremely successful in winning interest for biotechnology investment in devices and other products to address the opioid crisis and addiction more generally. Historically, addiction is a market that has scared away pharmaceutical companies and investors, who viewed it as small and risky and one that would not lead to recovery of investment. However,  NIDA’s medication development program expansion along with NIDA’s Office of Translational Initiatives and Program Innovations (OTIPI) are turning this around. OTIPI, which I highlighted previously on this blog, uses a wide array of funding mechanisms to support startups in developing or adapting devices, apps, and other technologies in ways that can better deliver treatment to people with substance use disorders and related conditions.

NIDA science continues to contribute knowledge to help guide policy. One example is from our annual Monitoring the Future (MTF) survey, which in 2019 showed steep increases in the use of vaping devices both for nicotine and for marijuana among teenagers.  The survey also revealed that a large proportion of teens vaped because they liked the taste. When these vaping data (along with those of the National Youth Tobacco Survey) were released last November, it prompted the makers of the popular Juul devices to pull their mint flavored products from the shelves, and it prompted the FDA to finalize their enforcement policy on flavored vaping (e-cigarette) products.

Find Help Near You

The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. Also, a step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

Narcotics Anonymous National Hotline: 1(877) 276-6883.

“I’m Ready to Go.”

Lines, no, cracks
in the walls—
all of them,
and the ceiling too;
the kind that morph
while you stare,
unaware,
drifting back and forth
from what was and
what can be.

I started packing
this morning, slowly,
still rigid with fear
that it will all start
folding in on me again,
drowning my voice,
shackling me to the past
like a stake and chain
for a dog.

It’s not that I want
to stay—I don’t;
The air here smells
like sweat and sick
and just a hint of desperation;
sunlight barely pushing
itself through five years
of rain scum
on the window panes.

Now there’s a curious
metaphor for sure,
the half-decade-old
film of forgotten responsibility
and lost opportunity
weighing me down,
causing the clown of bloodshot eyes and
rotten flesh to reappear,
a thick blanket of fear
wrapping around me, squeezing,
trapping my breath.

Last month, last year,
the last thousand years,
packed full of regrets
so heavy I spent most days
in bed or in my broken recliner.
If my vision were clearer back then
maybe I could’ve
recognized where I was—
then I would’ve been
(at least a little) more
likely to head to the door,

and flinging it open,
giving the sunshine at least
half a chance of falling on
my emaciated body, warming
my bones and clearing
my brain—which is, frankly,
a prerequisite to
freedom—victory from
the bondage of
self-deprecation.

No bother, though, because
I’ve been flexing my
heart lately, strengthening
my muscle of
hope now that I’m off dope;
shocked yet relieved that
I’m done with all that and
ready for this, whatever
this is—
I’m ready to go.

©2020 Steven Barto

Mental Health and Addiction

The first section of this post is taken from the blog of Sophia Majlessi,
National Council for Behavioral Health
Released January 8, 2020

Voters More Likely to Support a Candidate Who Promises to Address Mental Health and Addiction, According to New Polling from the National Council for Behavioral Health Released Ahead of December 16 New Hampshire 2020 Presidential Candidate Forum

WASHINGTON, D.C. (December 11, 2019)—New polling released today by the National Council for Behavioral Health shows strong bipartisan agreement among registered voters in New Hampshire that the federal government is not doing enough to address mental health (84% of Democrats and 72% of Republicans) and addiction (77% of Democrats and 53% of Republicans) in America. The National Council released the new polling in advance of the Unite for Mental Health: New Hampshire Town Hall, a public forum for 2020 presidential candidates to discuss mental health and addiction policies. The National Council for Behavioral Health, Mental Health for US and the NH Community Behavioral Health Association will host Unite for Mental Health: New Hampshire Town Hall on December 16 at the Dana Center at Saint Anselm College in Manchester, N.H.

“The message is clear: candidates who want to win New Hampshire need to tell voters they have a plan to address the mental health and addiction crisis, one of the most important health issues facing the nation,” said Chuck Ingoglia, president and CEO of the National Council for Behavioral Health. “The Unite for Mental Health: New Hampshire Town Hall will provide an important opportunity for presidential candidates to engage with New Hampshire families, mental health professionals and local policymakers to discuss the issues and share solutions voters—and the nationare eager to support.”

This statewide poll comes on the heels of new national data from the U.S. Centers for Disease Control and Prevention (CDC) confirming that suicide is the second leading cause of death among teenagers in the U.S. The suicide rate among people ages 10 to 24 years old climbed 56% from 2007 to 2017, according to the CDC report. These findings, compared with high rates of death nationwide from drug overdose, are leading to calls for the 2020 presidential candidates to engage communities across the country in order to better meet the needs of millions of Americans.

“Mental health and addiction continuously poll as key issues for many Americans, yet our leaders rarely prioritize prevention, treatment, and recovery strategies,” said former U.S. Rep. Patrick J. Kennedy, founder of The Kennedy Forum and Mental Health for US co-chair. “This new polling data from New Hampshire is the catalyst we need for change. The Mental Health for US coalition is proud to stand with the National Council and the NH Community Behavioral Health Association as we call on policymakers and candidates to walk the walk for the those with mental health and addiction challenges.” “The results of this poll are compelling. The need to invest in caring for those with mental illness is clear, and the voters want to see candidates for public office at all levels address these important issues,” said Roland Lamy, executive director of the NH Community Behavioral Health Association.

Results from the full survey have a margin of error of +/-6%. Click here for full polling results.

My Thoughts

The struggle to break free from active addiction is among the hardest undertakings a person can face in his or her lifetime. Putting the drug down is more difficult depending on the substance, amount used, and duration of use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, has sequestered substance abuse under the new heading Substance Use Disorder (SUD). The substance-related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; cocaine (powder or rock); opioids; sedatives and hypnotics; stimulants (amphetamine-type, cocaine, and other stimulants; tobacco; and other (or unknown) substances. It is important to note that all drugs (when taken in excess) have a common direct activation of the brain reward system, typically leading to dependency and addiction.

Mental health issues can become a complicating factor; this is often referred to as dual-diagnosis, or, in the vernacular, “double-trouble.” Moreover, individuals with poor self-control may be particularly vulnerable to substance abuse. Accordingly, the roots of substance abuse for some individuals can be seen in behaviors long before the onset of actual substance use itself. It is also important to note that substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. These secondary issues can include intoxication, withdrawal, psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders.

Features of substance use disorders include a rather important element: change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral results of such changes may manifest in repeated relapses and intense craving for the individual’s favorite drug. This craving is often set in motion through a mere drug-related stimuli, which is referred to in the addictions field as a trigger. Typically, the longer an addict remains clean the easier it is to recognize and defeat such cravings. A craving is likely rooted in classical conditioning, and is associated with activation of specific reward structures in the brain. These structures are rather individualized; not every addict is triggered by the same thought or stimulus. Instead, triggers are established by what the individual is agitated or distressed by, and inversely related to the ability to properly handle such stimuli.

Not surprisingly, treating co-occurring substance abuse and mental illness calls for simultaneously addressing two critical and sometimes confounding problems. In fact, double-trouble can often complicate differential diagnosis—the comparison of symptoms from multiple likely mental or physical conditions. From a personal perspective, it was quite difficult for me to clearly determine what was “wrong” with me. Severe anxiety, constant ruminations, insomia, and underlying depression crippled me for decades. In addition, I felt powerless and helpless, unable to relax or sleep. This is likely what initially led to my substance abuse. I started drinking alcohol and smoking marijuana the summer following my high school graduation. My use was extensive from the beginning, but I was able to calm down, stop my thoughts from racing, and finally get some sleep. Unfortunately, I was not “sleeping” as much as I was passing out. It did not take long for my substance use to become excessive, leading to a decades-long season of poor choices and serious consequences.

Reasons for drug and alcohol abuse by individuals with mental illness varies by individual. Substance abuse could be primary or secondary to psychiatric issues, or may even in some cases be independent of mental illness. The association between mental disorders and substance abuse is complex. The relationship of substance abuse to onset, course, and severity of mental issues, and problems in the evaluation of dual-diagnosis patients, is often complex. Adding to this difficulty is the likelihood that the individual often engages in self-medication to alleviate troublesome symptoms for which they have no explanation. This psychodynamic perspective must also include neurochemical considerations. Affective disorders (those impacting mood, often including depression, bipolar disorder, anxiety disorder) are particularly difficult to manage. I found welcome relief through drug and alcohol us—albeit only temporarily.

Unfortunately, chronic substance abuse can also lead to the development of organic conditions, such as psychosis, mania, and mental confusion. Other disorders can include chronic apathy and dysphoria, and personality disorders such as Antisocial Personality Disorder and Borderline Personality Disorder. Again, there is often confusion regarding co-morbity. For example, addicts quite frequently use, abuse, manipulate, and disrespect friends, family, and other acquaintances in order to get what they need, whether it be money, shelter, or (at times) the drug itself. These traits are also typical of several key personality disorders.

As these traits become routine, the addict often slides down the slippery slope to criminal behavior—theft, embezzlement, forgery, kiting checks, burglary, armed robbery. A serious, unfortunate end-result for the dually-diagnosed addict can lead to suicide. I have personally considered taking my own life on many occasions during active addiction. I would become remorseful for the way I treated family and friends. The disconnect between my Christian worldview and my behavior haunted me. It seemed suicide was the only option. As my uncle once told me, I was unable to see the horizon. Truly, I have not faced a more difficult situation in my life than suffering from mental illness while in active addiction.

In my review of the diagnostic criteria for Borderline Personality Disorder, I determined I’ve displayed eight of the nine criteria for making such a diagnosis. I’ve demonstrated a pervasive pattern of instability in my interpersonal relationships, self-image, affect (mood swings), impulsivity (sexual behavior, drug and alcohol abuse, risk-taking, excessive impulse spending, reckless driving), recurring thoughts of suicide, chronic feelings of emptiness, and recurrent anger. Thankfully, I have seen a vast improvement in the lion’s share of these symptoms. However, I still deal with poor self-image at times, tend to “sanitize” the truth, occasionally manipulate others, and remain rather impulsive in areas such as impulsive spending.

Given the pervasive nature of dual-diagnosis, it is critical to identify when you are suffering from mental or emotional symptoms, and more importantly to recognize if you are using or abusing drugs or alcohol to dampen or defeat uncomfortable thoughts or feelings. Depression, anxiety, and insomnia tend to “respond” initially to substance use. However, the need for one’s drug of choice to “treat” these types of symptoms increases as use leads to abuse; abuse leads to tolerance; and tolerance leads to dependency. Consequently, self-medication of emotional or psychiatric difficulties by consuming drugs or alcohol is doomed to fail—often with quite devastating results. If you, or someone you know, is caught in the vicious cycle of addiction (with or without a co- occurring mental condition), it is vitally important to seek professional intervention.

It is impossible to “go it alone” and achieve anything like helpful results. In fact, it is likely your situation will deteriorate. I was told years ago by an addictions counselor that because I had an underlying mental illness, treating my addiction without addressing my psychiatric problem is like having two broken legs but only putting a cast on one of them.

If you or someone you know is struggling with substance use disorder and want more information or help quitting, please contact your local AA or NA chapter, or click here to visit the National Institute on Drug Abuse official website. You can also scroll back to the top of this post and click on the COMMENT bar to open an dialog with me. I will be glad to speak with you any time.

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (Washington, DC: American Psychiatric Publishing), 2013.

 

Recovery 2019: The Year in Review

From the Recovery Advocacy Update blog of the Hazelden Betty Ford Foundation originally posted on January 7, 2020.

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As Americans reflect on the past decade, the much more defining story, of course, was the opioid crisis, which fueled an unprecedented overdose epidemic that has barely begun to abate. Drug overdoses claimed a mind-boggling half-million lives in the 2010s and devastated countless others, while exposing the inadequacy of our nation’s overall approach and commitment to preventing and treating addiction, and supporting long-term recovery.

Amid the tragedy, we saw the beginning of positive change in addiction-related public attitudes, perceptions, policies, practices and systems. Hazelden Betty Ford has helped lead the way with many changes of its own. They began using opioid-addiction-treatment medications in 2012, and became a strong advocate for comprehensive care that includes medication options, psychosocial therapies and peer support. They emerged as a leading voice for breaking down barriers between the medical and Twelve Step communities.

Hazelden Betty Ford also transitioned to an insurance model so more people could access care; evolved away from the 28-day residential standard to a more individualized approach that enables people to stay engaged longer over multiple levels of care; launched a new era of aggressive collaboration with the broader healthcare field; made the evidence-based therapy “motivational interviewing” core to a more patient-centered clinical approach; initiated a new, innovative system for capturing and acting upon patient feedback throughout the treatment experience; developed new recovery coaching options; and much more. In addition, the foundation spoke up vigorously about the need for ethical and quality standards in recovery, and continued to support related industry reform efforts. It was a decade of big change for them, and they will likely evolve a great deal more in the 2020s, as they have consistently done since 1949.

Broader changes to the many systems that affect people with addiction are coming more slowly, but things seem to be pointed in the direction of progress. Indeed, most addiction specialists want addiction prevented and treated, rather than stigmatized and criminalized. The question arises, though: Does that mean it is wise to fully legalize and commercialize more addictive substances? Or are there policies and approaches in between that promote public health better than either extreme?

In the new decade, marijuana will be a case study and likely a defining story. The experiment with full legalization looks troubling so far. State-level data from the National Survey on Drug Use and Health finds that marijuana use in “legal” states among youth, young adults, and the general population continued its multi-year upward trend in several categories. New data and studies come in weekly, it seems—consistently showing cause for greater public health concerns. One of the foundation’s 2020 resolutions is to help ensure the facts about marijuana and the risks of expanded use get more attention.

One big concern, for example, is that marijuana vaping by teens surged in 2019, signaling that more adolescents are using the drug and consuming highly potent vape oils, according to new government data and drug-use researchers. Federal regulators are paying attention. They shut down 44 websites advertising illicit THC vaping cartridges, part of a crackdown on suppliers amid a nationwide spate of lung injuries tied to black-market cannabis vaping products.

The outbreak of severe lung injuries may have peaked, but cases are still surfacing, and the agency is urging doctors to monitor people closely after hospitalization, due to the risk of continued vaping. One Harvard graduate student writes, “I nearly died from vaping THC, and you could too.” Marijuana and vaping are both among the issues coming up on the campaign trail, and recent polling released by the National Council for Behavioral Health shows strong bipartisan agreement among registered voters in New Hampshire that the federal government is not doing enough to address mental health and addiction in America. Mental Health for US, a coalition trying to raise more awareness in the campaign, held a recent forum in New Hampshire. Watch the livestream replay here.

In Washington, the White House hosted a summit of its own on efforts to deliver mental health treatment to people experiencing homelessness, violence and substance use disorder. Watch Part 1 of the event, Part 2, and the President’s remarks. The Administration also issued its long-awaited vaping policy last week, with the FDA banning fruit, mint and dessert-flavored vaping cartridges but continuing to allow menthol- and tobacco-flavored cartridges as well as all flavored e-cigarette liquids. Many worry the guidelines don’t go far enough.

Since the foundation’s last update, the President also signed a $1.4 trillion spending package passed by Congress, averting a government shutdown. The package maintains funding levels for most areas relevant to the field of addiction counseling, with modest increases in a few SAMHSA grants as well as at the CDC and at the National Institutes of Health. Most notably, the legislation gives states more flexibility in spending State Opioid Response (SOR) grant funds; specifically, they’ll now be able to use the money to also address the growing problems associated with addiction to meth, cocaine and other stimulants. Here’s a thorough overview from our friends at the National Association of State Alcohol and Drug Abuse Directors.

If you are interested in more information about these topics or the Hazelden Betty Ford Foundation, please visit their website by clicking here.

If you or someone you know is struggling with substance use disorder and want more information or help quitting, please contact your local AA or NA chapter, or click here to visit the National Institute on Drug Abuse official website. You can also scroll back to the top of this post and click on the COMMENT bar to open an dialog with me. I will be glad to speak with you any time.