Recovery

Recovering

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I’m all alone and feel I’m smothering.
It’s because of the addiction I’ve been covering.
Why does the chaos never cease?
All I need is just a little peace!
I feel so beaten down and weak-
Yet all day long it’s drugs I seek.

Today I’ll try a brand new scene.
It’s to my Heavenly Father I’ll lean.
I prayed so hard with all my heart.
I heard Him say, “You’ll have a fresh start.”
For now I’m held in His hand.
Life is a lot easier to understand.
I’m not alone and no longer smothering.
I’m just an addict truly recovering.

Addressing the Stigma that Surrounds Addiction

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nida-banner-science-of-abuse-and-addiction

From the Monthly Blog of Dr. Nora Volkow, Exec. Dir.
NATIONAL INSTITUTE ON DRUG ABUSE

Original Date April 22, 2020

Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.

Man sitting alone in streetlight at night

Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.

Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.

In a Perspective published recently in The New England Journal of Medicine, Dr. Volkow tells the story about a man she met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit to that country several years ago. His leg was severely infected, and Dr. Volkow urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation. This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

Previously on her montly blog Dr. Volkow highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.

The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.

There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.

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.

The Choice to “End it All.”

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Suicide Definition Graphic

Written by Steven Barto, B.S., Psy.

IT WAS FOUR IN the afternoon. I was driving along the river in my home town. It was the fourth decade of my struggle with active addiction. Overwhelmed with thoughts of utter failure, rabid hypocrisy and complete hopelessness, I started ruminating about the idea of suicide. Why not? It made sense. I was in bondage to drugs and had grown tired of living a life so out of touch with my Christian upbringing. Seems I could not stop lying, cheating, stealing. Doing whatever it took to keep getting high. Duplicity was the word that most described my existence. I’d grown weary of living on the down-low. I was defeated, exhausted and tired of failing.

I turned into an area boat launch and stopped about fifty yards from the edge of the water. I closed my eyes and took my foot off the brake. I’d barely touched the accelerator when I heard an audible voice. It filled the cabin of my car: Don’t. I jammed the brake pedal to the floor and gripped the steering wheel in a panic. I must be losing my mind! There was no one else in the car. The radio was off. Yet, somehow, I heard a voice that seemed to fill the interior of my car. I could feel the voice, insistent but not loud. No sense of anger or disappointment. It was simply an audible, gentle, compassionate insistence.

Don’t end your life!

It’s been said that suicide is a permanent solution to a temporary problem. Perhaps if some in-between state existed—some alternative to death—many suicidal people would take it. One question every surviving family member has asked without exception, that they ache to have answered more than any other, is simple: Why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note is left behind, it still never makes sense. Yes, they felt enough despair to want to take their own life, but Why did they feel that way? Alex Lickerman, MD said, “People who’ve survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy, but a valid one nevertheless” (1).

A friend of mine took his own life in 1996. We met a few years earlier as co-workers at a Philadelphia law firm. We were both on staff as litigation  paralegals. He had recently started a new career trading stocks. Apparently, he was under investigation by the SEC for insider trading. His wife kicked him out and filed for divorce. He moved in with his parents and had become quite depressed and withdrawn. He stayed home from work on a Tuesday. After his parents left the house, he took his father’s .357 handgun and drove to his wife’s place. When she answered his knock, he shot himself on the stoop in front of her. I always knew him to be outgoing, hilarious, and always up for a good time. His death made no sense to me.

Unfortunately, suicide without warning is common. Patrick J. Skerrett quoted Dr. Michael Miller, a psychiatrist at Harvard Medical School, in a recent article on suicide: “Many people who commit suicide do so without letting on they are thinking about it or planning it” (2). Currently, suicide is the tenth overall cause of death in the United States. In 2018 there were 48,334 suicide deaths in America. Had I not heard God’s voice that afternoon in 2018, the total would have been 48,335. There were an estimated 1.4 million suicide attempts in the U.S. in 2018. The rate of suicide is highest in middle-age white men in particular. It was the second leading cause of death among individuals between the ages of 10 and 34. On average, there are 132 suicides per day. In 2018, firearms accounted for 50.57% of all suicide deaths in America (3).

America’s suicide rate has increased for 13 years in a row.—The Economist

According to the National Vital Statistics Report, suicide was the second leading cause of death for age groups 10 to 24, or 19.2% of deaths, and 25 to 44, or 10.9%. This report presents final 2017 data on leading causes of death in the United States by age, sex, race, and Hispanic origin. These data accompany the release of final national mortality statistics for 2017 (4). In 2017, the 10 leading causes of death were, in rank order: heart disease; malignant neoplasms; accidents (unintentional injuries); chronic lower respiratory diseases; cerebrovascular diseases; Alzheimer disease; diabetes mellitus; influenza and pneumonia; nephritis, nephrotic syndrome and nephrosis; and intentional self-harm (suicide).

Suicidal Ideation and Social Media

Various social media platforms offer an unprecedented volume, velocity, and variety of social data to researchers. Among these, the most consistently studied is Twitter, a microblogging platform in which participants broadcast 140-character posts directly to one another or to the Twitter community simultaneously. Twitter’s sociological and psychological relevance for researchers and treatment providers is elevated due to ease of accessibility to data, the fact that most data collection activities can be undertaken at no cost to the researcher, and the ease of data management. For example, because Twitter limits individual posts to 140 characters, the information is more easily stored and reviewed than longer Facebook posts.

Facebook Suicide Prevention webpage can be found at www.facebook.com/help/594991777257121/ [use the search term “suicide” or “suicide prevention”].

As with a variety of social media platforms, Twitter has been a boon to suicide researchers, who can observe the behavior of individuals in a non-invasive manner, collecting “live” (time-sensitive) information that might not otherwise be shared because of the stigma of mental illness and suicide. One researcher was able to analyze 125 users who publicly announced they had attempted suicide. Analysis of these individuals’ posting history revealed distinct signals in previous posts that could have been used to predict their upcoming attempts and initiate an intervention (5). This is a relatively large sample that otherwise might have been overlooked.

Strong correlations have been discovered between suicidal expressions on Twitter and state-specified age-adjusted suicide rates. It is believed that posting suicide-related content on social media specifically identifies at-risk individuals. In fact, unique posting patterns have been posthumously discovered for Twitter members who died by suicide when compared to those who died of other causes (6). Such results demonstrate the value of verbal content people post on social media sites—providing unique insight into suicidal behavior.

Twitter’s Best Practices in Dealing With Self-Harm and Suicide at https://support.twitter.com [use the search term “suicide,” “self-harm,” or “suicide prevention”].

Psychologists and sociologists have begun to analyze social media data—correlating the content of social media posts regarding the topic of suicide with eventual suicides or attempts. Analysis has proven most useful in this regard. It must be determined whether suicidal behavior can be correlated to online comments among peers beyond one degree of social separation. Also, it must be determined whether that correlation persists after excluding innocuous commentary regarding mood and attitude. In other words, if mood is held to a constant in the analysis, will the observed association in suicide-related behavior still be higher than chance? Recent research has determined that comments on social media relative to suicidal expressions can be studied and correlated  up to three degrees of separation between peers, but no further. 

N.A. Christakis and J.H. Fowler (7) noted that correlation held between suicidal remarks and suicidal actions even when accounting for the distribution of mood among participants in the social media network. They used the bootstrapping method (employing computer-intensive analysis of  variability within their data samples) to study real-time posting activity on Twitter. Their samples were comprised of two non-consecutive 28-day periods. Mechanical Turk (MTurk; Amazon, 2016) raters have compiled suicide-relatedness ratings for each of the 10,222 most common words in contemporary English for use in evaluating social media posts for occurrence of “suicidal conversation.” These words are correlated with a preexisting list of “sad” words (as they relate to the sad/happy continuum) used to infer the general mood of social media users. Collection and analysis was conducted via double-blind method for accuracy and to allow for detecting statistical variation and spurious correlation.

Some variants of “sad/happy” word expressions that may or may not be associated with suicidal ideation include “I’m so sad! I’m gonna kill myself!” “I’m the worst! LOL!” “My final day on earth…” “Just got in a fight…” “It’s a sad day.” “I love my life!” Analysis included placing “sad,” “happy,” and “suicidal” words into columns on a graph and quantifying the number of uses of such words or phrases. Also, degrees of separation (direct friend versus once, twice, thrice removed) were determined at one through six degrees: friend, friend of friend, friend of friend of friend, and so on. The Sad Column, Happy Column and statistically relevant variables were each plotted along the graph comparing “mood” and “suicide-relatedness” comments. Amazingly, this study may be the first of its kind, and involved collection and analysis of over 64 million post from over 17 million unique social media users in two nonconsecutive 28-day periods. Analysis of this real-time data helped predict (by an algorithm) the information collected, which typically has infinite possibilities of correlative meaning.

You might ask, But why is this important? What does it mean? How can it be utilized? Suppose a counselor is concerned with the suicide risk of students in a high school where a fellow student recently took her own life. To get the best data in the shortest amount of time, the counselor would do the following:

  1. Ask a teacher for a list of the decedent’s closest friends and screen them;
  2. Ask any friends on that list to name their closest friends and screen those friends;
  3. Ask any friends from the new group to name closest friend and screen them, and so on; and
  4. Once there are no more positives in a friend group, screen students at random until a positive is found and begin the procedure again until the resources run out (i.e., there are no more students in the population).

Although the above process will provide an  initial “hint” of an assortativity-informed treatment approach, additional research would be necessary before beginning any efficacious intervention. Researchers warn that no offline behavior was included in their study, and therefore was not available for comparison.

Co-occurring Issues and Suicide

Suicide is a major public health problem and a leading cause of death in the United States. Everyone who chooses to attempt suicide has an underlying reason for wanting to do so. Suicide does not discriminate—people of all genders, ages, religious faiths, and ethnic groups can be at risk. Most people at risk will not follow through. Still, assessing the risk for suicidal behavior is complicated. Researchers tell us that people who attempt suicide may do so in reaction to a particular event, thought, or emotion. These individuals make decisions differently than those who do not attempt suicide. Such factors for increased risk are depression, anxiety, personality disorders, psychosis, severe bullying, rape or trauma, and substance abuse. 

Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the primary motivation for the suicide, they can precipitate it as underlying or co-morbid triggers. A major underlying cause of suicide has been combat stress and other related PTSD issues. People in this at-risk category do not necessarily have to experience the horrors of a war zone. Other types of immediate stress include natural disasters, terrorism at home, or catastrophic loss from such events as a structure fire or a serious motor vehicle accident.

People suffering from chronic pain, severe disability, or a major illness may attempt suicide, believing their suffering is too great or that their death is inevitable. Victims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. Situations that fit this category may include torture, confinement, sexual assault, or persistent physical abuse. Also, occupational stress has been indicated in some suicides due to extreme tension, anxiety, disillusion or “burnout,” and job-related financial pressures.

Cyberbullying, Substance Use Disorder

In addition to the above precipitating factors, many suicide attempts are preceded by a severe change in mood that do not correlate to an underlying psychiatric diagnosis. Mood changes most likely to lead to suicide often include extreme sadness, unresolved anxiety, frustration, anger, or shame. Unfortunately, the number of teens and young adults who take their own lives has increased due to bullying at school or on social media sites. Nearly 1 in 5 students (21%) report being bullied during the school year, impacting over 5 million youth annually. See National Center for Education Statistics [NCES], 2018. 

There has been a spike in cyberbullying over the last couple of years. This is willful and repeated bullying behavior that takes place using electronic technology, including texting, comments during gaming, Internet sites, social media, emails, blogs, cell phones, and so on. Unlike traditional bullying it can happen anywhere at all hours of the day. Approximately 34% of students report experiencing cyberbullying during their lifetime. See Hinduja & Patchin, 2015. Students who experienced bullying are nearly 2 times more likely to attempt suicide. See Hinduja & Patchin, 2018.

Worldwide, more than 1 million people die by suicide every year. Self-harm deaths have been on the rise in nearly every state in America. In the U.S., suicide deaths (47,173) were almost equivalent to the number of deaths from opioid overdoses (47,600) in 2017. It is essential that suicide prevention practices be implemented and expanded wherever possible (8). Opioid Use Disorder (OUD) has a distinctly strong relationship with suicide as compared with other substance use disorders (9). Pain causes alterations in brain circuitry in the brain’s reward center (involving the ventral tegmental area, nucleus accumbens, and the amygdala), resulting in vulnerability to suicide and a higher risk of opioid addiction. This is supported by epidemiological data that have shown chronic-pain diagnoses are linked to suicide. These associations are only partially explained by co-occurring mental health conditions, which tend to further complicate morbidity.

Tolerance to THC can build quickly in cannabis users. Teens who seek help for cannabis-use problems often report withdrawal symptoms such as anxiety, insomnia, appetite disturbance and depression (Budney & Hughes, 2006). These symptoms are of sufficient severity to impair everyday functioning (Allsop et al., 2012) and they are markedly attenuated by doses of an oral cannabis extract (Sativex) that contains THC (Allsop et al., 2014). Bagge and Borges (2015) conducted a case-crossover study of 363 persons who had recently attempted suicide and were treated in a trauma hospital for a suicide attempt within the previous 24 hours in Mississippi. The researchers compared rates of cannabis use in the 24-hour period leading up to the individual’s suicide (case period) to individuals who used cannabis during the same time period but did not commit suicide (control period). They found that 10.2% of those who attempted suicide had used cannabis within 24 hours of their suicide.

Cannabis was involved in an estimated 6.5% of drug-related suicide attempts, and in 46% of attempts the person had also used alcohol. In the 23% of drug-related suicide attempts with toxicology reports, 16.8% tested positive for cannabis, although this cannabis use could have occurred days or even up to one week earlier. In general, 9.5% of all toxicology reports for deaths by suicide (Borges, Bagge & Orozco, 2016) show the presence of cannabis. There is preliminary evidence of higher detection of cannabis among suicide decedents that do not involve overdose (CDC, 2006) and higher detection among male suicide decedents using non-overdose methods than among females (Darke, Duflou & Torok, 2009; Shields et al., 2006).

So Now What?

The Centers for Disease Control and Prevention (CDC) released data on the ten leading causes of death in the United States recently. Tragically, suicide—too often a consequence of untreated mental illness and substance use disorders, and as such a preventable condition—remains on that list as the 10th leading cause of death for adults and the second-leading cause of death in our youth. Suicide rates increased from 29,199 deaths in 1996 to 47,173 deaths in 2017. Click here for more information.

What are the contributing factors to a state of mind that ends in a person taking his or her life? What can be done to intervene? How can we turn the numbers around? The increased number of suicides year after year say something about the conditions under which people live and die, and about our society at large. Our teens and young adults are deciding in record numbers that killing themselves is the best solution to what is usually a temporary situation. Citizens at the lower end of the socioeconomic scale are significantly more vulnerable due to negative views about life and an increased amount of psychological and social difficulties. Many of these conditions are not diagnosed in time or go untreated. Many are turning to substance abuse to cope, which often increases the risk of self-harm behavior. This speaks to an environment that can promote depression, anxiety, and elevation in substance use disorder. Some sociologists have referred to these suicides as “deaths of despair.”

There are a number of interventions we can apply to these dire circumstances:

  • Safety Planning. Personalized safety planning has been shown to help reduce suicidal thoughts and actions. Patients work with a caregiver to develop a plan that describes ways to limit access to lethal means such as firearms, pills, or poisons. The plan lists coping strategies and people and resources that can help in a crisis.
  • Follow-up phone calls. Research has shown that when at-risk individuals receive proper screening, implementation of a Safety Plan, and a series of supportive phone  calls, their risk of suicide goes down.
  • Cognitive Behavioral Therapy (CBT) can help people learn new ways of dealing with stressful experiences through training. CBT helps individuals recognize their thought pattersn and consider alternative actions when thoughts of suicide arise.
  • Dialectical Behavior Therapy (DBT) has been shown to reduce suicidal behavior in adolescents. DBT has also been effective in reducing the rate of suicide in adults with Borderline Personality Disorder or related personality disorders. These mental illnesses are typically characterized by an ongoing pattern of varying moods, self-image, harmful or risky behavior, and impulsive actions. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.

If you are struggling with thoughts of suicide, please reach out to someone before the fog of desperation clouds your mind. If you have a friend or loved one who has expressed an intent to take their own life, do not dismiss it as a cry for attention—instead, it is a cry for help. If you are interested in becoming a volunteer or mental health professional and want to be a part of the solution for this national epidemic, please talk to a teacher, professor, mental health professional, pastor, or mentor to find out how to get started.

NATIONAL SUICIDE PREVENTION HOTLINE
1(800) 273-8255

Footnotes

(1) Alex Lickerman, M.D. (April 29, 2010). “The Six Reasons People Attempt Suicide.” Psychology Today. https://www.psychologytoday.com/us/blog/happiness-in-world/201004/the-six-reasons-people-attempt-suicide

(2) Patrick J. Skerrett (Sept. 24, 2012). “Suicide Often Not Preceded by Warnings.” Harvard Health Publishing.

(3) “Suicide Statistics.” American Foundation for Suicide Prevention. https://afsp.org/about-suicide/suicide-statistics/

(4) Melonie Heron, Ph.D., (June 24, 2018). “Deaths: Leading Causes for 2017.” National Vital Statistics Reports, Vol. 68, No. 6. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

(5) Wood, A., Shiffman, J., Leary, R., and Coppersmith, G. (2016). “Language Signals Preceding Suicide Attempts.” CHI 2016 Computing and Mental Health, San Jose, CA.

(6) Bryan, C.J., Butner, J.E., Sinclair, S., et al. (2018). “Predictors of  Emerging Suicide Death Among Military Personnel on Social Media Networks.” Suicide and Life-Threatening Behavior, 48, 413-430. http://dx.doi.org/10.1111/sltb.12370

(7) Christakis, N.A., and Fowler, J.H. (2013). “Social Contagion Theory: Examining Dynamic Social Networks and Human Behavior.” Statistics in Medicine, 32, 556-577. http://dx.doi.org/10.1002/sim.5408

(8) https://doi.org/10.1016/j.jcjq.2019.10.001

(9) Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Addiction 2017; 112:1193–1201.

 

 

The Prodigal Son (God’s Reckless Love)

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“And the son said to him, ‘Father, I have sinned against heaven and before you; I am no longer worthy to be called your son.’ But the father said to his servants, ‘Bring quickly the best robe, and put it on him; and put a ring on his hand, and shoes on his feet… for this my son was dead, and is alive again; he was lost, and is found.’ And they began to make merry” (Luke 15:21-22, 24, NRSV).

Written by Steven Barto, B.S., Psy.

IT’S NO SECRET THAT there are many ways to read, study, and interpret literature. Such investigation and analysis is called exegesis. It involves the careful historical, literary, and theological analysis of a text. Some call this “scholarly reading,” which I’ve learned to apply to my graduate studies in theology. Exegesis is described as reading in a way that ascertains the crux of a text; a type of “close reading,” deliberate, word-by-word and phrase-by-phrase, considering all the parts for a better understand of the text or verse as a whole.

There are three major approaches to exegesis: (1) the synchronic approach (meaning “within time” or “same time”), which can be considered a narrative-critical, social-scientific, or socio-rhetorical analysis; (3) the diachronic approach (meaning “across time,” focusing on origin and development and the “long view,” which is essentially an historical-critical analysis; and (3) the existential approach (something to be “engaged with,” looking at the reality beyond the text, “spiritual” truth beyond the “literal” truth). I will be using the existential method to analyze the story of the prodigal son. Please note this does not imply any connection to the philosophy of existentialism associated with Jean-Paul Sartre and Soren Kierkegaard. Rather, existential exegesis is theological and transformative; it is done in the context of a specific religious tradition or theological purpose.

The parable of the prodigal son is one of the most well-known stories of Jesus. Although many pastors, teachers, and biblical scholars refer to it as the story of the prodigal son, the word prodigal does not appear in the Bible. The son is best characterized as lost, emphasizing that all sinners are lost or alienated from God. To characterize him as “prodigal” casts too much emphasis on wayward lifestyle. If we limit our analysis of the prodigal son to his wanton worldly behavior, we will miss the point of the story. It is in fact more akin to the tale of the lost sheep. This story is meant to demonstrate that we  do not have to stay in our hopeless state. Moreover, it is an example of Scripture imitating life, in that it shows us what repentance means: turning away from sin and back toward the Father; doing a 180 as they call it.

Eugene Peterson puts the story of the prodigal son under the heading The Story of the Lost Son in his translation The Message. This parable shows the nature of repentance, and, more importantly, the joy and the willingness of God to welcome and restore all who return to Him. It shows us the riches of the gospel and its efficacy to overcome any form of sin. Matthew Henry draws a unique parallel between our heavenly Father and the prodigal’s earthy father. He says, “It is bad, and the beginning of worse, when men look upon God’s gifts as debts due to them” (1). Scripture tells us to not seek the wealth of this world. Jesus said, “Do not lay up for yourselves treasures on earth, where moth and rust consume and where thieves break in and steal, but lay up for yourselves treasures in heaven, where neither moth nor rust consumes and where thieves do not break in and steal. For where your treasure is, there will your heart be also” (Matt. 6:19-21).

Matthew Henry draws a parallel between the prodigal son and our First Parents. Their foolish ambition to be independent from the Father is at the bottom of every sinner persisting in sin and autonomy. The First Sin relates to man’s departure from God, toward a willful reliance on his own thoughts and valuations rather than ascribing to God’s. We see from the prodigal son that his desire to be free from his father led to a vile, hedonistic, slavish state of being. When we walk in the flesh (fulfilling its every desire) we become the devil’s servant. Walking according to fleshly desires and instincts invariably leads to a state of constant discontent. This is what it means to be a lost sheep, wandering the face of the earth in search of constant gratification, separated from God.

Exegetical Analysis

The parable of the prodigal son reveals two distinct issues: one literary, the other theological. From a literary perspective, the story revolves around two brothers: one younger, the other older. This does not indicate two separate stories, but two parts that compliment one another. Because of this focus on two brothers, it is helpful to analyze this parable from both an existential and historical/sociopolitical perspective. Historically, the “share of the estate” that the younger son would receive on the death of his father would be one-third. Culture during those times dictated that the older son would receive two-thirds, often referred to as a “double portion,” and the second son would receive the remaining one-third (see Deut. 21:17). When the property “was divided” in the story of the prodigal son, the older son was made aware of his share of the father’s assets prior to his father’s death. This was unusual in the prevailing society.

From a sociopolitical perspective, when the prodigal son asked for his portion of the inheritance, it’s as if he wished his father dead! New Testament scholar Kenneth Bailey (2), who spent over 15 years in the Middle East, asked a number of people there what it meant for a son to request his inheritance while the father was still alive and well. The answer was always the same: the son wanted his father dead. In that culture, a father was expected to have complete control over his property during his lifetime, so the request of the prodigal son was quite offensive. The father’s willingness to comply with his son’s request was generous beyond all expectations. In addition, the older son in such cases was typically expected to step in and help the father save face with anyone attacking his estate. This does not happen in the parable of the prodigal son; neither son lived up to what was expected.

The wasting of all the son had while “in a foreign land” is culturally understood as acting against the family, whose inheritance can be traced back to the promises of God to Abraham. The famine made employment and food quite hard to get. The “distant country” was likely outside strictly Jewish territory. It is no coincidence that the son also ended up with the demeaning job of feeding pigs—these are unclean animals for the Jews. He had fallen so low that “no one gave him anything,” which indicates a state of complete destitution and neglect.

From a theological perspective, it is important to note there were 100 sheep (15:4), 10 coins (15:8), and 2 sons. One is lost from each number. The sheep and coin were sought after diligently until they were recovered. However, the lost son was not sought after. He was personally responsible for his coming back home. His rebellion was deliberate and “of the heart,” meaning only a change of heart would suffice for his restoration. This is extremely important from a theological perspective. It is one thing to “know” in your head what is right and what is wrong, but it is a different matter to make a heart-felt decision to change one’s behavior, one’s path—to “do a 180” as I said earlier. This was quite true regarding my wandering in the wilderness for decades in active addiction, making choices that belied morality. I never considered this crucial element in the prodigal son’s restoration before now.

The lost son’s behavior is deemed “riotous living” (15:13). The Greek word is asotos, which translates “living ruinously.” It is properly interpreted as meaning “unsavedness” or, by implication, profligacy, suggesting excess or riot. It is from the root asôtia, referring to being “not savable; incorrigible, dissolute, beyond hope.” It also implies debauchery or drunkenness (see Eph. 5:18). Of course, theologically speaking, the lost son “came to himself” (Luke 15:17). His condition brought him to his senses and he realized how his riotous life would end. Further, he considered his current predicament as being worse than his father’s hired servants, who had bread enough to spare (15:17). He decided he would return to his father’s house and ask his forgiveness.

The prodigal son showed true repentance—confession of sin, genuine sorrow, and humility. The Greek word for repentance in this verse is metanoeo, meaning “to change one’s mind for the better” (see Luke 13:3). This is more than forsaking sin; it involves a complete change in one’s attitude and orientation toward all sinful behavior. In fact, it is this degree of repentance God expects from us as a condition for receiving His forgiveness and grace. The prodigal son demonstrated complete humility. He said, “Father, I have sinned against heaven, and in thy sight, and am no more worthy to be called thy son” (15:21). 

The motivation for the son’s return was hunger, but theologically it was to his “father” that he wanted to return; not to the dinner table. The words “against heaven” (15:21) can mean “to heaven,” indicating he believed his sins were so many as to reach the Heavenly Father—perhaps he believed his sins were ultimately against God. The Jews were aware of Yahweh’s “fatherly” love. Psalm 103:13 says, “As a father pities his children, so the LORD pities those who fear him.” The son knew he had no right to return “as a son.” He imagined saying to his father, “I am no longer worthy to be called your son; treat me as one of your hired servants” (15:19). In other words, he planned to earn his room and board when he returned home.

The Lost Has Been Found!

“When he was still a long way off, his father saw him. His heart pounding, he ran out, embraced him, and kissed him. The son started his speech: ‘Father, I have sinned against God, I’ve sinned before you; I don’t deserve to be called your son ever again.’ But the father wasn’t listening. He was calling to the servants, ‘Quick. Bring a clean set of clothes and dress him. Put the family ring on his finger and sandals on his feet. Then get a grain-fed heifer and roast it. We’re going to feast! We’re going to have a wonderful time! My son is here—given up for dead and now alive! Given up for lost and now found! And they began to have a wonderful time” (15:20-24, MSG).

What does this parable tell us? We’ve looked at several specific words and phrases (lexical items), such as “loose living” (15:13), “came to himself” (15:17), and repentance (15:21; 13:3). Looking at these words and phrases as they appear in utterances, verses, stanzas, and the text as a whole, we see the “completeness” of this story. This great parable speaks of true repentance and the complete joy a father has for a penitent son. Jesus addressed the “murmurings” of the Pharisees early in the story, saying “What man of you, having a hundred sheep, if he has lost one of them, does not leave the ninety-nine in the wilderness, and go after the one which is lost, until he finds it? And when he has found it, he lays it on his shoulders, rejoicing” (15:4-5). He then drove the point home: “Just so, I tell you, there will be more joy in heaven over one sinner who repents than over ninety-nine righteous persons who need no repentance” (15:7).

The details in this story are vivid and moving. Further, they accurately reflect actual customs and legal procedures of the relevant time period. The older son is much like the Pharisees. He could not comprehend the meaning of true forgiveness. In fact, the viewpoints of the two sons are diametrically opposed. The lost son rises and returns; the older son turns and walks away from his father in disgust, falling in moral stature. The central figure, the father, remains constant in his unconditional love for both sons regardless of their behavior or their attitude. Jesus identifies himself with God in his loving attitude toward the lost. He represents God’s perspective during his entire ministry on earth. This parable is one of the greatest examples of God’s willingness to forgive and to accept the return of every lost son or daughter. 

Concluding Remarks

Who are you in this parable? Are you the lost son, a Pharisee, a servant? Are you the older son who was bitter and jealous over the father’s forgiveness and blessing of the younger son who repented and returned home? Are you able to rejoice when a lost sheep is found, or are you taken captive by a righteous indignation, saying, “Why do you lavish him so? He disrespected and disowned you! I’ve been here all along. Where is my adoration?”

Family dynamics is rather fascinating. Even in the family of an addict or alcoholic we can see various roles played out: the Scapegoat (the one blamed for every wrong and ill within the family, sometimes the addict); the Punisher (often a sibling who has “always been there” for the family, and who doles out “consequences” on the addict or protects the family from the addict); the Enabler (usually a member who covers for the addict, trying to smooth things over or restore peace and order in the family, giving him or her enough rope to maybe change one day); the Hero (usually a Type-A personality who is hard-working, overachieving, a perfectionist, who is trying to create a degree of normalcy in the family); the Masot (often the funny, outgoing, class clown of the family always trying to quell the stress of the situation by supplying humor); and the Lost Child (often the middle or youngest child, shy, withdrawn, usually hates confrontation, and has difficulty with establishing outside relationships).

The parable of the prodigal son provides a wealth of theological meaning and puts an historical and sociopolitical spin on the nature of family dynamics during the era when this story was told. It can serve as an in-depth analysis of dysfunctional families today, showing us how easily we can resent the success of others; acceptance of a rebellious, riotous son or daughter who is welcomed back into the fold; righteous indignation by others in the family when a wayward son or daughter returns. It is not easy to forgive others who have harmed us or our loved ones. Thankfully, the parable of the prodigal son can serve to broaden our horizons regarding true repentance, unconditional love, and forgiveness. This is, after all, the point of the gospel itself.

Footnotes

(1) Matthew Henry, Matthew Henry’s Concise Commentary on the Whole Bible (Nashville, TN: Thomas Nelson, Inc., 1997), 962.

(2) Jirair Tashjian, “Inheritance Practices in the First Century,” The Voice, Christian Resource Institute (2018). URL: http://www.crivoice.org/inheritance.html

 

 

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

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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

Submitted by Dennis G Fisher on March 13, 2020

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

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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

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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

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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.”

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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

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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 nation—are 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.