The Choice to “End it All.”

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; 112:11931201.

 

 

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

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

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.

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.

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.

Do You Look for Loopholes as a Christian?

Written by Steven Barto, B.S. Psych.

The standard definition of a loophole is an ambiguity or inadequacy in a system, such as a law or a set of rules, which can be used to circumvent or otherwise avoid the purpose, implied or explicitly stated, of the system. It is basically a small mistake which allows people to do something that would otherwise be illegal. Generally, the cause of a loophole is a divergence between the text of the law (how it is written) and the meaning of the law (its intended effect).

Loophole Graphics

PHARISEES AND THEIR THEOLOGICAL LOOPHOLES

Pharisee Pointing

It’s no secret that the Pharisees of Jesus’ days were typically angry over infractions of the Sabaath. This was a huge issue between them and the Lord. Interestingly, the Pharisees created a loophole that allowed them to break their own rules regarding the Sabbath whenever convenient. According to Rabbinic teaching, a Jew could take no more than 3,000 steps on the Sabbath, nor carry more weight than half a dried fig. To circumvent this law, the Rabbis designed a small wearable tent. The tent had poles that rested upon their shoulders, lifting it from the ground. A chair was fastened to their rump Accordingly, they were not technically carrying anything. They would walk 3,000 steps, sit on the stool, then stand and walk 3,000 more steps, repeating the process over and over until they arrived at their intended destination. They declared the tent to be their home each time they sat down. Their “theology” gave them a loophole for travel and manual labor on the Sabbath if they found it necessary. Technically, they were in the clear. That’s what loopholes do for us—permit us to be “technically” right while breaking the rules.

CHRISTIANS AND THEIR LOOPHOLES

When Christians look for loopholes, they change Scripture to fit their circumstances. A believer with this mindset is not concerned with what Scripture dictates; rather, they are concerned about making Scripture say what they need it to say. Individuals who are Christian “in name only” look for loopholes. True followers of Christ don’t look for an out. Unfortunately, many believers today claim certain doctrines, proscriptions, or edicts in Scripture for “back in ancient times” rather than the modern church. This is basically a form of “progressive” Christianity, which flies in the face of God’s unchanging Word. Jesus is the same yesterday, today, and forever. Second Timothy 3:16 says, “All scripture is given by inspiration of God, and is profitable for doctrine, for reproof, for correction, for instruction in righteousness” (NIV). Ecclesiastes 3:14 says, “I know that whatever God does, It shall be forever. Nothing can be added to it, And nothing taken from it. God does it, that men should fear before Him” (NKJV).

PAUL

The Apostle Paul 001

Romans 7:19-21 says, “For I do not do the good I want to do, but the evil I do not want to do—this I keep on doing. Now if I do what I do not want to do, it is no longer I who do it, but it is sin living in me that does it. So I find this law at work: Although I want to do good, evil is right there with me” (NIV). It is important to note that Paul was not speaking about a non-believer, nor was he describing a carnal Christian. He was talking about a victorious disciple still at risk for sinful behavior. Admittedly, Paul is not speaking of the practice of sin by a believer—willfully sinning despite knowing the consequences.

Paul was leading a crucified life, putting on the righteousness of Christ (see verse 25). He delighted in the Law of God in the inward man (see verse 22). That means he was gratified by love, goodness, righteousness, and mercy. The part of his mind that was focused on serving God no longer practiced sin. His thoughts were on Jesus. He told the Christians at Corinth, “I resolved to know nothing while I was with you except Jesus Christ and him crucified” (1 Corinthians 2:2).

There were several aspects of Paul’s life where he had not yet received light. In such instances, he was taken captive by the law of sin in his flesh, causing him to do things he hated (see verse 23). Someone who is willfully committing sin is not doing what he hates. His mind approves of it. When desire is conceived, it gives birth to sin. We actually consent to the desire in our mind and sin is born. James 1:14-15 says, “But each person is tempted when they are dragged away by their own evil desire and enticed” (NIV). Such Christians are serving the law of sin with his or her mind.

THE LOOPHOLES OF ADDICTIVE BEHAVIOR

Addicts frequently use denial, rationalization, and loopholes to hide or downplay their abuse of drugs or alcohol. Heavy or chronic alcohol use leads to psychological and physical dependence and possible addiction. The Diagnostic and Statistics Manual of Psychiatric Disorders, Fifth Edition (DSM-5) says substance abuse related disorders encompass separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives; hypnotics; and stimulants. 

Here are four common loopholes used by alcoholics and addicts:

  1. I’ve already ruined everything. Addicts try to avoid or not acknowledge the consequences of their actions—at least until these consequences are severely compounded. Whether it’s losing a job, legal trouble, homelessness, dysfunction in the household, or all of the above, addiction progressively destroys lives. Although hitting “rock bottom” causes some to seek treatment, others justify continued addiction because they focus on the perceived irreparable damage they’ve caused. 
  2. I don’t deserve a happy, healthy life. According to the Journal of the American Medical Association, roughly half of all individuals diagnosed with a mental health disorder are also affected by substance abuse. Although this is a co-occurring diagnosis (often referred to in 12-step parlance as “double trouble”), it is not a loophole for addiction. Admittedly, feeling undeserving of a happy, healthy life due to mental health symptoms can be a trap. This often leads to drinking or drugging to self-medicate for chronic anxiety or depression. Accordingly, a loophole is created for continued use. 
  3. Now I can finally handle it. This justification is a loophole for relapse, as well as active addiction. When someone feels that their life is now more manageable—perhaps, due to a period of sobriety or fixing certain problems while in active addiction—they may justify drinking or taking drugs again or continuing to use. Unfortunately, the progressive nature of addiction quickly disproves this rationale. This loophole often rears its ugly head following inpatient treatment at a rehab. The individual feels he or she is “armed with” enough information to finally use safely.
  4. For me, it’s just normal life. For some, addiction is a solitary issue. For others, however, addiction may be shared with friends, family members, or partners. These individuals tend to justify their actions because they feel their behavior is part of the fabric of a relationship or social agenda. Even if someone believes their own addiction may be a problem, they can justify their dependency by referring to getting drunk or high as part of the “norms” of social life. 

MY FAVORITE LOOPHOLE

Unfortunately, I have often looked at certain habitual sins in the light of Paul’s own struggle, saying to myself, If the apostle Paul failed to resist the flesh and do what’s right, then how can I ever hope to do so? I am sure you see the hypocrisy of this conclusion. Basically, I have allowed this part of Paul’s teaching to serve as an excuse for what amounts to the “practice” of sin. Worse, the type of habitual sin that has been prevalent in my life involved deception, lying, and stealing narcotic painkillers from family members.

THE ADDICTED CHRISTIAN

Morgan Lee edited and published a provocative article in Christianity Today, called “Why a Drug Addict Wrote a Christianity Today Cover Story.” The article was written by Timothy King, a Christian who contracted very painful acute necrotizing pancreatitis. He was discharged on IV medication and given opiates for pain. Eventually, King’s doctor realized King’s reliance on narcotic painkillers was impeding his ability to eat and to recover from pancreatitis. Despite being a believer, King had become addicted to opiates.

Here is an excerpt from King’s article:

I use the term addicted. There are some medical professionals who use the word dependent because I didn’t go out and engage in behaviors typically associated with addiction. I chose to use the word addicted because it accurately describes my situation. It is a term I hope other people feel less stigma about in the future to describe their own situation. When we give the right name to something that is going on in our life, it kills its power over us. Naming something is incredibly important. Opioid addict is now tied to my name. I’ve had to think through that, but once again I have had a great community of support to encourage me about this story.

Whether deserved or not, believers struggling with an addiction are often shamed by the church rather than being provided an atmosphere for healing. Believers and non-believers alike are dying every day because of drug overdose. This should be cause for concern and a great opportunity for the church to be the church (the Body of Christ). After all, Christians are called to be a loving community of grace and healing. The church should not choose to see active addiction as a moral issue, ignoring the physical and psychological elements of the disorder. This only serves to ignore or sidestep this crisis, evidenced by believers (and some church leaders) who choose to sit on the sidelines, judging and ostracizing those who are suffering.

THE MINDSET OF A DISCIPLE

Paul answers his own question regarding his—indeed, our—struggle with sin that dwells within us. In Romans 7:25, Paul writes, “Thanks be to God through Jesus Christ our Lord! So then, on the one hand I myself with my mind am serving the law of God, but on the other, with my flesh the law of sin” (NASB). Before Jesus overcame the power of sin and darkness, leaving us with an example to follow, it was impossible to completely overcome all sin in the flesh. But Jesus sent the Holy Spirit Who can show us our sin (convict us) and teach us the way through it. Like Paul, when we repent and begin to serve God, we have a new mindset—it is no longer our conscious, daily choice to serve sin. What comes from our flesh is not necessarily done willfully.

When we are in Christ Jesus and choose to serve God with our mind and our spirit, there is no condemnation if we absentmindedly do the things we hate (see Romans 8:1). We aren’t condemned for being tempted (thoughts or feelings that entice us to sin), nor for actions we do which haven’t passed our conscious mind first, allowing us to make a conscious choice. But in order to accomplish this, we need to walk in the Spirit, which means acting according to the light that we receive. This comes only from allowing that light to illuminate our habitual sins. We will then be able to recognize the desires of the flesh—the body of sin that is to be crucified daily through Christ. How do we accomplish this? We count ourselves dead to sin. We can then be disciples of Jesus, denying ourselves and taking up our cross daily (see Luke 9:23-24).

Disciple is another word for a follower of Christ; one who is learning to be like his Master. originally meant pupil or apprentice. Too many Christians believe they became disciples of Jesus when they accepted His death, burial, and resurrection for forgiveness of their sins. We were certainly dead in our trespasses. Thankfully, we are forgiven through Christ. He made us alive together with Him (see Colossians 2:13). However, forgiveness of sin is not discipleship. Once we have received atonement for our sins and are reconciled with God through the crucifixion of Christ, we come to the beginning of a new us. We are now instructed to start following Jesus. Emulating the examples He provided to us during His life and ministry.

CONCLUDING REMARKS

If you or someone you love is struggling with addiction, closing the loopholes of active addiction may be imperative before seeking treatment. In reality, we can rebuild our lives. But this involves realizing that addiction is progressively destructive. Further, it is important to believe we deserved to be happy and healthy, and that active addiction is not a normal, fulfilling human existence. Jesus said, “The thief does not come except to steal, and to kill, and to destroy. I have come that they may have life, and that they may have it more abundantly” (John 10:10, NKJV). Eugene Peterson translates this verse as follows: “A thief is only there to steal and kill and destroy. I came so they can have real and eternal life, more and better life than they ever dreamed of” (MSG). Living life in bondage to addiction is certainly not an abundant life.  

Second Corinthians 5:17 talks about new life in Christ: “Therefore, if anyone is in Christ, the new creation has come: The old has gone, the new is here” (NIV). When we recognize that old things have passed away, we stand a better chance of living life without resorting to loopholes. Frankly, making decisions based upon loopholes is the hallmark of an unrepentant carnal Christian. When we are truly “in Christ,” we are a new creation. Old things have passed away. This is the “abundant” life we read about in John 10:10. We cannot hope to have an abundant and glorious new life in Christ if we excuse our occasion to sin as something not even the apostle Paul could avoid.