Addiction has permeated the human culture since civilization began, and probably long before that in hunter-gatherer societies.
Dr. Prashant Shukla, consultant Psychiatrist “Asha Hospital - Rehab and Drug De-addiction center” has gained firsthand experience on addiction from Department of addiction medicine, NIMHANS, Bangalore. He has been battling in and around Lucknow city, for rising rates of addiction and drug overdoses.
How do we define addiction and why is it so pervasive in humans?
In order to understand addiction, we have to understand why people use these drugs. And the reason actually is very basic:
People use drugs because they bring short lived euphoria. These drugs are powerful and immediate in terms of affecting people's physical and psychic pain, turmoil or trauma, even just transporting them away from the everyday grind. That is why they are so commonly used. They work until they don't work anymore (generating tolerance) and that is what these drugs do.
Every living being on earth uses intoxicants. But any approach to understand addiction needs to start with an appreciation that people are using these psychoactive substances because it serves them. It's their best possible solution that they have found to address their pain or problems. Addiction is a lifelong trait, one is born with it so treatment involves giving a twist to what they are addicted to. And as doctors of the mind and brain we at Asha Hospital are in a position to help people suffering from addiction find them other solutions.
Among drug addicts we hear mostly about the opioid and heroin epidemic. What is contributing to the rapid rise in opioid overdoses?
The most sensitive marker of an epidemic is death. Opioid-related deaths continue to increase every year. We have not caught up with it despite our efforts and it’s rapidly becoming a universal phenomenon.
There have been a lot of recent studies on opioids among middle-aged men and school going teenagers. These patients have spent their lives facing these problems and are now experiencing long term sequels of opioid abuse like arthritis, viral infections like HIV or HCV and are jobless with very little prospects for their kids. Conditions of scarcity, the experience of trauma, and hopelessness about the future are all risk factors that breed addiction because people are in pain and are looking for a solution. This kind of environment invites the use of opioids again and again as a solution to feel better.
Commonly used opium products in Lucknow, include crude opium (Afeem), Poopy husk (Bhuki) and Poopy seeds (Khuskhus). Heroin is locally known as smack or white powder, and is often taken as injectables (Chitta). We have seen a lot of opioid use in parts of Barabanki district where farmers have been given license for growing poppy in their fields, thereby readily providing the drug to commoners.
What approaches to addressing addiction have clinicians and policymakers tried in the past?
We have to address addiction as another human behavior, which we want to change and to understand that we have to understand about how human brain works. Let’s first talk about things which we have been doing and have not produced the desired results so far:
We have seen warnings on cigarette packets for many decades but are they working. Warning stimulates the fear circuit in our brain, which in turn activates the fight/freeze/fly response. Animal studies have seen that mostly fear induces a freeze or fly response rather than the fight response. So these big pictures on cigarette and gutka packets are actively suppressed by our subconscious mind which uses rationalization as a defense mechanism saying my grandfather died at ninety taking regular cigarettes, so I have great genes to cover me up. These mind changes produce more resilience to change and humans use the ostrich phenomenon selectively suppressing the negative phenomenon.
Prohibition as tried in many states of India like Gujarat and Bihar leads to black marketing and switching from one more socially acceptable drug like alcohol to illicit drug like opium or cannabis.
Criminalization of drugs which only leads to more addicts into jails but the problem continues whenever they come out.
Another failed approach is exhortation. Exhortation is when we say to somebody, "Don't you know that this is destroying your life? Don't you know that you are losing your job?” It is a one sided monologue without any empathy. This usually drives a person away from health care professional.
Our mistake is that instead of working with the positive image that people tend strongly maintain, we put a clear mirror and say image is just going to get worse and worse. It doesn’t work because mind will change this using Photoshop or coloured lenses.
Instead what works is:
1. Social incentives - Humans are social beings and give a lot of importance to social cues. We like to imitate others and like to produce a farce copy which is better than original.
In a study conducted in Cambridge University using F-MRI showed that amygdala (emotional center of brain) gets activated in response to positive social cues. This principle was used by the British government to remind people to pay their taxes on time so when they forgot to pay their taxes British citizens were send letters highlighting the importance of paying taxes on time and that it helps to boost the economy of the country. Later on they added a line saying nine out of every ten people pay taxes on time in Britain.
This one sentence ensured compliance by 15% in that group and helped government collect 5.6 billion pounds. So highlighting what other positive cues people are doing is a very strong motivator to change.
We remember the Satyamev Jayate series run by Aamir khan where he dedicated a serial to addiction and showed various famous personalities who were once addicted but have successfully moved on in life. These social cues help to change the addictive behavior successfully.
2. Immediate appreciation and reward
People value a lot about the rewards we tend to get now, rather than the rewards we may get in future. It is not because we don’t care about our future. We all want to be healthy and successful in our future, but future is so far away, and it is so uncertain. We may have something unhealthy now and be all fit and fine in the future or we may all together die in the future. So we tend to choose something sure now rather then something unsure in the future. If we decide to reward people now for actions that are going to be good for them in future, people tend to make these changes more readily. We try to link quitting addiction with a reward until it becomes a habit and later on a lifestyle.
So the possible techniques that can help include announcing to the whole world that one has quit the drug, on social messenger sites. This not only gets boosted by a number of likes, but also puts in peer pressure to continue abstinence. There are a number of applications which send motivational messages after regular intervals if people tend to leave smoking which acts as immediate rewards helping to bring out desired changes.
3. Changing the Addiction from drugs to anything positive - Addiction is a lifelong trait. Addiction to drugs has to be replaced with any other healthy coping mechanism. Asking people to invest time on their body, do regular exercises, playing outdoor games or reinvent there hobbies like drawing, painting etc.
4. Changing the fanatic behavior from drug seeking to drug eradication - Like people working in Cults like Jai Guru Dev and Alcoholic Anonymous where numbers of days are spent in abstinence is considered a badge to be proudly displayed in a subgroup of people. They have all fought against the menace of drugs and have now taken a pledge to help other get over this menace. Subconscious defense mechanism employed over here is reaction formation.
What approaches to treating addictions have worked? And what is the role of medication?
To understand how we need to treat addiction, it helps to take a tour of our brain. There are four specific brain regions, in particular that are involved in addiction. If we can touch those areas in one way or another, we can make a difference. We can better combat addiction and help people towards recovery.
The first is the reward center, the ventral tegmental area and nucleus accumbens. This is where dopamine is released in response to pleasurable experiences. It fires like an accelerator, mobilizing the brain toward pleasure seeking. We have very effective US Food and Drug Administration–approved interventions that act on the reward center. We can quell cravings with a medication called buprenorphine, an agonist which is often life-saving, it prevents overdoses. Then we have antagonists which prevent somebody from having that dopamine burst. The two antagonists are naloxone, which is a lifesaver when someone is in an overdose, and naltrexone, which is best, delivered in monthly injections for abstinence maintenance. These are the medication-assisted addiction treatments. Currently they are really underutilized.
The second addiction center is our memory center, the amygdala and hippocampus. This is where we encode the memory as - "Boy, that felt really good." Remember Pavlov's dogs? He trained dogs to salivate to the bell, not to food. This is a conditioned response, and conditioned responses are among the strongest, most powerful risk factors for relapse. If someone with an addiction who is in recovery has a friend who calls and is high, this could be a cue for relapse triggered by the memory center. We have approaches, particularly cognitive-behavioral therapy, that are effective in helping people not respond to those cues and helping them prevent relapse.
The third center is the orbital frontal cortex. This is where neuroscientists believe motivation resides. Motivation means, "Oh, I really liked that stuff. I want more of it." How can we tip the balance in somebody? We have techniques called motivational interviewing and motivational enhancement which are readily learned, not just by addiction doctors or psychiatrists, but by all doctors because it's an approach of getting behind the patient's need and helping the patient begin to seek help.
The fourth center is our prefrontal cortex. This is where we can put the brakes on things. The problem is - it's not a very powerful brake. So how can we enhance it? Support groups, 12-step groups, individual psychotherapy, and family interventions are all re-enforcers of the prefrontal cortex and can be effective in helping patients overcome their addictive urges. If we intervene at each of these four areas, we're giving somebody much more of an opportunity to recover. These are additive interventions.
What is the most important advice given to care givers of drug addicts?
There are a couple of important recommendations that we at Asha Hospital give to all the family members and also try to remember ourselves while dealing with drug addicts.
1. The first is to be nonjudgmental. The moment that we start to get judgmental or we take the attitude that there is something bad or wrong about a person - we lose them. That person runs away from us and then we don't have anyone to ally within terms, or making them successful in getting over their addiction.
2. The second message, and maybe the more important of the two, is having hope (ASHA). We see that people who have addiction to opioids or alcohol have relapses. These are chronic, relapsing conditions, and each time a person experiences a relapse, it depletes them of their own confidence. Their loved ones begin to wonder whether this is ever going to change. There are times when we as clinicians also begin to wonder if we can stand by the person. That is the moment where we have to keep hope alive because there is irresistible evidence that, over time, people recover from addictions to alcohol, opioids, cannabis and even tobacco. But we don't know when. So, when those relapses occur, we need to keep hope alive.