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Examining Roots Of Addiction, Exploring Treatment Options

The lives of a generation are at stake as experts explore appropriate treatment for addiction and examine roots of the current drug epidemic.

Dr. Clay Marsh, vice president and executive dean of West Virginia University Health Sciences, sees addiction, drug abuse and overdose as a problem of all people, crossing socio-economic, geographic, ethnic and age boundaries. “Labeling people is a thing of the past. The stigma of drug overdose is being overshadowed by an incredible need to save a generation,” he said.

“It is an extraordinary problem that is happening for a variety of reasons and it is complicated,” Marsh said.

To combat this epidemic, Marsh thinks it is essential “to help the people who are addicted to the drugs, but also punishing those who are producing and selling the drugs.

“You can’t arrest your way out of this epidemic … We want to make sure the users of heroin or opioids get the help they need,” he said. “We need to go after sellers with everything we have. There have to be clear consequences.”

He said the medical community is starting to rebound from a number of decisions made by agencies such as the American Medical Association regarding treatment of pain. Opioids were prescribed more liberally after pain was labeled the fifth vital sign. He said, “Pharmaceutical companies became more committed to putting out more drugs and saying that they were not addictive.”

Then, a “pill mill” economy opened, and abuse of opioids became more widespread.

Now, it is recognized that “we have to control the prescribing habits and patterns of physicians,” he said. Medical schools and hospitals have adopted guidelines for prescribing opioids, pain management and alternative therapies. Marsh acknowledged that pain is debilitating if not treated appropriately.

Drug take-back programs provide a vehicle to dispose of unwanted prescriptions. Police officers and other first responders are being trained to administer naloxone (Narcan) as an antidote for narcotic overdose. Marsh considers naloxone as “a bridge to getting real treatment.”

Roots of Addiction

Many forms of addiction have common elements, but differ greatly in terms of cause, severity, treatment and outcome.

“There is a similar strand that runs through all addictions,” said Brad Lander, a psychologist and clinical director of addiction medicine at The Ohio State University Wexner Medical Center in Columbus.

Chemical addictions involve drugs and/or alcohol, while process addictions include gambling, sex, pornography, shopping and excitement.

Richard Takacs, an area addiction expert, said process addictions also have physiological and psychological effects on people caught up in a cycle. “The gambler seeks that high or that rush in a similar way to those addicted to chemicals or other substances that are out there,” he said.

Eating in a compulsive manner is “somewhere in the middle,” Lander said. “There is debate as to whether it’s process or chemical.”

Dr. Carl “Rolly” Sullivan, director of the addictions program at WVU Medicine Chestnut Ridge Center, said a substance or behavior can become addictive if the brain perceives it as rewarding and reinforcing. In addition, he said, genetics appear to play a strong role in addiction.

“Opioids seem to hit the craving center,” Sullivan said, adding, “It happens with monotonous regularity; once people start taking opioids, it quickly becomes a terrible problem for them. The withdrawal and cravings are so bad that they will do virtually anything to get their drugs.”

Lander contends there really isn’t an addictive personality. However, he said a person may have a genetic vulnerability to a particular type of addiction.

Noting the roots of alcoholism appear to be genetic, Lander said, “You almost have to have the gene set to become an alcoholic … People who have that set of genes have no monitor or no ‘off’ switch that says ‘enough.'”

Sullivan said, “We all suspect to see a strong genetic tie with opioids. We’re a generation away from (proving) that … People who come here hooked on prescription opioids also have a strong history of alcoholism. I tend to think that is related.”

Lander recommends those who have alcoholic genes should “probably not drink for safety sake. If you don’t know until you get addicted, it’s too late. Once you get an addiction, it’s permanent.”

An addiction is never cured, but can be put into remission. Lander said addiction follows a reward pathway into a primitive part of the brain, which adapts to the drug and creates networks of neurons. He said the neuron connections can be made dormant, but if awakened, will kick back in again and cause a full-blown pattern of addiction.

“We try to write over those pathways with stronger, healthier pathways. That takes time for the brain to get used to a sober environment. It’s going to take a long time. It gets better as it goes along,” Lander said. Some may be complacent after a year in recovery and think they can take a drink or use a drug, but, he said, “It doesn’t work that way.”

Marijuana

While states and communities are considering or have legalized marijuana for medical purposes, experts signal a cautionary note regarding recreational use of marijuana.

“Marijuana is becoming the biggest problem,” Lander said. “Marijuana is more accessible to people. There are people who are sensitive to that and become addicted to that. We definitely see marijuana addicts.”

Sullivan said, “Most people think marijuana is nothing, and the truth is that 10-15 percent of people become dependent.”

Treatment

WVU has developed Comprehensive Opioid Addiction Treatment, an outpatient, group-based treatment program for opioid disorder using Medication Assisted Therapy. Directed by Sullivan, COAT is an internationally recognized program, Marsh said. In this approach, Suboxone is prescribed to reduce withdrawal symptoms and block opioid receptors, and clients participate in individual and group therapy and 12-step therapies.

The university operates clinics in Morgantown; conducts teleconference programs to extend community health outcomes; supports needle exchange programs and provides training to monitor for hepatitis B, hepatitis C and HIV.

Discussing treatment, Lander said, “There are two kinds of addicts or users. Some use recreationally and get addicted. Others are self-medicated, have depresssion or have a physical problem and get addicted to pain medication.

“Treatment is different for those two groups … Those people (who had pain issues) are different than the people who were going out to get high, so the treatment is different,” he said.

“The key element of any treatment program is that it addresses the individual needs. One size does not fit all,” Lander said. “If I’ve got an 18-year-old heroin addict and a 50-year-old crack addict, those are just not the same. The same program isn’t going to work for both.”

Lander said, “There are so many variables to look at, to form-fit the plan to the individual. Saying that, group therapy is the best way to go. Typically, it is more effective than individual therapy. But you can still do individual treatment plans with group therapy.”

Depending on their needs, addicts may require hospitalization, partial hospitalization, intensive outpatient therapy or counseling, Lander said. The length of treatment may range from 30 days to 30 months.

Since reclassification of addiction in 2011, Lander said, “It’s now being treated more like chronic disease. We are understanding more what the problem is and the way we’re going about treatment is much different and much more effective … We are using more medications that we’ve never used before and it really is helping.”

Suboxone is “a real game changer” if used properly as part of treatment, Lander said. Criticizing doctors who prescribe Suboxone alone, he said, “That’s not the treatment. Suboxone is given so someone can do treatment.”

Sullivan agreed, “Suboxone is amazing when used as part of a treatment program. It has to be part of a treatment program.” Of clinics that solely dispense Suboxone, he said, “That’s not recovery; that’s just handing out drugs.”

Sullivan explained that Suboxone hits the same sites in the brain as heroin, morphine or oxycodone and allows the user to feel normal without getting high. “Once people feel normal, they can do Medication Assisted Therapy. Our job is to kick in with all the community 12-step support groups or peer support, individual therapy, group therapy. They learn a new way of life that does not involve addictive drugs,” he said.

Outlook

While statistics about drug abuse and overdose appear grim, experts are optimistic that treatment programs do help and that recovery is possible for many addicts.

Lander said, “The good news is when I first started 34 years ago in a large treatment center, I was the only one who had a college degree … There wasn’t a lot of good scientific medical data. Genetic studies and brain scanning have revolutionized (treatment). Science is starting to really understand what is going on and how to treat it. I’ve been seeing leaps and bounds in treatment.”

In the long term, Marsh thinks it is key to re-engage people at a community level, with opportunities to promote health and resilience, connection to other people and a sense of purpose. Therapists, counselors, case managers and 12-step leaders can build a community of support and help people deal with underlying issues that contribute to addiction.

Marsh sees a need for more care providers and standardization of programs. “Having a standard approach to this problem is very important,” he said. “We need to create programs that are consistently taking care of problems that are creating the underlying issues. We have to start to help people regenerate and reconnect.”

Lander said, “People who are in recovery have something special. You learn to appreciate what personal freedom you have to make your own decisions. When you get into recovery, you don’t take that for granted. Some people say they’re grateful they have the addiction in the long run because they have to work harder at being better people.”

A decade ago, some thought opioid addiction was a hopeless disease, but now treatment options do exist.

Sullivan said, “The problem is we don’t have nearly enough treatment. The workforce to treat addicts is woefully inadequate. We’re trying to expand Medication Assisted Therapy by finding willing partners around West Virginia.

“People are already in practice, in medicine and therapy, who want to try to help with this. We will try to give them the skills and the backing to run a successful program,” he added.

But Sullivan said, “Our need at this point vastly outstrips our capability. We have 450 active patients in our clinic; 60 percent are women. The average amount of time in treatment is about 30 months … Two months ago, our waiting list was over 600. This would never be tolerated for diabetes.”

Sullivan said, “I feel optimistic that there is no longer this silence about opioid addiction. Everyone knows someone affected, someone who died. Everyone is affected. Now people are starting to talk about it … I can’t tell you how helpful that is.”

Regarding recovery, Takacs said, “It’s not hard, but it’s not easy. People do succeed. It’s not hopeless, but also not magical. They need support; they need a family. It’s just not as simple as a person stopping. They need much more than that to become much more happy with their life and satisified and productive and not putting anyone else at risk either.”

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