Junkies

Weave a circle round him thrice,
And close your eyes with holy dread,
For he on honey-dew hath fed,
And drunk the milk of Paradise.

"Kubla Khan"


1. Referrals to the clinic in the last few months have suggested an uptick in heroin availability, relatively cheap and "high-quality" stuff, in this area. Hard to resist, apparently, at least when you're young, bored, and have few prospects. It brings to mind Mexican drug violence, which has been in the news more lately and which for me had come appallingly to life in Robert Bolano's fictionalized account in 2666. It makes me wonder, with any given person, what awful things happened so that this guy could get his fix?

Folks in Mexico complain that the real problem is demand north of the border--is this due to our uniquely depraved American culture, or merely disposable income enabling the potential depravity of human nature? As a moral argument this is terrible; a prostitute could similarly say, "Well, the guys want it and will pay for it, so what's a gal to do?" Worse than vice is the inciting of vice in others. Purely as a practical argument, though, it does pay to arrest the Johns too. And the flood of American guns to Mexico sounds like another good reason for gun control to me. But I'm just a Liberal with a crush on Obama.

2. What is one to make of marijuana habits? It's illegal, it's bad for the lungs, and some studies suggest long-term cognitive damage with extended and heavy use. Rarely, it makes someone psychotic. But the problem is that in some areas, such as the ones I've worked in, its occasional use is endemic, and if one focuses on that with everyone who uses it a few times per month, one would never talk about anything else. And the evidence for marijuana as a "gateway drug" or as a cause of other mental disorders is pretty flimsy.

I don't use it and as a physician I don't condone it, but psychiatry doesn't seem to be too worked up about it. My current Textbook of Psychiatry (American Psychiatric Publishing, Inc.) devotes about one and a half out of nearly 1800 pages to cannabis. My Textbook of Substance Abuse Treatment (also APPI) devotes separate chapters to alcohol, nicotine, opioids, cocaine, stimulants, sedatives, and hallucinogens, but not to cannabis. Patients are surprisingly forthcoming about their marijuana, as if they not only don't see it as a problem, but can't imagine that even a stuffy shrink would either.

3. In Psychology Today Stephen Mason, Ph. D. makes a questionable attempt to revive the generally discredited notion of the "addictive personality." But the concept has all kinds of problems, including its tendency to overdefine a person and the splitting of folks into addicts and non-addicts. If one considers behaviors like eating, sex, the Internet, and gambling, I'm not sure there is even a consensus on what qualifies as addiction, much less any coherent construct of an addictive personality.

"Addicts" comprise a surprisingly diverse group and a wide spectrum of severity. Those who really will use any psychotropic substance within reach are rare. It is far more common to see the pure alcoholic, or the opioid abuser with no taste for cocaine, or the cocaine abuser with no taste for opioids. There are, to be sure, people whose impulsivity and whose need for external rewards put them at risk for problematic behaviors--I'm thinking of a former patient who was morbidly obese (largely due to binge eating) and who also had a pathological shopping habit, but she didn't abuse substances. It is hard to see how the notion of "addictive personality" is really helpful, unless it amounts to a global admonition like "If you drink or use drugs you will go to hell." On the contrary, individualize, individualize, individualize...

Classical Tragedy

My smile is stuck,

I can't go back t'yer Frownland.

Captain Beefheart and his Magic Band

"I have come," he said. "But I do not choose now to do what I came to do. I will not do this deed. The Ring is mine!"

Frodo

I read an interesting profile by Jason Zengerle in The New Republic today of Brent Cambron, an anesthesiologist who developed an opioid addiction to which he eventually succumbed. As the article describes, anesthesiology is a high-flying, ambitious specialty, but one whose practitioners develop substance abuse disorders at an alarming rate. Cambron's was a sad story.

The presumed explanation is access--anesthesiologists are the only physicians who regularly and literally handle controlled substances (as opposed to merely prescribing them, at a remove). However, apparently pharmacists, who have similar access, do not seem to be so high-risk. Why? The article proposes two possibilities. One, admittedly far-fetched, is that small but significant quantities of opioid medications may accumulate in vaporized form around anesthetized patients, enough so that the anesthesiologists hovering over them could experience enough exposure and even tolerance to develop subtle craving for the drugs.

Zengerle suggests that the more likely reason may be that anesthesiology attracts candidates that are particularly high-strung "control freaks" who gravitate toward self-medication. However, the pharmacists whom I have known have been similarly enamored of meticulous control, perhaps even more so--why would it be that they would be less likely to "self-medicate?"

The question raises the perennial issue of what motivates drug use--pleasure or need, and is there ultimately a difference? The article suggested Cambron's belief, like that of many drug users, that he needed substances to feel "normal." However, an alternative explanation is that anesthesiology attracts candidates who are highly inclined toward both novelty-seeking and mastery. Drug experimentation, like the professional drug administration of anesthesiology, satisfies both. In other words, drugs are exciting and pleasurable, and some are less able than others to resist the lure. To be sure, once an addiction develops, volition decreases greatly, but there are always initial crucial choices.

The article points out that Cambron's drug use, in the beginning, was far from impulsive. Indeed, it seemed to have been deliberate and carefully weighed, a virtually pure act of hubris--he was highly intelligent and capable, and sincerely believed that he could master the kinds of substances that had conquered countless others. He fell, like Icarus and like Macbeth. I don't mean to speak ill of the dead--Cambron was a highly talented individual with many virtues.

There was some question as to whether his death via overdose was recreational or intentional--but it involved vecuronium, which, as Zengerle pointed out, is a highly lethal, non-narcotic drug that no anesthesiologist would confuse with an opioid. High-potency opioids, like automobiles, make available more power than we are, evolutionarily, able to wield without significant risk. We must continue to optimize protections and limits, but it seems there will always be casualties.

Strung Out

Heroin be the death of me

Heroin, it's my wife and it's my life

Because a mainer to my vein

Leads to a center in my head

And then I'm better off than dead

The Velvet Underground

"An orgasm is nature's pale imitation of heroin."

Unattributed (if anyone knows source let me know)

Psychology Today blogger Stanton Peele, Ph.D. has a post proposing, according to him, the seven most addictive "substances," from cocaine (least) to, believe it or not, love (most). I won't quibble with his ranking per se, but since many people ask whether one can be addicted to such things as shopping, food, the Internet, and sex, it brought to mind how we go about defining addictions.

The problem is that the very concept of addiction is controversial and philosophically problematic, touching on great questions of free will, emotion, and even spirituality. Most of this is beyond the scope of this post (and, it must be said, beyond the scope of this amateur philosopher), but it seems safe to say that addictions are never entirely chosen nor entirely determined. They always hover somewhere in between, and it's hard to get one's mind around that (sort of like the uncertainty principle of quantum mechanics on a psychological level, perhaps). It is simple-minded to claim that willpower is absolute, but with addictions there is always room for choice ("Do I stop by the liquor store on the way home? Just two won't hurt.").

When we say that someone has a "conventional" addiction to something like nicotine or alcohol, we mean that the direct neurobiological effects of the substance are, if not removing, at least significantly impairing a person's capacity to avoid the substance. If a person stopped smoking three days ago and , feeling intense craving, gives in and takes a smoke, do we say that he was absolutely compelled (against his will) to do this? Well, no, but we think he has diminished volition--because of biological withdrawal effects--as compared to someone, say, who takes a smoke after being abstinent for a year.

We have a great deal of evidence now, from neuroimaging and other sources, that substances of abuse powerfully affect brain pathways. The conundrum is: how do we get form there to inferences about free will? After all, it is pretty likely that, say, flying into a rage is accompanied by certain neurobiological changes as well. If someone looks at me the wrong way and I take him down (I have not, generally, been known to do this), what keeps me from saying that "my brain made me do it?"

There would seem to be two answers to this, one biological and one sociological. Biologically, the question is how specific and how intense the neurochemical changes are as compared to what one might think of as a "normal" pleasurable experience (such as a walk on the beach, an enjoyable concert, or even sex). The more specific and prominent these changes are, the greater reduction in free will we might expect.

The sociological answer would seem to be that society, over time, develops, one hopes, a more refined consensus about what can reasonably be expected from individual behavior. It is reasonable to expect people not to fly into a murderous rage; it is not reasonable to expect all people at all times to be able to stop smoking at will without biological and other cessation strategies that may reduce hindrances to their free will.

Which brings us to the questionable "addictions" to sex, the Internet, and even food. The problem is that these activities just may not override the brain's volitional system in the same way that nicotine, etc. do. After all, just as a thought experiment, suppose that I enjoy reading books; I may even read them, at times, to cope with life's slings and arrows. In fact, I enjoy reading books so much that if I were prevented from reading them for a day or two, I could deal with it, but if it went on for much longer I would start to miss them, would become mentally restless, and would overall feel less happy. Would I be in "withdrawal" from a book "addiction?"

Similarly, if a materialistic person suffers a major financial hit, is he in withdrawal from a money "addiction," or if a "workaholic" is obliged to reduce his hours, does he suffer from "work withdrawal?" We may jokingly say yes, but we shouldn't really mean it.

To return to my example, what if I felt compelled to read so much that I neglected family and work responsibilities? (Note to wife if reading this post: please do not comment here). And after all, inasmuch as reading is pleasurable for me, it is probably associated with release of endorphins and other neurobiological changes at some level. The problem is that these changes are not above and beyond the evolutionary normal pathways that dictate our values and how we choose to attend to them. I would be overindulging in reading not because of an addiction, but because I was repeatedly choosing to do so (as emotional distraction or whatever).

There may be interesting gray areas. One might think sex would be one--after all, sex is arguably, in a purely biological sense if nothing else, one of the most focused, intense, and "rewarding" experiences we are naturally equipped to have. But the operative word here is "naturally," as nothing is evolutionarily normal if not sex. For eons societies have expected individuals to govern their sexual impulses without appeal to anything like a sex addiction clinic.

A true gray area could conceivably be video games and other virtual experiences. As these grow in intensity and engagement, perhaps they could stimulate the brain's reward systems in a way that may be beyond the evolutionary pale, such that cyberdetox would be necessary. Ars Psychiatrica does make for compelling reading, I know, but generally speaking the Internet doesn't appear yet to have reached that point.

None of this is to say that overindulgences in food, sex, or the Internet aren't problems; they certainly can be. But the issue, which may well be amenable to psychotherapy or other means of amelioration, is the individual's basic system of emotional self-regulation, not an "addiction."

Literature and the Cocktail Hour

Deluged by Tropical Storm Hanna today, a good day for blogging I suppose...Not long ago I came across a good quote: "Alcohol makes other people more interesting." At the time I took this to mean alcohol in the perceiver (so true), although it could of course mean alcohol in the perceived as well (somewhat true). As with any psychotropic substance, though, there is clearly a dose-response curve such that beyond a certain point, alcohol does the opposite.

It occurred to me that literature, or the arts in general, may act in the same way. Nietzsche famously wrote that "we have art so that we don't die of the truth." Could he have also written "so that we don't die of boredom?" Sometimes I think that a love of the arts is like a deficiency--wouldn't it be nice if the world just as it is, without all these...ornamentations, were enthralling, engaging, and lovable enough?