The Anatomy of Addiction (16 page)

Over the course of six months, Samantha steadily improved. I saw her every week for the first month and then once every two weeks for next three months. Then I saw her just monthly. That time when she passed out was the last time she used ecstasy, though she confessed to continuing to smoke pot on occasion. She no longer goes to raves but still enjoys seeing live music with her friends. And she quit her job and is now pursuing a master's degree in economic anthropology. “I finally figured out what I was passionate about, and it wasn't either fashion or Hollywood,” she said.

Individualized Treatment

To overlook the individuality of a patient with dual disorder is likely not only to result in ineffective treatment but also is a gross
violation of medical ethics and professional conduct. Because of both the complexity of the disease and the individuality required for its treatment, there is no simple one answer fits all treatment —in spite of what many rehab clinics would have you believe.

Despite the general consensus among medical professionals that those with dual diagnoses of addiction and mental illness must be treated for both conditions if they are to stay sober, very few rehab clinics, and even very few doctors, are trained to treat the afflicted.

I
n 1982, when then First Lady Nancy Reagan was asked by a schoolgirl what to do if she was offered drugs, she responded saying, “Just say no!”

Thus began a forty-year public relations campaign that, incredibly, in spite of its abject failure and $50 billion price tag, continues today. There's no evidence that the campaign has had any measurable effect on alcohol or drug addiction, and if anything, addiction among young people has gotten worse. Though it's no longer actively promoted, the Just Say No campaign, an offshoot of the larger war on drugs initiative, still influences politicians, educators, police authorities, and even the judiciary.

That an entire multibillion-dollar program to stymie youth addiction evolved not from research but from a knee-jerk phrase speaks volumes about the misplaced priorities and wasted resources of a nation. If anyone truly believes that tossing a throwaway phrase at kids is sound strategy for dealing with the drug culture all around them, then they must really think kids are stupid. And they're not.

The Just Say No campaign, the war on drugs, and virtually every other effort to stop teen addiction since Congress approved the Harrison Narcotics Act in 1914, including the now hilarious 1936 documentary film
Reefer Madness
, have failed because they don't pass the smell test: Their scare tactics and propaganda that any and all drinking and drugging lead to a straight and narrow path to addiction is false, and kids know it.

The Just Say No phrase, however, is not only useless but pernicious because it reinforces the false notion, promulgated by a well-intentioned AA community and exploited by the unscrupulous rehab industry, that addiction is simply something you can say no to. If you try hard enough, you can just stop. Addiction is like all other chronic diseases, including diabetes, heart disease, or arthritis. Just say no and you can just stop suffering from these diseases. (Oh, that's not right, is it?)

Why Treating Teenagers and Young Adults Is Different

It's no big secret that teenagers drink alcohol and do drugs. What's not understood by the public and even most medical professionals is why. Young people begin their quests for identity, for their sense of self, in their teen years. To be clear, teenagers base their self-identity entirely on how they see themselves, not on how their parents see them. Studies have shown that one primary way teens demonstrate their struggles with identity is indulging in forbidden behavior, including drinking and drugging, behaviors associated with adulthood.

Compounding the problem of teens' natural predilections to experiment with drugs and alcohol is that physiologically they are more sensitive to brain damage from addiction because their brains are still developing. Unfortunately, most efforts at teen addiction are rooted in the early twentieth-century doom-and-gloom
philosophy, which most teens correctly perceive as irrelevant to their lives.

It's important to underscore, however, that not every teen who experiments with alcohol or drugs will become an addict; in fact, most will not. Maia Szalavitz, one of the nation's leading neuroscience and addiction journalists, pointed out in a recent column for Substance.com that the average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within fifteen years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. A self-described addict who shot cocaine and heroin in her youth, she stopped when she was twenty-three years old, theorizing that, in effect, her brain finally grew up: “Although I got treatment, I quit at around the age when . . . the prefrontal cortex—the part of the brain responsible for good judgment and self-restraint—finally reaches maturity.”

Truly successful teen addiction education and treatment are based on nonjudgmental harm-reduction programs, grounded in reality (not some war on drugs spin). Bottom line: The treatment for a binge-drinking teen must be entirely different from that of a middle-aged alcoholic with decades of continual consumption.

First, Do No Harm

If we are truly to reduce harm, we must give practical, short-term harm-reduction messages with which youth can identify and personalize. We have a much better chance of preventing a drunk-driving tragedy the night of the prom than we do preventing liver failure in forty years.

Writer, comic, and self-confessed screw-up Amy Dresner—known for her no-holds-barred skits that frequently incorporate references to her own personal addiction—recalls how she used to shoot meth directly into her bloodstream with a needle. As she did it more and more, she began having violent seizures. She rightly perceived the danger of possible traumatic brain injury during a meth-induced seizure. “I realized that shooting meth was an extreme contact sport requiring safety equipment,” jokes Dresner. “I started wearing a football helmet when shooting up.”

Silly as it sounds, Dresner was taking a positive step by considering and using the concept of harm reduction. She protected herself from a possible traumatic brain injury. The natural progression of harm-reduction thinking is to reduce harm as much as possible at all times and under all conditions. This leads to the realization of the need to stop the dangerous behavior. Dresner no longer shoots meth, and the football helmet is no longer required.

Preventing a drunk driving casualty can be accomplished by alerting teens to the real immediate danger of such behavior and by providing alternative transportation to and from parties and events. The obstacle to this life-saving strategy is that it requires dealing with reality, and harm-reduction strategies run into difficulty because they are predicated on dealing with the fact that many teens are already drinking.

As international researchers have noted, this is a major problem in the United States, where the uniform minimum legal drinking age is twenty-one, but the average age when people start drinking is thirteen or fourteen. This means that that alcohol education programs used in American schools start out with a major handicap: The erroneous assumption that a significant segment of
the target audience is not already drinking or experimenting with drugs.

Peter E. Nathan, in his study “Alcohol Dependency Prevention and Early Intervention,” cited research indicating that “students who are most responsive to school-based programs probably are those for whom such programs are least necessary. Programs may not be reaching those children who are at greatest risk to develop alcohol and drug problems.”

In the high-risk category were teens with a family history of abuse, those with a history of antisocial behavior, and those from ethnic and racial minority groups who were “physically or psychologically beyond the reach of traditional, school-based prevention programs.”

Successful programs use honest and effective educational strategies that treat drug use as just another part of a broad health curriculum that includes topics such as medical care, nutrition, exercise, hygiene, ecology, safety, and other activities that affect the students' quality of life.

In the prevention of addiction and alcoholism, addressing only drugs and alcohol overlooks other factors contributing to the onset of drug- and alcohol-related illness and addiction. An effective school program should send an honest, positive message that includes models beyond abstinence, embracing moderation, harm reduction, and personal responsibility. If possible, school-based prevention programs should be integrated into the school's academic program, because school failure is strongly associated with drug abuse. Integrated programs strengthen students' bonding to the school and reduce their likelihood of dropping out.

Any program used to prevent or reduce underage drinking and drug use must be continually evaluated. An evaluation needs to answer the following questions:

• What was accomplished in the program?

• How was the program carried out?

• How much of the program was received by participants?

• Is there a connection between the amount of program received and outcomes?

• Was the program run as intended?

• Did the program achieve what was expected in the short term?

• Did the program produce the desired long-term effects?

Repeated research and evaluation of successful methods shows that the most proven and practical approach for dealing with teen drinking and drug use is strategic harm reduction. In other words, make the world a safer place—safe
for
the drunk teen and safe
from
the drunk teen. Just as seat belts and airbags are harm-reduction strategies for road safety, the idea is to put a separation between the individual and harm, and society and harm.

Harm-reduction projects have aimed to minimize potential casualties and other damages associated with drinking in bars and nightclubs. Bars in the United States are now forbidden to serve alcohol to someone who is obviously intoxicated. They are also legally restrained from verbally encouraging people to get drunk. If a drunk driver kills someone and that driver was served alcohol when he was already drunk, the bartender may be criminally
liable. While it can be argued that the person refused service will go elsewhere, it is hoped that his or her degree of intoxication will not increase.

Taking keys away from drunks and calling them a taxi to get them home is a major harm-reduction policy that is saving lives, as is the concept of the designated driver. “Friends don't let friends drive drunk” is a major harm-reduction campaign in the United States, and it is having a beneficial effect.

Reducing Harm

Harm reduction is a health-centered approach that seeks to reduce the health and social harms associated with alcohol and drug use, without necessarily requiring users to abstain.

Harm reduction is a nonjudgmental response that meets users where they are in regard to their substance use rather than imposing a moralistic judgment on their behaviors. This approach includes a broad range of responses, from those that promote safer substance use to those that promote abstinence.

The following features of harm reduction are clear indicators of why programs and campaigns based on this premise work:

•
Pragmatism:
Harm reduction accepts that some use of psychoactive substances is inevitable and that some level of substance use is expected in a society.