Canada Drug Rehab

By Daniel Jordan
General Manager
Sunshine Coast Health Center

Earlier this week, I had a thoroughly enjoyable discussion with Paul Murray, a private-practice psychologist based out of West Vancouver, British Columbia. Our discussion covered a lot of ground but one topic that I found particularly engaging was the notion of powerlessness. Both Paul and I marvelled at how two people declaring powerlessness over their addiction may have two very different treatment outcomes based on fundamentally opposing underlying intentions: one may reflect a preference for the status quo while the other could be ready to turn over a new leaf.

How Powerlessness Became Synonomous with Addiction

Obviously, this idea of powerlessness is not something that Paul and I invented. As friends of Bill W. will tell you, powerlessness lies at the heart of the 12 Steps of Alcoholics Anonymous and it’s first step: We admitted we were powerless over our addiction - that our lives had become unmanageable. Al-Anon has also consoled family members for years by telling them that they, too, are powerless over alcohol.

Over the years, however, Alcoholics Anonymous and other 12 Step programs have had their fair share of critics with powerlessness frequently at the heart of the dispute. For example, SOS, has created an alternative self-help group for “… those people who find that the ideas of reliance on a Higher Power or God, “powerlessness” and the emphasis on character defects to be an obstacle to recovery.”

The addiction treatment community has long since argued for and against the notion that individuals with addictions are ’powerless’. Powerlessness proponents tend to be traditional 12 Step treatment programs, physicians, and psychiatrists while those opposed tend to be psychologists, scholars, and mental health practitioners. The ongoing debate between these opposing camps has only hampered efforts by moderates to find common ground.

Furthermore, the debate over powerlessness and addiction is more than just a trivial concern judging by the vitriol one hears expressed on talk-back radio programs.

Defining Powerlessness

Let’s consider five different ways that powerlessness is understood in relation to addiction:

1) Powerlessness is a Choice

Recently, a book by Harvard psychologist Gene M. Heyman (*), Addiction: A Disorder of Choice, has suggested that individuals choose to be powerless. Dr. Heyman argues that addiction is voluntary rather than compulsory, and that addicts respond to incentives just like most other people. According to Dr. Heyman, interviews with drug users in recovery shows that quitting was preceded by such factors such as finances, family, career, and health.

People who suffer from diseases such as Alzheimer’s or schizophrenia, however, will rarely find improvement in their condition due to good intentions, even when followed by concrete steps. In other words, human beings are only truly powerless when faced with ‘real’ diseases.

One important difference between Dr. Heyman and other opponents to the concept of powerlessness, however, is that while Dr. Heyman believes that to remain powerless over an addiction is a choice, noone chooses to become an addict. As our Program Director, Geoff Thompson, often reminds our clients, children rarely tell their parents ”when I grow up, I want to be a drug addict.”

(*) Note: For more information, see Interview with Gene M. Heyman.

2) Powerlessness is a Lack of Willpower

Society often believes that, with a little bit of willpower, people can simply stop using drugs or alcohol or reduce their consumption to socially acceptable levels. This mistaken belief, however, is actually a failure to distinguish between the separate, progressive stages of compulsive use of chemicals or processes: abuse and addiction. As Carlton K. Erickson points out in his book, The Science of Addiction: From Neurobiology to Treatment, addiction is a failure to stop using in spite of negative consequences. Abusers of alcohol or drugs, most notably college students, will often stop excessive consumption when they are in a new environment where getting high or drunk is no longer encouraged, or when they experience negative consequences. For individuals with addictions, however, drinking or drug use will continue even after job loss, divorce, or illness.

Even for people who don’t struggle with addiction, however,  it is arguable whether simply trying harder is an effective method for attaining any worthy goal. Most who have tried to lose weight or have implored their children to improve their grades know that trying harder may work, but only temporarily. Without an effective strategy and implementation plan, willpower is not enough.

3) Powerlessness is the Same as Helplessness

Helplessness can be understood as the tendency for some addicted individuals to assign blame to external forces and avoid taking personal responsibility. So, when someone says “I am powerless to stop my addiction” they could be actually saying, for example, “my drinking wouldn’t be a problem if only my wife would get off my case.” This lack of accountability is typically obvious to everyone but the individual with the addiction, including those of us working in the field.

However, while it may be easy to spot helplessness in another person, determining the root cause of why someone is so incapable of taking action is far more challenging. For example, helplessness could be a response to childhood trauma, a phobia or depression. Taped recordings of AA Founder Bill Wilson suggest that he understood the link between helplessness and addiction. Following the sudden death of his childhood sweetheart, Bertha Banford, Bill Wilson concluded that “He knew now …. His need, his loving, didn’t matter a good goddam. His wanting, his hunger and desire, meant nothing to the terrible ongoing forces of creation and he would never forget this truth which he saw and accepted that night.” * Helplessness, as illustrated by Bill Wilson’s recollection, may not simply be a result of laziness but a reflexive survival mechanism in respsponse to painful past experience.

(*) Source: Thomsen, Robert (1975) Bill W.

4) Powerlessness is a Symptom of a Disease

The disease concept of addiction found an early advocate in the recovery movement with Dr. William Duncan Southworth, physician to AA founder Bill Wilson. By providing a physiological explanation for why alcoholics are powerless over their use of alcohol and through his close affiliation with Bill Wilson, Dr. Southworth helped shift the balance of power in addiction from organized religion to medicine. 

Dr. Southworth’s observation that alcoholism cycles between mental obsession and physical lack of control (or powerlessness) has stood the test of time. Defined this way, powerlessness is a common criterion used in the assessment of addiction. For example, Sunshine Coast Health Center recommends an addiction test, called the 3 Cs of Addiction: compulsion, control, and consequences. * What the 3 Cs test calls compulsion and control, Dr. Southworth calls, respectively, mental obsession and physical allergy. While the term ‘allergy’ may be arguable, alcoholics do appear to be physically powerless to stop drinking once the obsession to drink overpowers their decision not to drink.

(*) Note: see the Helplessness section above for information on the 3rd C - consequences.

5) Accepting Powerlessness is Critical to Lasting Recovery

First of all we had to quit playing God.
~ Alcoholics Anonymous, p. 62

This last example of powerlessness has been intentionally left to last since, unlike the first four definitions, this last definition will conclude this blog article on a hopeful note. Fortunately, many individuals have successfully come to terms with their addiction and have gone on to lead fulfilling lives in recovery. At Sunshine Coast Health Center, clients learn spiritual principles that often prove helpful as basic action guidelines in recovery. One spiritual principle, acceptance, seems particularly effective and is closely tied to the notion of powerlessness.

In his book, Not-God: A History of Alcoholics Anonymous, Ernest Kurtz suggests that “from the alcoholic’s acceptance of personal limitation [read powerlessness] - arises the beginning of healing and wholeness.” Furthermore, this message of “not-God” is, for Ernest Kurtz, an “affirmation of one’s connectedness with other alcoholics.” At Sunshine Coast Health Center, we wholly endorse the notion of connectedness, however, would extend it further to include family members, co-workers, and friends.

Conclusion

In the early days of Sunshine Coast Health Center, I will always remember how insistent one of our first clinicians was on the importance of making sure clients understand, at a gut level, Step One . As far as he was concerned, without a firm understanding of powerlessness, it is difficult, if not impossible, to properly work the remaining 11 Steps. However, I have learned over the years that words can often have multiple meanings and can trigger certain emotions depending on the perspective of the listener. By avoiding rigid absolutes, Sunshine Coast Health Center believes that it’s integrated approach allows clients to embrace multiple perspectives and, therefore, to appreciate the complexity that is inherent in any meaningful discussion on addiction.

Geoff Thompson, MA, CCC

Geoff Thompson, Program Director for Sunshine Coast Health Centre, discusses internalizing the negative stigma of addiction and overcoming the need to defend yourself.

Geoff Thompson, MA, CCC

Geoff Thompson, Program Director for Sunshine Coast Health Centre, talks about the stigma of addiction and the impact this can have on your life and your recovery.

By Geoff Thompson - MA, CCC

The March 3, 2008, issue of Newsweek magazine reported, “Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it.”

One in 10. I suspect this figure bothered many who read the Newsweek article. It is certainly disconcerting to most people I know. I was the technical expert on the first crystal meth task force in Canada, whose work was praised in the federal Parliament. When I pointed out that there was no evidence that anyone could get hooked on meth after a few uses, the other task force members, with admirable candor, dismissed me outright. They had to, of course. Why bother demonizing a drug if nine out of 10 people can use it without risking addiction?

The public believes that the drug does the addicting. Their reasoning goes something like this: the addict can be anyone who does enough of a drug enough times until he or she becomes an addict. But researchers have known for years that there is nothing magical about a white powder or a liquid or a dried plant. Neuroscientist James Kalat put it this way: “Addiction is not in the drug; it’s in the person.”

It’s important not to misinterpret the science. No one believes that ninety percent of us can take a drug without risk. Anyone can suffer serious consequences for using any drug, including alcohol: DUIs, medical complications, even death. But scientists distinguish between “substance abuse” and “substance dependence.” The latter is addiction, and its defining feature is that the person continues to use a substance “despite knowledge” that it will lead to severe consequences. Abusers use drugs for a specific reason; once the reason is gone, or the drug causes them too much trouble, they stop.

Interestingly, in September, 2008, a Texas neuroscientist, Carlton Erickson, spoke in Nanaimo about the genetic predisposition. In his view, the high success rates claimed by many programs were because the clients were substance abusers and not addicts.

The genetic component is called a ‘predisposition’, which means that it is not a ‘cause’. Being born with the special brain biology is a necessary condition of addiction, but not a sufficient one. There are many people with the predisposition who are not addicts. We know, for instance, that some children growing up in addicted families are so scared of becoming addicted that they never touch a drug. We also know that the addiction rate among children in very religious families is less than the national average. It is likely that many of the kids have the genetic predisposition, but their psychology or environment works against drug use.

The implications of the genetic one in 10 dispel many popular beliefs. For example, most people still believe that addiction equals physical dependence. For decades, physical dependence was the defining feature of the addict, and anyone who experienced withdrawal after quitting the drug was an addict. This concept of addiction became controversial in 1971 when Dr. Lee Robins published her famous study on addiction in Vietnam veterans. Robins studied returning vets who had been using lots of opiates (heroin, morphine, opium) overseas.

Popular opinion at the time was reflected in the movie, The Panic in Needle Park (1971), which portrayed the powerlessness of the heroin addict. But Robins found the opposite. When the young men returned to the US, the majority gave up the habit. They went through withdrawal, of course, but they didn’t seek out the local drug dealer. 

On learning Robins’ results, many experts were astounded. They declared that all those physicians who had us convinced that addiction is a disease, over which the addict had no control, must have got it all wrong. If these soldiers could simply stop taking opiates, then how could the addict be powerless, a victim of a medical condition?

Today, however, we do not diagnose someone an addict simply because he or she experiences withdrawal. We can understand how the soldiers gave up the drug so easily, if we remember that addiction is in the person and not in the drug. The answer: they were not addicts. So why were they using so much heroin, morphine, and opium? They were in a war, and opiates are the best painkillers available. Back in the comfort of their hometowns, they no longer needed a painkiller. Only those returning vets who were addicts sought out the dealers.

Nora Volkow, head of the US National Institute on Drug Abuse, one of the US Institutes of Health, told USA Today, in its October 10, 2005, issue: “Everyone given an opiate…will become physically dependent, but not everyone will become an addict.”

And psychologist Stanton Peele reminds us in his latest book, Addiction-Proof Your Child, that many parents anxious that their kids will use drugs seem to have forgotten that they, too, used a lots of drugs and quit fairly easily.

I suspect that most readers will find this idea that addiction is not in the drug confusing. In fact, research contradicts a great deal of the popular opinion that we read in newspapers and hear in political speeches.

Perhaps there’s a lesson here. If we want to do something about the problem, it’s probably a good idea to pay more attention to reality.

About The Author

By Daniel Jordan

I was at an addiction conference yesterday in beautiful Nanaimo, British Columbia sponsored by our friends over at Edgewood, a private drug treatment center located on Vancouver Island. The keynote speaker of the conference was Dr. Carlton Erickson, Ph.D., Professor of Pharmacology, and director of the Addiction Science Research and Education Center in the College of Pharmacy at the University of Texas at Austin. Dr. Erickson, a research scientist, has been studying the effects of alcohol on the brain for over 40 years and he did a commendable job of trying to summarize all of his knowledge in a 3-hour presentation.

Here’s what I learned from Dr. Erickson:

Lesson One: Addiction is a “Brain Disease”

It’s not surprising that a neuroscientist would suggest that addiction is a brain disease but Dr. Erickson does make a compelling argument by comparing chemical dependence to several other diseases such as Type 2 Diabetes, hypertention, Parkinson’s Disease, and Attention Deficit Hyperactivity Disorder (see page 11 of Erickson’s book, The Science of Addiction ).  The presentation included some very colourful, scientific images of the brain and it’s good to know the latest in addiction research on the brain and the exact brain area that is affected in the chemically dependent person, the mesolimbic domamine system.

At Sunshine Coast Health Center, we have found that clients love the psychoeducation classes on the brain since, for the first time, many can start to understand why they have the thoughts, feelings, and behaviours normally experienced with a dependence to drugs or alcohol. With this  biological, rather than a moral, explanation clients begin to question their attachment to detrimental emotions such as guilt and shame.

Lesson Two: Our Terminology Needs Fixing

More than the scientific presentation showing how addiction impacts the brain, I was particularly fascinated by Dr. Erickson’s claim that many of the the words, or terminology, that the general public and the treatment field use to describe drinking and drugging are leading to continued prejudice and discrimination in North American culture. This stigmatizing, Dr. Erickson argues, is a big part of why governments are not providing adequate funding for addiction research, prevention, and education.

“Addiction” is a Vague Term

The term “addiction,” for example, has been used for way too many behaviours and things including but not limited to cell phones, television, work, food, sex, exercise, oil, shoes, “crackberries,” etc.  As a result, Dr.  Erickson suggests that “addiction” is an imprecise, unscientific term. The term addiction is now used in popular vocabulary as a way to describe something desired such as “I love the Oprah Show so much I think I’m addicted to it.” Obviously, the negative impact of watching too much Oprah and smoking copious amounts of crack cocaine cannot compare. The use of “addiction” to describe America’s over-reliance on foreign oil shows how far the term has been adopted beyond its original intended use.

Another problem with the term “addiction” is due to the umbrella-like nature of the term which fails to distinguish between conscious drug abuse and pathalogical chemical dependence (see Lesson Three below).

Alcoholics Anonymous has Broadened the Term “Alcoholism”

Alcoholism is another term that should be replaced due, unintentionally, to its popular use at Alcoholics Anonymous meetings. If you have ever attended AA or watched a video such as Clean & Sober (starring Michael Keaton) you will have witnessed participants starting off their testimonials with the words, “Hi, my name is ____ and I’m an alcoholic.” The truth is, suggests Dr. Erickson, many of these people standing up are problem drinkers and not necessarily dependent on alcohol since joining AA is open to any problem drinker seeking to get better.

 ”Abuse” is a Perjorative Term and Should be Retired

In his book, The Science of Addiction, Dr. Erickson calls the term “abuse” the number 1 myth that prevails in the treatment field or in the minds of the public. The word abuse * is an inappropriate term for several reasons, such as:

1. the term being used, for centuries, as a morally sinful act such as child abuse, sexual abuse, spousal abuse
2. the implication that alcohol, an object, is being abused by someone just like a child is being abused by someone (a preferred term in Europe is misuse)
3. the use of the term substance abuse does not distinguish between voluntary use (”misuse”) and uncontrolled use (”dependence”) similar to the generalized use of the term “addiction” 

By continuing to refer to people as drug, alcohol, or substance abusers, according to Bill White *, “misstates the nature of their condition and calls for their social rejection, sequestration, and punishment.”

More myths can be found at the the University of Texas website. 

(*) Note: See page 4 of “The rhetoric of recovery advocacy: An essay on the power of language,” written by WIlliam White.

To summarize, Dr. Erickson idetifies the terms “addiction,” “alcoholism,” and “substance abuse” as sloppy and stigmatizing because they do not distinguish between intentional, voluntary use of drugs or alcohol (”abuse”) and the impaired control over drug use (”dependence”).

Lesson Three: Drug Misuse and Dependence are Two Different Conditions

I have always understood that someone who “abuses” drugs or alcohol is not necessarily chemically dependent but Dr. Erickson really drove the point home by making several important distinctions.

To start this important discussion, Dr. Erickson made reference to DSM-IV critieria and pointed out to the audience that abuse of drugs or alcohol needs to show a maladaptive pattern of drug use leading to impairment or distress presenting as one or more of the following in a 12-month period:

1. recurrent use leading to failure to fulfill major obligations
2. recurrent use which is physically hazardous
3. recurrent drug-related legal problems
4. continued use despite social or interpersonal problems

On the other hand, dependence on drugs or alcohol needs to show a maladaptive pattern of use leading to impairment or distress, presenting as three or more of the following in a 12-month period:

1. tolerance to the drug’s actions
2. withdrawal
3. drug is used more than intended
4. there is an inability to control drug use
5. effort is expended to obtain the drug
6. important activities are replaced by drug use
7. drug use continues despite knowledge of a persistent physical or psychological problem

Source: Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - Text Revision, 2000.

If you have just one or two symptoms, it is not dependence. For example, you may think you are dependent on coffee but it is unlikely that your caffeine use has led to anything beyond symptoms one and two in the list above.

However, the implication of making a clear distinction between the two conditions has one clearly controversial implication that has been hotly debated in the treatment field: ”abusers,” unlike people that are dependent, can go back to moderate or controlled drinking (see pg. 17 of the Science of Addiction) *.

(*) Source: Wallitzer, K.S., & Connors, G.J. (1999). Treating problem drinking. Alcohol Research & Health, 23, 138-143.

How treatment providers like Sunshine Coast Health Center make the distinction between clients who are pathalogically dependent and those that are merely voluntary misusers is another matter. Clearly, however, this information needs to be handled, if at all, with clients. It does, however, explain why many addiction professionals claim that there is a cure for addiction since, in their research or clinical experience, they may have been working with “abusers” rather than truly chemically dependent individuals.

Lesson Four: Some Drugs are More Addictive Than Others

Dr. Erickson calls the likelihood that a person will become dependent on a drug its “dependence liability.” Some drugs have a dependence liability while others do not. The criteria for dependence liability is how it acts on the mesolimbic dopamine system. Caffeine, antidepressants, and newer anti-seizure medications do not have dependence liability. However, some drugs do and the following chart shows that a certain percentage of people (depending on the drug) will become dependent *:

Drug / Percentage of People Who Become Dependent

Nicotine - 32%, Heroin - 23%, Cocaine - 17%, Alcohol - 15%, Stimulants - 11%, Cannabis - 9%, Sedatives - 9%, Psychedelics - 5%, Inhalants - 4%.

Source: Anthony, J.C., Warner, L.A., & Kessler, R.C., (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the national comorbidity survey. Experimental & Clinical Psychopharmacology, 2, 244-268.

Lesson Five: There are Different Types of Alcohol Dependence

Dr. Erickson presented compelling research showing that some types of alcohol dependence occur early in life while other types occur late in life:

1. Early Onset - some adolescents are at higher risk for alcohol dependence, especially when they drink at an early age
2. “Instant” Onset - some people become “instantly addicted” to alcohol or cocaine with the first use of the drug, that they “feel normal” for the first time in their lives.
3. Late Onset - after age 25 for some, or geriatric age for others.
4. Absence of Onset - just like some people eat a lot and never get fat, some people can misuse drugs or alcohol forever and never become dependent.

In this way, alcohol dependence is not onlike other diseases that have different onsets such as diabetes, leukemia, and heart disease. Dr. Erickson did point out, however, that more research is needed to confirm these findings.

Conclusion

Regardless of whether you were a professional who advocates a harm reduction or abstinence-based approach, Dr. Erickson’s presentation had some good news and some bad news. With his clear support for research validity, however, one thing that the treatment field should not do is dismiss his work out of hand. Kudos to Edgewood for presenting Dr. Erickson, an addiction professional who is clearly an advocate for change.

For More Information

For those interested in learning more about addiction and the brain, Dr. Erickson recommends the following websites:

University of Texas Addiction Science and Research Center

National Institute on Drug Abuse (NIDA)

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Join Together Online

Faces & Voices of Recovery

Brain SPECT Imaging (Daniel Amen, MD)

NIH/NLM Publications

For those that want to learn more about this important topic, pick up a copy of The Science of Addiction: From Neurobiology to Treatment.  I have since found a criticism of this book by Harvard University psychiatrist Edward J. Khantzian, M.D. and it’s worth a look for those interested in the polarization in the field of addiction between psychiatry and addiction medicine.

About the Author

Daniel Jordan is the General Manager of Sunshine Coast Health Center and hopes that these postings will help  take away some of the mystery often associated with addiction and its treatment.