Sunday July 5, 2009

Addicted to ...
Age Well
By Dr RAMINDER KAUR

Understanding the complexities of drug abuse and addiction.

MANY people do not understand why individuals become addicted to drugs or how drugs
change the brain to foster compulsive drug abuse. They mistakenly view drug abuse and
addiction as strictly a social problem and are apt to characterise those who take drugs as
morally weak.

One very common belief is that drug abusers should be able to just stop taking drugs if they
are only willing to change their behaviour. What people often underestimate is the complexity
of drug addiction – that it is a disease that impacts the brain and because of that, stopping
drug abuse is not simply a matter of willpower.

Through scientific advances, we now know much more about how drugs exactly work in the
brain, and we also know that drug addiction can be successfully treated to help people stop
abusing drugs and resume their productive lives.

Drug abuse and addiction are a major burden to society. Estimates of the total overall costs
of substance abuse in the United States, including health and crime-related costs as well as
losses in productivity, exceed half a trillion dollars (RM1.75trillion) annually. This includes
approximately US$181bil (RM663.5bil) for illicit drugs, US$168bil (RM588bil) for tobacco,
and US$185bil (RM647.5bil) for alcohol.

Staggering as these numbers are, however, they do not fully describe the breadth of
deleterious public health and safety implications, which include family disintegration, loss of
employment, failure in school, domestic violence, child abuse, and other crimes.

What is drug addiction?

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking
and use despite harmful consequences to the individual who is addicted and to those around
them. Drug addiction is a brain disease because the abuse of drugs leads to changes in the
structure and function of the brain.

Although it is true that for most people the initial decision to take drugs is voluntary, over time
the changes in the brain caused by repeated drug abuse can affect a person’s self control
and ability to make sound decisions, and at the same time send intense impulses to take
drugs.
It is because of these changes in the brain that it is so challenging for a person who is
addicted to stop abusing drugs. Fortunately, there are treatments that help people counteract
addiction’s powerful disruptive effects and regain control.

Research shows that combining addiction treatment medications, if available, with

behavioural therapy is the best way to ensure success for most patients.

Treatment approaches that are tailored to each patient’s drug abuse patterns and any co-
occurring medical, psychiatric, and social problems can lead to sustained recovery and a life
without drug abuse.

Similar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease,
drug addiction can be managed successfully. And, as with other chronic diseases, it is not
uncommon for a person to relapse and begin abusing drugs again.

Relapse, however, does not signal failure – rather, it indicates that treatment should be
reinstated, adjusted, or that alternate treatment is needed to help the individual regain
control and recover.

What happens to your brain when you take drugs?

Drugs are chemicals that tap into the brain’s communication system and disrupt the way
nerve cells normally send, receive, and process information. There are at least two ways that
drugs are able to do this: (1) by imitating the brain’s natural chemical messengers; and/or (2)
by over stimulating the “reward circuit” of the brain.

Some drugs, such as marijuana and heroin, have a similar structure to chemical
messengers, called neurotransmitters, which are naturally produced by the brain. Because of
this similarity, these drugs are able to “fool” the brain’s receptors and activate nerve cells to
send abnormal messages.

Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release
abnormally large amounts of natural neurotransmitters, or prevent the normal recycling of
these brain chemicals, which is needed to shut off the signal between neurons. This
disruption produces a greatly amplified message that ultimately disrupts normal
communication patterns.

Nearly all drugs, directly or indirectly, target the brain’s reward system by flooding the circuit
with dopamine. Dopamine is a neurotransmitter present in regions of the brain that control
movement, emotion, motivation, and feelings of pleasure. The overstimulation of this system,
which normally responds to natural behaviors that are linked to survival (eating, spending
time with loved ones, etc), produces euphoric effects in response to the drugs. This reaction
sets in motion a pattern that “teaches” people to repeat the behaviour of abusing drugs.
As a person continues to abuse drugs, the brain adapts to the overwhelming surges in
dopamine by producing less dopamine or by reducing the number of dopamine receptors in
the reward circuit. As a result, dopamine’s impact on the reward circuit is lessened, reducing
the abuser’s ability to enjoy the drugs and the things that previously brought pleasure.

This decrease compels those addicted to drugs to keep abusing drugs in order to attempt to
bring their dopamine function back to normal. And, they may now require larger amounts of
the drug than they first did to achieve the dopamine high, an effect known as tolerance.

Long-term abuse causes changes in other brain chemical systems and circuits as well.
Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn.
When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to
compensate, which can impair cognitive function.

Drugs of abuse facilitate non-conscious (conditioned) learning, which leads the user to
experience uncontrollable cravings when they see a place or person they associate with the
drug experience, even when the drug itself is not available.

Brain imaging studies of drug-addicted individuals show changes in areas of the brain that
are critical to judgment, decision making, learning and memory, and behaviour control.

Why do some people become addicted, while others do not?

No single factor can predict whether or not a person will become addicted to drugs. Risk for
addiction is influenced by a person’s biology, social environment, and age or stage of
development.

The more risk factors an individual has, the greater the chance that taking drugs can lead to
addiction. For example:

·Biology. The genes that people are born with, in combination with environmental influences,
account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the
presence of other mental disorders may influence risk for drug abuse and addiction.

·Environment. A person’s environment includes many different influences, from family and
friends to socioeconomic status and quality of life in general. Factors such as peer pressure,
physical and sexual abuse, stress, and parental involvement can greatly influence the course
of drug abuse and addiction in a person’s life.

·Development. Genetic and environmental factors interact with critical developmental stages
in a person’s life to affect addiction vulnerability, and adolescents experience a double
challenge. Although taking drugs at any age can lead to addiction, the earlier that drug use
begins, the more likely it is to progress to more serious abuse. And because adolescents’
brains are still developing in the areas that govern decision making, judgment, and self-
control, they are especially prone to risk-taking behaviours, including trying drugs of abuse.

Prevention is the key

Drug addiction is a preventable disease. Results from research have shown that prevention
programmes that involve families, schools, communities, and the media are effective in
reducing drug abuse.

Although many events and cultural factors affect drug abuse trends, when youths perceive
drug abuse as harmful, they reduce their drug taking. It is necessary, therefore, to help youth
and the general public to understand the risks of drug abuse, and for teachers, parents, and
healthcare professionals to keep sending the message that drug addiction can be prevented
if a person never abuses drugs.

Sunday September 4, 2005

Fighting drug addiction

This week sees the introduction of a new column, Your Health Matters, contributed by
members of the Federation of Private Medical Practitioners’ Associations Malaysia. To
kick of the series, Dr Steven KW Chow looks at the issue of drug addiction.

SEVENTEEN thousand six hundred people – that’s the number of drug addicts detected
from January to July 2005. About 70% of these cases were youths.

More alarmingly, according to a United Nations report, for every one case that is reported, up
to four more go undetected. This means that the actual number of Malaysians caught in the
web of addiction could be much higher than that.

These figures do not lie. Drug addiction remains a serious threat to our nation. Drug abuse is
a major public health problem that impacts society on multiple levels. Directly or indirectly,
every community is affected by drug abuse and addiction, as is every family.

The good news is that drug addiction can be treated effectively. Over 40 years of research
and clinical science have indicated that addiction is a chronic disease and require tailored
treatment strategies, like other chronic diseases that can be treated successfully using a
medical approach.

What is drug addiction treatment?

There are many addictive drugs, and treatments for specific drugs can differ. Treatment also
varies depending on the characteristics and the history of the patient.

Problems associated with an individual’s drug addiction can vary significantly. People who
are addicted to drugs come from all walks of life. Many suffer from mental, occupational,
health, or social problems that make their addictive disorders more difficult to treat.

Even if there are few associated problems, it is important to remember that the severity of
addiction itself ranges widely among people.

A variety of scientifically-based approaches to drug addiction treatment exists. Drug

addiction treatment can include behavioural therapy (such as counselling, cognitive therapy,
or psychotherapy), medications, or a combination of both.

Behavioural therapies offer people strategies for coping with their drug cravings, teach them
ways to avoid drugs and prevent relapse, and help them deal with relapse if it occurs. When
a person’s drug-related behaviour places him or her at higher risk for HIV or other infectious
diseases, behavioural therapies can help to reduce the risk of disease transmission. Case
management and referral to other medical, psychological, and social services are crucial
components of treatment for many patients.

The best treatment plans provide a combination of therapies and other services to meet the
needs of the individual patient, which are shaped by such issues as age, race, culture,
sexual orientation, gender, pregnancy, parenting, housing, and employment, as well as
physical and sexual abuse.

Treatment medications, such as buprenorphine and methadone, are available for individuals
addicted to opiates.

Nicotine preparations (patches, gum, nasal spray) are available for individuals addicted to
nicotine.

Medications, such as antidepressants, mood stabilisers, or neuroleptics, may be critical for

treatment success when patients have co-occurring mental disorders, such as depression,
anxiety disorder, bipolar disorder, or psychosis.

Treatment can occur in a variety of settings, in many different forms, and for different lengths
of time. Because drug addiction is typically a chronic disorder characterised by relapses, a
short-term, one-time treatment often is not sufficient. For many, treatment is a long-term
process that involves multiple interventions and attempts at abstinence.

In all cases, it is important to remember that no one treatment regime is right for everyone,
and that treating drug addiction successfully requires flexibility, and a thorough
understanding of each individual’s problem.

When to seek medical advice

Addiction is a chronic relapsing disorder, meaning you tend to fall back into old addictive
behaviours, including drug use, even after treatment. The sooner you seek help, the greater
your chances for a long-term recovery.

Because denial is nearly always a characteristic of addiction, people who are addicted to or
who abuse drugs often won’t seek medical treatment on their own. Family members, friends
or co-workers may need to persuade someone to undergo screening for drug addiction.
Breaking a drug addiction may involve counselling, an outpatient treatment program or
residential treatment.

Screening and diagnosis

Diagnosing drug addiction often starts at the level of the family doctor, perhaps after one
family member has raised concerns about another family member’s behaviour. Your doctor
may ask questions about your frequency of drug use, whether any family member has
criticised your drug use or whether you’ve ever felt you might have a problem.

A definitive diagnosis of drug addiction usually occurs after an evaluation by a qualified

doctor trained in addiction medicine, psychiatrist, psychologist or a specialised addiction
counsellor. Laboratory tests often aren’t able to result in a diagnosis of a drug addiction, but
blood and urine tests can help a doctor detect the presence of a drug when its use has been
denied.

Where to seek help

Launched in July 2005, the “Drs Who Care” programme is the latest public outreach
programme spearheaded by the Federation of Private Medical Practitioners Associations
Malaysia (FPMPAM). Its mission is to increase access to and improve the quality of addiction
treatment in Malaysia.

The “Doctors Who Care” programme seeks to educate the public to view drug addiction as a
chronic disease, rather than a social ill or weakness. The key strategy is to encourage
treatment of drug-addiction in a supportive family-orientated environment within the
community. With this approach, it is possible for the addict to return to useful and normal life
as soon as possible during their period of recovery.

The public can now be connected to over 250 qualified, compassionate and dedicated
doctors in their communities who are experienced and committed toward treating substance
addiction.

Patients can be assured that the doctors on the panel have undergone specific training in
addiction medicine and have the special skills and knowledge to diagnose and treat specific
problems and to medically manage the care of addiction disorders.

The promise of treatment is real. If you or someone that you care about has been abusing
drugs or if you suspect that she or he has become addicted, seek help today.

Drug addiction, a chronic brain disease

KUALA LUMPUR: The number of drug addicts is anticipated to double by
2015 from the current 270,000 and the figure indicates addiction to
drugs is more than a social or behavioural problem.

A recent workshop held in conjunction with World Anti Drug Month

emphasized that addiction is a chronic brain disorder. This view backed
by scientific studies is increasingly gaining acceptance.

Dr Sivakumar Thurairajasingam, a Consultant Psychiatrist with Monash

Universitys Clinical School in Johor Baharu explained that drug addiction
is a chronic, often relapsing, disease caused by the changes in the
structure of the brain due to prolonged drug abuse.

It will be difficult to kick the habit especially when the person has
reached the dependence level. A person who has reached the
dependence stage is actually suffering from an addiction disease.

At this stage, addicts take drugs not to attain the ‘reinforced feeling
anymore but to enable them to continue functioning psychologically and
physiologically.

Thus in treating them, they are given safe drugs as substitute (drug
substitute therapy). Dr Sivakumar said the treatment goals for the
addicts focus on rebuilding their life, work towards harm reduction and
lessens the dependence on substances.

The Association for the Prevention of Dadah Abuse (Pemadam) revealed

that it costs RM50 million annually to rehabilitate the addicts but the
question remains whether they can be fully rehabilitated?

Dr Salina Abdul Aziz, Consultant Psychiatrist and Clinical Epidemiologist

at the Kuala Lumpur Hospitals Department of Psychiatry said probably
there is no cure for those who have reached the dependency stage but
the problem can be controlled and managed.

“Its like diabetes and asthma, drug addiction can be managed

successfully if not cured completely.

“No one could claim as an ex-addict even after staying away from
drugs up to 20 years because the habit could relapse anytime.

“So that’s why we often hear from those in the recovering process
stating that ‘Im a recovering addict or ‘a clean addict.

“Also those who come to seek treatment must be confided that

relapse does not signal failure, it goes to indicate that the treatment
should be reinstated, adjusted or alternate treatment methods are
needed to regain control and recover,” she said.

As addiction is now seen as a disease, drug substitute therapy tailored

according to individual needs is recommended. The process starts with
detoxification before undergoing the substitute therapy using methadone
or buprenorphine/ naloxone.

Addicts also undergo counseling and treatment for ailments including HIV
infection and others as part of the rehabilitation programme.

Dr Salina emphasized that the therapy had to be easily accessible when

considering the easy availability of drugs.

“Drugs can be sent to your door step upon request. Synthetic drugs
can be made anywhere,” she said adding that if treatment is not easily
accessible then they will return to drugs.

To ensure easy access to treatment, a number of private medical

practitioners provide the Community Based Treatment (CBT) under the
guidance of the Ministry of Health. CBT offers addicts confidential drug
substitute therapy in settings such as private clinics, specialist centres or
at homes all over the nation.

So far 528 private medical practitioners have enlisted to provide the

services with 18,000 patients on the register. Selangor has the highest
number of patients in the register, about 4,000 of them.

The CBT program utilizes a centralized surveillance Internet platform

called the National Drug Substitution Therapy (NDST) Register to monitor
the supply of the substitute drugs for patients undergoing addiction
treatment.

Dr Salina noted that surveillance would help avoid the abuse of substitute
drugs.

If drug addition is a disease, can the addicts be exonerated from any

blame for their own destruction?

Here both Dr Sivakumar and Dr Salina had the same thing to say,
don’t tempt fate in the first place by trying drugs.

“If you are addicted, then you have to blame yourself,” said Dr
Sivakumar.

The road for recovery is a long one with no guarantees on the outcome.

Nevertheless, drug addicts must be given assurance that change is

possible through rehabilitation.