THE TRUTH ABOUT ADDICTION 
by
Akikur Mohammad, MD 











©2011 Akikur Mohammad all rights reserved




Author's Forward
This is an exciting time in medicine. We have advanced far beyond the dark days of blood letting, leaches and superstition. Astonishing technology allows us to study the actual workings of the human brain, and there are continual breakthroughs in the treatment of chronic illness, including addiction. 
I am an addiction medicine specialist, psychiatrist, and  Assistant Clinical Professor of Psychiatry and the Behavioral Sciences at the University of Southern California.  I treat patients, educate medical students, and conduct research.   
I wrote this book to deliver a clear message:  alcoholism and addiction are preventable, treatable medical conditions. 
 That's the good news.  The bad news is that the majority  of alcohol and drug rehabs fail to provide anything beyond 1930's support group concepts and enforced abstinence. This means that patients are not receiving  comprehensive medical care for what is universally recognized as a medical illness. The consequences of a non-medical approach to the medical illness of addiction are tragic. 
The following true story motivated me to write this book:
	In addition to diagnosing and treating  patients, I also provide hands-on education to medical students and doctors in training at Los Angeles County Psychiatric Emergency Services.  It was in this capacity that I met an emotional and physical wreck of a man  brought in by the California Highway Patrol. He flagged them down on the Interstate Freeway, and begged them to rescue him from the voices in his head, and those who were pursuing him.
	 They immediately brought him to the Emergency Room, and I was promptly notified. I gathered my team of doctors and interns, and we went to the ER to ascertain what was going on.  I will never forget what I saw, and what I heard from the lips of this most distraught and disheveled young man.
	Drenched in sweat, he was a walking nightmare. His clothes were dirty, tattered and torn, and his skin had numerous scrapes and scratches. Highly agitated, his eyes darted back and forth as if expecting someone to break in at any moment. 
	We calmly assured him that we were there to help him, and we needed to know what was going on, and how he wound up on the freeway. Despite his extreme agitation, or perhaps because of it, he eagerly poured out his story.
	He was a thirty year old man from Sacramento who came to Los Angeles for alcohol treatment.  He'd been drinking a case of beer and 1.5 liters of vodka every day for the past ten years, and finally turned to his father for help.  He was sent to a free, church sponsored rehab here in Los Angeles where there was no medical staff awaiting his arrival, no medical diagnosis of his condition, and no medical detox service.  All that awaited him was a bed and spiritual counseling. 
By the second day in rehab, he had shakes, anxiety,insomnia and paranoia – all signs of potentially life threatening alcohol withdrawal.  He asked the resident Pastor for help, and was given one Tylenol and told to pray. 
On the third day, he became further disoriented and even more paranoid. He was hearing voices and having disturbing hallucinations that got worse by the moment.  Fearing for his sanity and his life, he  made a daring decision.  He escaped from the rehab under the cover of darkness, scaled the chain link fence, and threw himself over the side to the bushes below. 
He tore his clothes in the process, and sustained numerous scratches and abrasions. Terrified, disoriented, and believing that he was being chased by the rehab staff, he struggled through bushes and brambles in the pitch black darkness before sighting the Interstate. 
He forced himself over the concrete wall on to the busy freeway where he dodged traffic until spotted by the Highway Patrol. He could have been splattered on the Interstate, or died of seizures in his delirious and psychotic state before being rescued. 
 We diagnosed his condition as alcohol withdrawal, and immediately started him on appropriate medications. His crises situation was under control within three days,but a CT scan revealed significant brain damage from years of heavy drinking. His brain looked as if it belonged to a demented seventy year old. 
I arranged a scholarship for him at one of the few medically based treatment centers in the area,  and I took care of his medical care personally.  He is now independent,working, attending church meetings and in a relationship.
 Had he not escaped from rehab, he would be dead. He needed far more than a Tylenol and prayer. I have no problem with prayer. Pray all you want. I absolutely assure you that whatever benefits prayer may offer are greatly increased when you take the right medicine.  
This one young man was fortunate that he didn't die from alcohol withdrawal, but others are not so lucky. There are detox places where patients are tied down to a bed and “allowed to detox.”  If they survive, they are the lucky ones. If not, that's too bad. One of my patients referred to these places as “Death Bed Detox.”
If you are poor, that is what you can expect in the way of detox and rehab in the progressive an enlightened state of California. Even those who can afford high priced treatment centers often find themselves in facilities that don't bother to diagnose a patient's medical condition.  They evaluate insurance but not the patient. It's big business with big profits. Success rates are minimal, even for the most expensive facilities. 
While there are a few excellent treatment centers here that have full time medical specialists on staff, the majority of drug and alcohol rehabs do not offer comprehensive medical diagnosis or individualized care. 
I could tell you horror stories of the number of wrongful death lawsuits brought against reputable rehabs that ignored the medical aspect of alcoholism and addiction, but I would rather instill hope by giving you the truth about addiction, intervention and treatment, and tell you how to get appropriate treatment. 
This is why the book you hold in your hand exists.  If you think you have a problem with drinking or drugging, read this book NOW.  If you have a friend or family member whose drinking or drugging has you worried, read this book NOW.  
Everything in this book is the truth. There is no more time for superstition, lies or nonsense. This the time to tell the truth about addiction, intervention, and treatment
I began writing this books specifically for individuals concerned about the drug and alcohol use of themselves or someone they love. I wanted to dispel myths, counter outright propaganda, and give people hope where they previously had fear and despair.   The more I wrote, the more I realized the importance of reaching the largest audience possible.   Too many people believe that anyone who drinks more often than they do is an alcoholic, and anyone who uses a recreational drug is an addict at worse, drug dependent at best.  Those who are not addicts are told that they are; those who are addicts are being treated with two long standing failed methods: slogans and stigma.
The probability of becoming an addict is less than the probability of becoming dependent.  Your probability of becoming dependent is estimated to be 32% for tobacco, 23% for heroin, 17% for cocaine, 15% for alcohol, 11% for stimulants other than cocaine, 9% for cannabis, 9% for anxiolytic, sedative and hypnotic drugs, 8% for analgesics, 5% for psychedelics, and 4% for inhalants. 
A series of studies on the rate of addiction/behavioral dependence in chronic users of nicotine, alcohol, and opioids elegantly demonstrated that only a sub-population of chronic substance users become dependent 
A majority of substance users do not develop addiction.   Those who do develop addiction do so primarily because of genetics.  The genetic model of addiction predicts that addiction is more likely to develop after initial substance use in individuals with genetic susceptibility.  The more we know about genetics, and genetic testing, the more we know about predicting and treating addiction. The addiction is not in the drug, it is in the genes of the individual. 
The social stigma of addiction is more destructive in many cases than the disease itself, and the irresponsible continuation of false diagnosis of addiction by people with no medical credentials, combined with coerced treatment of people for a disease they may not have in the first place, especially when such treatment is devoid of comprehensive medical diagnosis, is an insult to both the patient and the entire medical profession. 
For the sake of saving lives, we must unite to eliminate prejudice against those born with this genetic predisposition, assure honest and accurate education on the topic of addiction, and protect people from fraudulent treatment. 
I'm going to keep this simple enough for people who want me to cut to the chase, and comprehensive enough for those who want details. Yes, I will give you a bit of history, and explain things that  people don't understand, or misunderstand, about addiction and disease. 
  I want you to have a firm foundation, a sense of perspective, and accurate information so you can make sensible decisions.  Even if all you do is read the statements in bold face type, you will know more and understand addiction better than most people in America. 
The book is short. So is life.  Let's save time and together, save lives.



ADDICTION
CHAPTER ONE
Critical Thinking About Addiction
In the all important life-saving profession of medicine, we must be clear and precise when discussing addictions.  If the general public is wallowing in ignorance, their decisions and actions based upon ancient errors and disproved assumptions, illness and unhappiness will not only continue, but increase.  No person of good will and integrity would willingly promulgate ignorance .
Superstition is the child of ignorance. In a world of superstition, people believe in magical thinking, distrust new information, and cling tenaciously to outworn and even dangerous practices.   A recent guest on a TV talk show insisted, with a perfectly straight face, that there was a “real danger” to the practice of Yoga because “Hindu demons could take up residence in your spine.” 
Our world is full of people who believe in demons but not in germs, despite overwhelming evidence of germs, and none for demons.  In this “Information Age” the proliferation of misinformation is unparalleled, and the erroneous beliefs regarding addiction and treatment are numerous.  
One fact is certain:Americans have an extreme prejudice against people suffering from the disease of addiction. This same prejudice is not shown against people with asthma,heart disease or diabetes despite these diseases sharing remarkable medical similarities. The reason we fear and distrust addicts is because of behavior.  
Diabetics don't write bad checks to buy Snickers bars, and people with clogged arteries don't break into McDonald's to steal hamburgers.  Alcoholics will write bad checks to buy more alcohol. 
The object of addiction takes priority in the damaged decision making of someone with addiction.  
A wealthy woman had a  20 year old son who battled a severe cocaine habit. She had tried to get him into rehab for several years without success. Finally, an intervention was performed and he checked into a high priced facility where all costs were non-refundable. Over the weekend, when family members were allowed to visit patients, the mother brought her son a reward for going to rehab – a $25,000 Rolex watch.  
You can probably guess what happened.  He signed out of the rehab, sold the Rolex, and went on a cocaine binge.  This behavior may be immoral, but it is perfectly understandable.  Addicts and alcoholics have structural or functional damage to the reward/motivation centers of their brains located in a part of the brain  known as the limbic lobe. When working properly, this reward system causes us to remember and return to pleasurable, life-affirming experiences  When the reward center is damaged, we keep doing things even when the result is pain instead of pleasure. 
  Families need to understand the disease of addiction, and have realistic expectations of behavior change.  This is accomplished when families are well informed participants in their loved one's treatment.  
 Critical thinking is also an integral part of evidence-based medical practice. Obviously, we need an increase in critical thinking abilities, in addition to factual information, to counter the lingering prevalence of harmful ideas regarding addiction, dependence and treatment. 
 “There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse – that is, to excessive or persistent use beyond medical need.” – World Health Organization 1964

People often use words without understanding what they mean. One word can have different meanings depending upon who is using it, and in what context.  Two examples are “Theory,” and “Addiction.” 
Before we discuss any Theory of Addiction, it is important that we understand the meaning of both “theory,” and “addiction.”  People often use “theory” when they mean simply a hunch or vague idea. That is not the word's meaning. We have all heard  people object to a particular concept by saying, “that's just a theory.”  No one, however, has argued that gravity is “just a theory.”
A theory is “an explanation of facts.”  Newton's Law of Gravity was the first theory (explanation) of how and why gravity works. Gravity was the fact; Newton's Law was the explanation. You can test a theory over and over again, and you will always get the same results  No matter how many times you drop something, it will always fall down, not up or sideways.   
Gravity existed long before Sir Isaac Newton (1642 – 1727) wrote the first theory of Gravity.   Newton thought that gravity was a force within all things, and he developed a mathematical formula for it.  Way back in the 17th Century, Newton's theory was a major breakthrough. 
We are no longer in the 17th Century.  Today,  we have the ability to make calculations to a degree of accuracy far beyond what was possible in Newton's time. Newton believed  the “why” of gravity was that there was a “force of gravity” within all things.  As science advanced, and we learned more facts, Albert Einstein came up with a new theory (explanation of facts) that basically says that Newton was correct about “how” gravity worked, but incorrect about “why.”
In our day to day lives, it really doesn't matter to us “why” gravity works, but “how” it works is very important.  Both theories of gravity are interesting, but the theory that takes into account the most amount of factual information, and proven research, is the theory that best explains the facts.
It is the same with addiction. People toss that word around to include all manner of things that do not fit the current medical definition .  You hear people say “I'm addicted to that TV show – I never miss it!” Or, “I'm addicted to ice cream. I eat it every day in the summer.”  What they mean to say is that they really enjoy something and look forward to doing it again.
The most common drug addictions are to legal substances such as Nicotine, Alcohol, and Caffeine.  Drug addiction is a medical condition, not a moral condition. Addiction to narcotics, for example, is a true physical condition characterized by increased tolerance, dependence, and withdrawal if the drug is discontinued.  Yet, within the context of medical treatment, this physical dependence does not, by itself, qualify as the disease of addiction. 
An increasing number of narcotic addicts are simply people who suffered an injury that resulted in chronic pain, were prescribed narcotics to counteract the pain, and became physically dependent on their medication within the framework of authorized medical treatment, and then obsessively continued seeking and using these pain killers long after both need for them, and that dates on their prescriptions, had expired.   
 No one says to themselves, “I want to be in such physical pain that I require higher and higher amounts of pain killers just to be pain-free.”  Wealth, fame, and celebrity are no protection against injury, chronic pain, or  drug dependance.  Jerry Lewis, the iconic comedian, chipped a vertebrae while taking a comedy fall on stage March 20, 1965. He did not have one day without non-stop pain, and considered suicide his only alternative if he were to stop his pain medication.  
Lewis was physically dependent on narcotic pain medication. Drug dependance becomes addiction is when the person is no longer taking the medication to stop pain, but to achieve a pleasure/reward response in the brain, and loses the ability to stop this indulgence.  Mr. Lewis never, to my knowledge, became an addict. Other people are not so fortunate.
It is an absolute medical fact that addiction, including alcoholism, is a brain disease. It is also a treatable medical condition very similar to heart disease or diabetes.  
Because of our particular culture, we are less harsh on alcoholics than we are on people addicted to other drugs. When we think of Heroin addicts, for example, our mental image is not one of a charming and upstanding citizen. We think of them as evil, scandalous thieves and criminals.  Most people don't know that Heroin was once  considered a “wonder drug,” was 100% legal and available over the counter. 
When Heroin was first introduced by Bayer, the same company that gave us Aspirin, tuberculosis and pneumonia were then the leading causes of death, and even routine coughs and colds could be severely incapacitating. Heroin, which both depresses respiration and, as a sedative, gives a restorative night's sleep, seemed a godsend.  Heroin was used in the treatment of asthma, bronchitis, tuberculosis, and even in the treatment of alcoholism.
"It possesses many advantages over morphine," wrote the Boston Medical and Surgical Journal in 1900. "It's not hypnotic, and there's no danger of acquiring a habit."
Heroin was widely used in America, and most medicines used by women for relief of menstrual pain, contained Heroin.  Cocaine, a stimulant and anesthetic, was also not illegal, and was often used in combination with Heroin in various medications, often in an alcohol base. 
 Both Heroin and Cocain were inexpensive until they became illegal. Suddenly, the price went sky high, and those already addicted had no choice but to get the money by any means necessary, and give that money to criminals. 
Alcohol, of course, has long been associated with compulsive, uncontrolled behavior among a certain percentage of the population.  The term alcoholism was first used in Sweden in 1849, but the first chronicles of uncontrollable urges to drink appear in the early 1800s under the term "dipsomania."  The word actually means compulsive thirst, but the term soon became used specifically to the compulsive uncontrolled intake of alcohol.
 The classic description of dipsomania was written by  Valentin Magnan in 1893, and you will see that he did a very good job of describing what today we call alcoholism. “Preceded by a vague feeling of malaise…. dipsomania is a sudden need to drink that is irresistible, despite a short and intense struggle. The crisis lasts from one day to two weeks and consists of a rapid and massive ingestion of alcohol or whatever other strong, excitatory liquid happens to be at hand, whether or not it is fit for consumption. It involves solitary alcohol abuse, with loss of all other interests. These crises recur at indeterminate intervals, separated by periods when the subject is generally sober and may even manifest repugnance for alcohol and intense remorse over his or her conduct. These recurring attacks may be associated with wandering tendencies (dromomania) or suicidal impulses.” 
Sigmund Freud saw the fevered consumption of alcohol as a complex  substitute for sexual obsession, and that the drunken stupor was a sort of twisted victory in that it successfully desensitization  the pain caused by the avoided obsession, and featured an alluring mastery of total passivity.  Freud considered that motor acts, with or without wandering,  were central to the obsession, and repetitive drinking was one of those motor skills. 
Whether or not Freud’s analysis was psychologically accurate, he offered profound insights into the alcoholic's crises: "He never rested until he had lost everything,” wrote Freud, and described, “The irresistible nature of the temptation, the solemn resolutions, which are nevertheless invariably broken, never to do it again, the stupefying pleasure and the bad conscience which tells the subject that he is ruining himself (committing suicide)—all these elements remain unaltered in the process…"
Freud postulated a hereditary component, and delineated similarities between compulsive drinking and compulsive gambling. He also suggested the hypothesis of these compulsions having an association with an organic, toxic brain disease.
There were early attempts to link alcoholism with manic-depression, now called bi-polar disorder, or that perhaps it was a “false manic-depressive” condition.  As there were no addiction medicine specialists in those days, there were no empirical medical studies of these conditions beyond noting their characteristics. 
Over time, there were put forward diverse concepts as to the causes of alcoholism, among them were:
Educational Model - a person drinks alcohol because they lack information regarding the dangerous risks associated with its use
Characterological Model - maladaptive personality traits and abnormal means of functioning are the underlying causes of alcoholism
Conditioning Model - alcohol elicits a positive response (whether internally or externally) which reinforces the desire to drink
Biological Model - heredity and genetics are the main influence on the body's response to alcohol
Social Learning Model - when one's social environment encourages the use of alcohol as a coping mechanism and frowns upon other means of relieving stress
General Systems Model - alcoholism is the result of a dysfunctional family unit that thrives on secrecy, control, and emotional distancing and ensures its way of life by bringing family members together in defense of positive change or healthy growth
Sociocultural Model - a broad theory that combines cultural acceptance, ease of availability, and lax regulation as the foundations for society's growing alcoholic population
Public Health Model - the dynamic relationship resulting between an agent (in this case, alcohol), a host (the alcoholic), and the environment that collectively contribute to continued drinking.
While there may be strong elements of truth in one or more of these models, none of them places the medical aspect at the core of diagnosis and treatment. Of course, when most of these models were first put forth, we didn’t have the amount of medical information about the illness of addiction that we have today.
In the early 1900's the majority of America's drug addicts were respectable white women, primarily in the Southern United States, and there was no link between addiction and crime because  these drugs was not illegal. 
In 1924 Dr. Charles O. Linder, completing a lifetime of honorable practice in Spokane, WA, was induced by a plant from the Treasury Dept. to write a prescription for 4 tablets of cocaine and morphine. Several Treasury agents thereupon descended on his office and broke in on him in the midst of a consultation. He was indicted, convicted, sentenced, and lost his intermediate appeal to the Circuit Court. But Dr. Linder persisted. 
The Supreme Court's unanimous decision came on April 13, 1925, in which his conviction was reversed and he was completely vindicated. The Court declared that addicts were 'diseased and proper subjects for treatment' and that it was not illegal for a physician acting in good faith and according to fair medical standards to prescribe moderate amounts of narcotics for purposes of alleviating withdrawal symptoms.  
The Court also expressed it's view that drug addiction is a disease and that relieving the "conditions incident to the addiction" may be medically appropriate. The Court could not intervene in matters of medicine, and as the Court did not define what constituted reasonable treatment, doctors were afraid to risk treating their addicted patients. 
When doctors stopped meeting the needs of their drug addicted patients, that's when organized crime filled the void, and in the process, raised prices. Instead of receiving their medication from a doctor, addicts were (and still are) compelled to purchase them at inflated prices, and of unknown quality, from illegal sources.
In the United States of America, it is not illegal to have the disease of addiction, nor is it illegal to use illegal drugs, but it is illegal to have, sell, or distribute illegal drugs.  Obviously, this is a problematic approach.
The person suffering from addiction to a particular medication, be it legal or illegal, must also endure the pain of social stigma due to the prevailing misunderstandings regarding addiction.  They are wrongly viewed as immoral and/or weak willed, when they are, in truth, suffering from a medical condition remarkably similar to other diseases, such as heart disease or kidney disease.  
Addiction: Alteration in Definition
The terms abuse and addiction have been defined and re-defined over the years. The 1957 World Health Organization (WHO) Expert Committee on Addiction-Producing Drugs defined addiction as “a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.”
In 1964, a new WHO committee found this definition to be inadequate, and suggested using the blanket term "drug dependence"  instead of “drug addiction”
In 2001, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine jointly issued the following definition:
“Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”
Physical dependence, by their definition, “is a state of being that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Tolerance is the body's physical adaptation to a drug: greater amounts of the drug are required over time to achieve the initial effect as the body...adapts to the intake.”
The Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR doesn't use the word addiction at all. Instead it has a section about substance dependence.
“When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders....”.
If those of us who treat addiction cannot agree on the exact wording of a definition, or  even if  we should use word “addiction” at all,  it is difficult to engender confidence among the general public.  People need things well-defined and perfectly clear in order to make informed decisions regarding their health, and the well-being of family members.  
The National Institute on Drug Abuse puts for the following definition:  “Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persist even in the face of severe adverse consequences. For most people, addiction becomes chronic, with relapses possible even after long periods of abstinence. As a chronic, recurring illness, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. Through treatment tailored to individual needs, people with drug addiction can recover and lead fulfilling lives.” 
In 2011,  The American Society of Addiction Medicine (ASAM) released a new definition of addiction highlighting that addiction is a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling or sex. This was  first time ASAM took  an official position that addiction is not solely related to problematic substance use.
"At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas," said Dr. Michael Miller, past president of ASAM who oversaw the development of the new definition. "Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions."
"Many chronic diseases require behavioral choices, such as people with heart disease choosing to eat healthier or begin exercising, in addition to medical or surgical interventions," said Dr. Miller. "So, we have to stop moralizing, blaming, controlling or smirking at the person with the disease of addiction, and start creating opportunities for individuals and families to get help and providing assistance in choosing proper treatment.”
Life is short. So is this book.  Please, don't go to rehab, or send someone to treatment, until you read this book. 



ADDICTION
CHAPTER TWO
The Medical Illness of Addiction 
In the world of medicine there are, as you know, medical specialists.  Some doctors specialize in treating heart disease, others are cancer specialists. For every treatable disease, there are those who focus their research, care, and careers to helping people afflicted with that particular disease. I am a proud member of American Society of Addiction Medicine. 
 A common problem faced by medical specialists working in the field of addiction  is the gap between what we, as doctors, know for a fact, and what the layman often believes. 
Many people do not believe that addiction is a physical disease, but that is only because they don't understand the meaning of disease, and the current definition of addiction.  
People often confuse addiction with physical dependence in the context of medical treatment.  Drugs that we often associate with abuse, such as opiates or central nervous system stimulants, are, in the proper context, beneficial medications.  Addiction is also not synonymous  with recreational or social use of mood altering agents, including alcohol. Once we clear up this misunderstanding, everyone understands why addiction is a true medical illness and why addiction is classified as a disease by every medical organization in the world, including the American Medical Association,  The World Health Organization, and the American Psychiatric Association. Obviously, if addiction were not  a medical condition meeting the clear definition of disease, our area of specialization wouldn't exist.
First of all, let's learn the meaning of disease.  According to the World Health Organization, disease is “illness caused by biological, chemical or radio-nuclear sources.” Genetics, of course, comes under the biological heading. We all know that exposure to  certain chemical substances such as mercury, arsenic, and asbestos can cause a variety of diseases such as cancer, lung ailments, liver disease, brain dysfunction, and many others.  
The smoking of tobacco, commercially marketed as cigarettes, fills the smokers  lungs with all manner of chemicals, in addition to Nicotine, and is known to cause chronic bronchitis, emphysema, gastritis and lung cancer. Not everyone who smokes gets lung cancer, but it is an absolute fact that your risk of lung cancer, or heart disease, increases if you smoke. 
Not everyone who drinks alcohol has cirrhosis of the liver, but heavy drinking absolutely assures you of that possibility, along with a  marked propensity towards diabetes, heart disease and many other diseases and conditions, none of which are pleasant or enjoyable.
Individuals who suffer from addiction often have one or more accompanying medical issues, including lung and cardiovascular disease, stroke, cancer, and mental disorders. Imaging scans, chest X-rays, and blood tests show the damaging effects of drug abuse throughout the body. In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system.
Alcohol brings damage to every organ in your body, even if you don’t consume it in big amounts. Consumption of large amounts of alcohol  may damage to your heart, liver and brain. When alcohol enters your brain, it numbs nerve cells, slowing down their ability to send messages to your body. If you continue to drink, the nerve centers inside the brain and you may lose control over speech, balance, vision, and judgment.
Alcohol  depresses the activity of your heart muscle and speeds up your pulse. When you drink too much, fats accumulate in the liver, resulting in a condition known as fatty liver. Continued heavy drinking rapidly produces 2 stages of liver disease: cirrhosis and alcoholic hepatitis. People with these diseases experience appetite and weight loss, enlarged and inflamed liver, accumulation of fluid in the abdomen. Cirrhosis usually leads to liver failure or liver cancer. Other possible effects of heavy drinking are heart failure, varicose veins in the esophagus, stomach bleeding, and inflammation of the pancreas.
Addiction is a chronic disease characterized by anatomical and/or functional changes in the human brain. The anatomical changes can be clearly seen and studied with brain imaging technology such as a standard MRI and CT scans. The functional abnormalities can be seen, studied and evaluated by a PET scan, or use of the Functional MRI.  These changes are in the brain’s reward, motivation, memory and related circuitry.  Some of these changes are repairable, while others are, so far, not reversible. 
Just as heart disease causes blatant decreased heart metabolism, drug abuse causes similar decreased brain metabolism. The similarities between addiction and heart disease, diabetes and asthma are remarkable. They share the same genetic risks, and are impacted by voluntary behavior. 
As the brain controls behavior, a disease of the brain is going to have behavioral consequences.  Because of these brain changes, people become unable to make conscious decisions in their own best interest.  The definition of  addiction clearly states that  the individual thus afflicted will compulsively pursue a detrimental course of action despite continual negative medical and social consequences.   
 The difference between someone who simply enjoys drinking or drugging, and someone who has the disease of addiction, is that the person with the disease has suffered actual physical or functional changes to their brain that make it impossible for them to simply stop a behavior once it has started, no matter how much they may honestly want to do so.  
As you can imagine, when the brain has the disease of addiction, it is if the brain has a mind of its own. You don't want to do something, but you are incapable of not doing it.  Don't confuse this with a lack of will power.  Ask yourself this question, how effective is will power when you have diarrhea.? After all, if will power is useless against something as simple as diarrhea, imagine how useless it is against a brain disease.
Let me give you an analogy.  Let's say that you are driving down the highway at 60 mph.. Suddenly, you see a block of concrete in the middle of the road.  If you do not stop, you will crash into it, and perhaps be killed.  What do you do? You put on the brakes.  The disease of addiction would compel you to keep your foot on the gas, or even increase your speed, no matter how desperately you want to put on the brakes.   It is difficult to imagine a living nightmare worse than addiction, and this is why there are specialists in addiction medicine to treat that certain percentage of our population who, for a variety of reasons, are at risk for this devastating medical illness.. 
Now, let us suppose that you use cocaine, or other stimulant, and have used it regularly  for several years. Stimulants such as cocaine can contribute to, or precipitate, stroke, seizure, heat arrhythmia, heart attacks, and hyperthermia – a potentially fatal elevation of temperature.  You go to the doctor for a checkup, and he tells you that because of the cumulative effect of your years of cocaine use, you must stop immediately or you will definitely have a heart attack or stroke.  What do you do?  Simple. You stop.  For most people, stopping this, or other life threatening behavior, is simply a decision they make in their own best interest.  For others, because of the years of habit, and their circle of social interaction, it requires significant changes in their life style, routine and friendships.  They may, in addition to medical advice, call upon family members, and various emotional support groups, to help them in implementing their decision to change their behavior. .
Addiction severely impacts your ability to simply stop a behavior, even with emotional support.. This is where a specialist in addiction medicine comes in.  We diagnose your specific condition, and know what medication, or combination of medications, to give you, along with other therapeutic techniques, that treat the disease and free you from the impending consequences of continued use.  
A question I'm often asked is whether or not addiction is a disease of choice. That's like asking if lung cancer or diabetes are something we choose. I said this to the husband of one of my patients, and he suddenly believed that he was innately blessed with more medical knowledge than the AMA , WHO, and the American Society of Addiction Medicine combined.  
“No,” he forcefully insisted, “you’re wrong. You’re comparing apples and oranges.”  Apparently he was also now an accomplished green grocer.  He insisted that people choose addiction, but don‘t choose heart disease. People choose addiction, but not diabetes.  “No one chooses lung cancer,” he said, “but people choose to be addicts.”
I told him  exactly what I will tell you:  No one chooses to get lung cancer, but you may choose to smoke despite the known risk of getting lung cancer. Speaking for myself, I personally wouldn't choose to have type 2 diabetes. My family has a strong history of type 2 diabetes.  I diet, exercise, watch my weight, check my blood work and for the warning symptoms of diabetes. If I didn’t care, I would gain 40 pounds in a couple of months, and develop diabetes. It’s my educated choice that I am at higher risk of developing diabetes, and so I need to watch it.
Many people know they have high cholesterol and high blood pressure, but make no attempt to control them. Finally, they have a heart attack or stroke.  That is their choice.  Many diabetics are not taking medication, cheat on their diet and are walking around with sky high blood sugar levels. Again, that is their choice. People choose to have unprotected sex, share needles, and possibly contract HIV/AIDS.  Would you say that they chose to get HIV? No, but their choices facilitated the disease. 
Can a person make a poor choice by drinking heavily knowing they have a strong family history of addiction? Yes, and that choice can lead to alcoholism, which is a form of addictive disease.  
The disease of addiction is, in many ways, similar to high blood pressure. People can't control their blood pressure by force of will or decision.  People with the disease of addiction can't control their disease by force of thought.  Patients with drug and alcohol addiction want to stop,  but they  need professional medical help, and true understanding from friends and family. 
Addiction,  like other chronic illnesses, has a biological/genetic factor. Genetic studies have shown that at least 50% of the risk factor of addiction is biological and hereditary. Allow me to share one little example of the biological factor. 
  The enzyme which breaks down alcohol is called aldehyde dehydrogenase (ADH).  Antabuse is a medication which prevents the activity of ADH. If someone takes this mediation and drinks, they will have a bad reaction to alcohol, and not want to drink.  Five to ten percent of Asians, and up to fifty percent of some Japanese populations, have an ADH deficiency. It is as if nature implanted Antabuse in them at birth. If they drink, they have a bad reaction.  These people, simply by matter of biology, will never become alcoholics. 
Antibuse, however, has proven a dismal failure in preventing alcoholics from drinking. It was the first drug approved for the treatment of alcoholics. This is how it was supposed to work: you take the pill and then, if you drink even a small amount of alcohol, you become so sick that you don't want to drink. Forty years later, we know this was a nice idea that didn't work. Patients either wouldn't take the pill, or would find clever ways to circumvent the effects.
I had one patient who was a brilliant chemist. Having been prescribed Antibuse, he promptly went out and purchased the required chemicals to make an antidote. While his approach is not one available to everyone, another patient figured out a more practical way of “getting around” the negative effects of Antibuse. He took the pill, then took a small sip of alcohol. He got sick. He repeated this three times in three hours.. By the fourth time, he no longer became sick. It was if he were inoculating his body to “over ride” the Antabuse.  The point of the story is people who are addicted  will find a way to keep that addiction going, and it doesn't have to be alcohol or drugs. In Scandinavia, for example,  there are studies of addiction related to carrots. These people will hoard carrot peelings for fear of not having their drug of choice. 
 In the 1970's, a highly intoxicated patient arrived at a treatment center. He had all the symptoms associated with some type of drug or alcohol toxicity, but no trace of either could be found in his system. His case was, at the time, most unusual. The object of his out of control cravings, and the source of his intoxication, was dry roasted peanuts.  Obviously, the percentage of people who have addiction resulting from continued ingestion of dry roasted peanuts, carrots or eggs is very small. But that one person's disease is very real, and requires medical treatment just as heart disease requires treatment whether it is the result of diet, smoking, or some other cause.  
We have discussed biological factor. Now let’s discuss the environmental, psychological and social factors. There are very few diseases which are purely biological in nature. The causes of most diseases are multifaceted. For the onset of a disease, and its progression, biology and environment must interact.
Psychiatric factors include depression, anxiety, or symptoms of bipolar disorder or other psychiatric conditions. . Social risk factors for drug abuse and addiction include male gender, being between 18 and 44 years of age, Native-American heritage, unmarried marital status, and lower socioeconomic status. According to statistics by state, people residing in the West tend to be at higher risk for chemical abuse or dependency. Men may be more at risk for alcoholism and addiction, but women run a higher risk of alcoholism at lower amounts of actual consumption. 
Emotional stress (psychological factor) can trigger the onset of a disease, including the disease of addiction, because stress may activate the genetic, biological factor.  Stress may also trigger relapse of a disease in remission. We all know this to be true, and perhaps have witnessed this among members of our own families.
According to current brain research and developmental psychology, the risk of addictive disease is heightened by, and directly related to, life experience as much or more than genetics.  The human brain's development takes place after we are born, and what we experience at pivotal points in our life determines a vast amount of our neurological development.  For the sake of simplicity, I'll put it this way:  Your are an individual, and what you experience in your life has just as much impact on your brain functioning as does heredity  and genetics.  
I am now going to reveal perhaps the most disturbing discovery, repeatedly verified by extensive international research, regarding the disease of addiction. Emotional pain, stress, and above all, alienation, social exclusion and emotional distancing create actual neurological damage that increase  risk of alcoholism and addiction, and the risk of never recovering.  
So, now you know that addiction is a  chronic medical illness, and not simply physical dependence in the context of medical treatment, or recreational social drug/alcohol usage.  Millions of people drink and drug and never develop the disease of addiction. There are, however, millions of people who are at great risk of this disease. I would rather prevent it than treat it. 
 People come to specialists in addiction medicine because they either have the disease, are fearful that they may have it, or want to know their risk of having it, and how to avoid it.  The health dangers inherent in various behaviors – be it stroke, heart attack, liver disease or mental health problems – are increased significantly if a person also has the disease of addiction. 
Honesty is imperative. I have had patients come to me for treatment of addiction, and upon thorough examination and diagnosis, I find that they do not have the disease of addiction. They may be drinking heavily, and doing more drugs than you can imagine, but they don't have the disease of addiction – yet.   Seeing an addiction specialist is like seeing a heart disease specialist. You smoke, you drink, you eat fatty foods, and don't exercise. Okay, you don't have heart disease -..yet.  Both types of specialists will encourage you to change your life style and behavior to prevent the onset of disease. Among the diseases you want to avoid is the disease of addiction, and as a specialist in disease medicine, my fellow specialists and I are here to both treat and prevent the disease of addiction. 
Addiction, as with other chronic medical illnesses,  doesn’t consider your race, religion, or political affiliation. It doesn’t matter if someone is Christian, Jew, Muslim, Buddhist, Hindu or Atheist. This disease afflicts people from all walks of life, rich and poor, doctors, successful businessmen, clergy, and elected heads of state.  The more people know about the disease of addiction, the less stigma will be attached to the individual who suffers from it, and more people will be willing to get the help they need.
Every physician and medical association world wide recognizes that addiction is a medical illness that is both preventable and treatable. It is to this mission – prevention and treatment – that I have dedicated my life and medical career.
As a result of scientific research, we know that addiction is a disease that affects both brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches … --` National Institute of Drug Abuse.

There are many social/cultural myths regarding alcoholism and addiction, among them being that  people who suffer from addiction are immoral losers.   Kirsty Alley, Robin Williams, Ray Kroc (found of McDonald’s), Ben Afleck, Leonard Nimoy, Betty Ford, Robert Downey, Jr., and famed actor Samuel L. Jackson would hardly be called “losers,” nor would the hundreds of other well know, or lesser known, leaders of business, industry, and entertainment who have sought treatment for problems symptomatic of addiction.
   Remember, addiction is a medical illness that severely impairs a person’s ability to simply stop or curtail unwanted behavior despite negative medical and social consequences. For someone to take the initiative to actually get help for this condition is praiseworthy, especially when we consider that an overwhelming compulsion to continue the behavior is, in itself, a primary symptom of the illness.  
You don't have to be an alcoholic to seek medical help if drinking is causing problems in your life, and you don't need to be an addict to seek treatment for problems related to drug use.  Addiction is preventable; addiction is treatable.


					ADDICTION
CHAPTER THREE
Addiction and Crime 
It is not a crime in America to have the physical illness of addiction, but if the object of your addiction is an illegal or controlled substance, you could be arrested and prosecuted for possessing it.  This situation places the person suffering from a known medical disorder in the tragic situation of continually interacting with the criminal underworld, rather than doctors and pharmacists.  
In the State of California prior to 1962, it was a crime to be addicted to drugs, and anyone  convicted under the law got a minimum of ninety days in jail. All this changed when Lawrence Robinson was, despite no wrongdoing, taken to jail on suspicion of being a drug addict due to marks on his arm, then subsequently arrested. . 
At his trial, Robinson denied ever using illegal drugs, and that the marks on his arms were an allergy condition he got from shots in the military. This was verified by two witnesses in his defense. Two police officers, however, testified that what they saw on Robinson’s arm was consistent with signs of drug addiction.  The jury was instructed that even if there was no evidence that Robinson used drugs in California, he could be convicted for being addicted while in the state. The court specifically stated that the law made the "condition or status" of drug addiction a crime.
He was convicted, and appealed his case to the Los Angeles Superior Court where they ruled against him. Mr. Robinson took his case all the way to the United States Supreme Court where, in a 6-2 decision,  the Supreme Court reversed Robinson's conviction. Writing for the Court, Justice Potter Stewart said drug addiction is an illness, not a crime. Punishing someone for an illness violates the Eighth Amendment of the U.S. Constitution, which bans cruel and unusual punishments.
California's law was intended to  punish drug addicts, not cure them. Justice Stewart rightly concluded that punishing someone for having a drug addiction is like punishing someone for having a mental illness, leprosy, venereal disease, or the common cold. "Even one day in prison,“ wrote Justice Stewart, “would be a cruel and unusual punishment for the 'crime' of having a common cold."
Addiction, including alcoholism, was not a “get out of jail free” card, unless the accused had crossed the line into legal insanity. In 1965, there was a landmark ruling in the District of Columbia Court of Appeals in the case of Easter v D.C.
"Extended habits of intemperance which produce permanent mental disease amounting to insanity relieve an accused of responsibility under the law,” ruled Judge Myer. “Insanity of this type is identical in law with insanity arising from other causes. On the other hand, habitual use of intoxicants causing dipsomania, defined in medical jurisprudence as an irresistible impulse to indulge in intoxicants, does not, if not resulting in insanity, afford any excuse for a crime committed while intoxicated. Voluntary drunkenness does not excuse crime, nor does our law recognize, as excusing, what is called dipsomania, or distinguish between an irresistible impulse for intoxicating drinks and a mere inordinate appetite for them, brought on by long and continual indulgence."
In America, addicts live under the continued threat of arrest and prosecution for possession of drugs.  Holland takes a different approach. That country considers drug users a public-health problem, not a criminal one. Addicts caught stealing or breaking other laws are prosecuted, but they aren't arrested for possession.
"The view is that addiction is a brain disease, and it requires treatment, not incarceration," says Wm van den Brink, a psychiatrist at the Academic Medical Center of the University of Amsterdam. That policy makes for a remarkable statistic: About 70 percent of Holland's drug addicts are in treatment programs as compared to America where the percent of addicts in treatment is only 10 to 15 percent 
Numerous studies show it's much less expensive to treat people with drug problems than to toss them into prison. A 1994 Rand analysis concluded that for every extra dollar spent on addiction treatment, taxpayers save $7.46 in societal expenses, including the cost of incarceration.
The Netherlands has also tried treating opiate addicts  with prescription heroin. A 2005 study found this method of crime reduction was successful and cost effective. It was financially favorable to the community at large because participants stopped committing crimes to support their habits.  This is similar to the harm reduction Managed Maintenance  model now more widely used in American treatment centers, although with Heroin substitutes such as Suboxone.



ADDICTION
CHAPTER FOUR

Medical Consequences of Addictions 

 All excessive behaviors have consequences.  If someone drinks too much alcohol, they first lose coordination, then their thinking gets screwed up. This is called “neurological impairment.”  It is also called being really drunk.   
Despite alcohol consumption  being both socially acceptable and perfectly legal, it inflicts more damage and kills more people than any other drug in the United States. Alcohol is the third leading cause death because it attacks every vital organ system in the human body.  
Alcohol directly or indirectly causes stomach cancer, rectum cancer, colon cancer, throat cancer, liver cancer, larynx cancer, and esophageal cancer. Alcohol doesn't cause lung cancer, but as most drinkers also smoke, you might take that into consideration as well.
I'm not going to give you a big lecture on the dangers of over indulgence in alcohol.  There is an old and accurate expression: “A word to the wise is sufficient.”    I hope you are wise.
The list of medical problems directly related to immoderate use of alcohol is more than all other recreational drugs combined. 
 Alcohol may mix harmlessly in polite social settings where moderation and decorum are the established and observed standards, but alcoholism is something else entirely  Folks who overindulge in alcohol often use other drugs as well, and that's a big problem. Alcohol does not mix well with anything else. There is a potentially dangerous interaction between cocaine and alcohol. This mixture is the most common two-drug combination that results in drug-related death.  Mixing alcohol and heroin may be the true reason for overdose deaths attributed to heroin. 
I have previously mentioned the the various types of damage alcohol does to your body. If you want a more detailed list of alcohol related damage, here it is:
High blood pressure, damage to the heart muscle, heart failure,  strokes, severe thiamine deficiency, diabetes, pancreatitis, night blindness, pneumonia,  dehydration, kidney failure, Vitamin D deficiency leading to bone fractures,  inflammation of the digestive system, ulcers, holes in your intestines or stomach, infections of the urinary tract, and, as a last resort, death from alcohol poisoning, excessive intoxication, and organ malfunction. 
We haven't even mentioned sexual problems such as erectile dysfunction and impotence, cirrhosis of the liver, and long term brain damage. Your liver can only handle one drink per hour. Binge drinking is devastating to the liver. Between 10 and 35 percent of alcoholics have hepatitis or inflamed livers. Cirrhosis occurs when healthy liver cells become replaced by scar tissue. The damage can be so bad that the only treatment option is a liver transplant. 
 Alcohol slows your reactions, impairs your decision making abilities, and makes performance of any task requiring accuracy pretty much a lost cause.
 Alcohol increases confidence but reduces performance.   You do everything worse on alcohol, and everyone knows it except the person on alcohol.  
Drinking alcohol in extreme weather conditions can be suicidal. Drinking to “warm you up” in the freezing cold has the exact opposite effect.  You think you are warmer because of increased blood flow at the surface of your skin, but you are actually losing heat quicker. 
If you keep drinking when you have cirrhosis of the liver, you will most likely be dead within seven years.  In the meantime you can develop kidney failure and all kinds of disgusting  brain disorders. 
Brain Damage
 At first, the brain damage shows up as headaches, blackouts, and numb hands and feet.  Keep on drinking and you can have permanent structural damage and premature aging.  A 35 year old alcoholic may well have the shriveled up brain of a sick 70 year old.  
You can tell when this brain destruction is going on.  Between 45 percent and 70 percent of alcoholics do not perform well in tests of problem solving, abstract thinking, memory, and shifting concepts. About 10 percent have serious impairments. 
As long as we're talking about brain damage, let's mention damage to the entire central nervous systems causing alcoholic blackouts, memory loss, seizures, convulsions, delusions, hallucinations, dementia, and violent behaviors .
Psychiatric Problems
 More than 40% of investigated alcoholics turned out to have one or more psychiatric conditions. .  Research also shows that  out that of the group of people with a psychiatric disorder, 28% suffer from alcohol dependence. So the question often asked is what came first, the psychological problem or the alcohol problem?  
Yes.
Alcohol and other drug use can cause psychiatric symptoms and mimic psychiatric syndromes. Alcohol can cause delusion, auditory and visual hallucinations, anxiety and depression. Some patients may experience auditory hallucination for weeks or months after they stop drinking, and are then misdiagnosed as Schizophrenics.  
According to a recent study, people with alcohol problems have psychiatric disorders almost twice as often as those you don't have alcohol problems. Drinking and drugging can initiate psychiatric disorders and make them worse. It can also mask psychiatric symptoms. Withdrawal can cause psychiatric symptoms and mimic symptoms. 
It is also very possible for psychiatric disorders and alcohol/drug problems to exist independently of each other.  
 To make it even more complicated, psychiatric behaviors can be misinterpreted as drug/alcohol problems. This is one more strong argument for diagnosis by an addiction medicine specialist before initiating treatment, as well as psychiatric evaluation. 
Suicide in a Bottle
There is a high rate of suicide in chronic alcoholics, which increases the longer a person drinks.  Approximately 18 percent of alcoholics commit suicide, and over 50 percent of all suicides are associated with alcohol or drug dependence.
Because alcohol is not digested, but absorbed directly through the lining of your mouth, throat, stomach, and intestines, it irritates the hell out of these organs' linings. The result: gastrointestinal disease.  If that word is too big for you, let me put it this way: horrid stomach aches, terrible pain, and uncontrollable diarrhea.    If you enjoy vomiting and diarrhea, just keep on drinking.
	If  you didn't already have enough problems, add to this being under nourished.  That doesn't sound so bad until you realize it means your pancreas isn't going to work right. That makes more work for your liver. Your glucose levers are low, and that causes more brain damage. 
If you're a guy, and you want shriveled shrunken testicles, and a nice set of man-boobs, keep drinking. Your testosterone levels drop with excessive alcohol use, as does your sperm count. You won't have to worry about sex issues, because you will probably be impotent and unable to have sex anyway. 
Female alcoholics often quit menstruating, begin early menopause, or menstruate without ovulation. If they get pregnant, they often miscarry. The babies who survive often suffer from fetal alcohol syndrome.
Fetal Alcohol Syndrome – 100% Real, 100% Preventable
 In 1968, Christy Ulleland, M.D. Chief Resident at Harborview Medical Center, University of Washington first discovered the link between prenatal alcohol exposure and adverse outcomes in infants. In January 1968, Dr. Ulleland received funding to conduct an 18-month study to scientifically assess her clinical observation that infants born to alcoholic women had impaired outcomes.  Dr. Ulleland's conclusion:  “Chronic alcoholism can be appropriately added to the list of maternal factors that create an unhealthy intrauterine environment for the developing fetus; the consequences of which may be life long.”  
The number one cause of mental retardation in America is women drinking alcohol while pregnant. If you are pregnant, or planning to become pregnant, you must absolutely not touch a drop of alcohol.  There is no safe amount of alcohol at any time during pregnancy.  
It is an absolute fact that even the slightest amount of alcohol, depending upon the metabolism of the mother, can cause irreversible birth defects in her child, especially in the first trimester of pregnancy.   A baby can emerge from a drinking mother's womb appearing perfectly normal on the outside, but damage to the baby's brain is permanent and irreversible. FAS is the most direct cause of mental retardation in America. FAS is also 100% preventable. 
There is nothing complex to preventing FAS.  All you have to do is not drink alcohol while pregnant. If you can simply refrain from alcohol, you can prevent your child from alcohol caused mental retardation, physical disabilities, and possible future behavioral problems leading to problems with the law. .   
 Many mothers stop drinking only after they know they are pregnant, but damage to the developing fetus may already have been done. The Surgeon General's recommendation is that a woman refrains from drinking during pregnancy and even earlier if she is planning to become pregnant.  The only good thing about Fetal Alcohol Syndrome is that it is 100% preventable
Once again, there is an enormous gap between what people believe and what is actually true.   Many people mistakenly believe that mothers of children born with Fetal Alcohol Syndrome were all  heavy drinkers, or full-blown alcoholics.  This is a false and dangerous belief.  
It is an established fact, beyond dispute, that even one drink of alcohol during the first critical trimester may cause irreversible brain damage in the unborn child. The degree of damage depends upon the metabolism and liver functioning of the mother during pregnancy, and no two women are exactly alike. 
  As you don't know details of your metabolism or liver functioning, there is no way to know the severity of damage to your child by having a drink.  Drinking a wine cooler while pregnant is not much different from placing a  handgun in front of a baby, spinning the cylinder, closing your eyes, pulling the trigger, and hoping to hear “click” while having no idea how many chambers, if any, are empty.
Even brief exposures to small amounts of alcohol may kill brain cells in a developing fetus. A study carried out by John Olney, M.D., at the Washington School of Medicine in St. Louis showed that just two drinks consumed during pregnancy may be enough to kill some developing brain cells, leading to permanent brain damage.
The Canadian Paediatric Society states: "Fetal alcohol syndrome (FAS) is a common yet under-recognized condition resulting from maternal consumption of alcohol during pregnancy. While preventable, FAS is also disabling.. FAS diagnostic and treatment services require a multidisciplinary approach, involving physicians, psychologists, early childhood educators, teachers, social service professionals, family therapists, nurses and community support circles.”
All of those “diagnostic and treatment services” would be unnecessary if women would simply not drink while pregnant, if they plan on becoming pregnant, or run the possibility of becoming pregnant. 
There are at least two reasons why a pregnant woman would drink despite being informed and warned about FAS, and the risk of brain damage and/or mental retardation. The first reason would be that the woman understands the danger, but is willing to put her child's brain at risk in exchange for the pleasure she derives from drinking.  Obviously she isn't going to win “Mother of the Year.”   
The second reason would be that the mother, despite understanding the danger, has the medical illness of alcohol addiction known as alcoholism.  The addict cannot stop without professional medical help.  If you are pregnant and can't stop drinking, get help immediately.
Another problem doctors face in alerting women to the very real danger of FAS is the culture of disbelief resulting from media driven “crack baby” scare of the 1980s.  The same process of medical research that disproved the crack baby myth, is the same process of professional research that has continually proven the truth of FAS, and taught us that fetal alcohol syndrome isn't a single birth defect. It's a cluster of related problems and the most severe of a group of consequences of prenatal alcohol exposure. Collectively, the range of disorders is known as fetal alcohol spectrum disorders (FASD).
As with the illness of addiction, both the physical and functional brain damage of  FAS can be seen with brain imaging technology.   According to a study recently published by a team of researchers at the University of Washington, it is possible to differentiate FASD-diagnosed brains from "normal' brains with 80% accuracy using magnetic resonance (MR) brain images. 
For purposes of distinction, the term FAS is commonly used for the condition where there are distinctive facial abnormalities which may be discerned by a trained medical expert. These facial features including small eyes, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip
Doctors have used other terms to describe some of the signs of fetal alcohol syndrome. Alcohol Spectrum Disorders (FASD), Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), Partial Fetal Alcohol Syndrome (pFAS), Alcohol Related Neurodevelopmental Disorders (ARND), Static Encephalopathy Alcohol Exposed (SEAE) and Alcohol Related Birth Defects (ARBD) are all names for a spectrum of disorders caused when a pregnant woman consumes alcohol. Alcohol-Related Neurodevelopmental Disorder (ARND) refers to the mental and behavioral impairments; Alcohol-Related Birth Defects (ARBDs) refers to the physical defects that occur from fetal alcohol exposure. Most of these are not characterized by the tell-tale facial features, and require a higher level of testing and evaluation.
Signs of fetal alcohol syndrome may include:
Heart defects
Deformities of joints, limbs and fingers
Slow physical growth before and after birth
Vision difficulties or hearing problems
Small head circumference and brain size (microcephaly)
Poor coordination
Sleep problems
Mental retardation and delayed development
Learning disorders
Abnormal behavior, such as a short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety
The facial features seen with fetal alcohol syndrome may also occur in normal, healthy children. Distinguishing normal facial features from those of fetal alcohol syndrome requires expertise.
Devastating Life Long Brain Damage	
The most devastating disability caused by a mother’s prenatal use of alcohol is the organic brain damage that impairs an individual's executive brain function - ­the ability to understand and adapt to the world. A consideration of the following  incidents of disease, while more accurate in the generality than the specificity, will give you a sense of perspective.
 On any given day in the United States, 10,657 babies are born.  1 of these babies is HIV positive. 2 of these babies are born with Spina Bifida. 3 of these babies are born with Muscular Dystrophy. 10 of these babies are born with Down Syndrome. 120 of these babies are born with Fetal Alcohol Syndrome/Alcohol Related Neurodevelopment Disorder, the number one cause of mental retardation in America.. 
 The Institute of Medicine's Report to Congress on FAS was clear in their presentation that the incidence figures were to give a sense of perspective, and “to emphasize the magnitude of a problem that has serious implications - for the individual and for society. "
Life Problems Only End at Death.
 Individuals with FASD have problems planning and organizing information and daily life, have trouble comprehending the consequences of their behavior,  and will act on impulse with diminished control. According to expert Kay Kelly, Project Director of the FAS/FAE Legal Issues Resource Center at the University of Washington, “These individuals typically have an excessive desire to please others, an attitude that may lead them to take (or acquiesce in) actions that are harmful to their own interests.”
The social functioning skills of people damaged in the womb by alcohol are destined for a difficult life, despite having an average I.Q.  “Most individuals with an average IQ lead productive and organized lives,” says Kelly. “Individuals who have an average I.Q. but who also have brain damage caused by alcohol in uteri, often struggle unsuccessfully to deal with the usual demands of life.”
Easy Prey for Predators
The behavioral disabilities make folks with FAS, be they kids or adults, easy prey for criminals and perverts.  They are more likely to put up with abuse, and not complain about it, because they don’t want to upset the person abusing them.  They want to keep people happy and be accepted. Hence, they are easily exploited. Some 72% of adolescents and adults with FAS/FAE have been physically or sexually abused." Sexual abuse of children with FASD by adults in their own home is a particularly serious problem.
In the court system, or in law-enforcement, a victim or witness with FASD can compromise a case because they are eager to please, and are very believable.  They may think that the “right answer” to a question is the answer the questioner wants to hear. To the FAS person, they are not lying, but simply giving “the proper answer.“ 
 For the millions of individuals who already have Fetal Alcohol Syndrome, and the effects, it is too late to protect them from the harm that maternal alcohol caused their developing brains. But it is still possible to take effective measures to protect them from criminal abuse.
Adults with FAS, if left to fend for themselves, will too often end up living on the streets or in other circumstances where they are likely to be particularly vulnerable to crime. The social services that many of these adults need, ranging from supported community living environments to job training, are as important to preventing victimization as they are to preventing poverty.
"We can envision few things more certainly beyond one's control than the drinking habits of a parent prior to one's birth." -- The Florida Supreme Court, 1994 
Studies of FAS in America, Canada and the UK, portray horrific medical and social consequences for the innocent victims of their mothers' drinking. Children afflicted with full-blown FAS display both physical and mental abnormalities. Those with partial FAS may not have the obvious physical characteristics, but they suffer the same behavioral and psychological problems. These include a low IQ, difficulty in learning from experience, poor judgment, poor cause and effect reasoning and an unawareness of the consequences of behavior. These, obviously, are the very attributes that can lead them to prison. 
The child born with FAS will also be an adult with FAS. It cannot be cured; it doesn't get better. A person born with FAS is very impulsive, and will do things without thinking about consequences. They are not malicious in their behavior. In fact, they are usually exploited by more talented criminals to some of the running, or high risk behavior, and are more likely to get caught.
As many as half the young offenders appearing in court may be there because their mothers drank during pregnancy, says Royal University Hospital psychologist Josephine Nanson. Her assessment has tremendous implications for how the criminal justice system handles youth in custody, says University of Saskatchewan law professor Tim Quigley.
"It's analogous to the mental disorder defense, in the sense that we've said that people who are affected should not be punished in the usual criminal justice sense," he said.  "Are these victims just as much affected by something over which they have no control, and are they deserving of punishment?"
Legal Aid Commission lawyer Kearney Healy says our new information about FAS strikes to the basic principles of criminal justice. "The criminal justice system is based on the premise that people understand there are rules, why they have to be obeyed, and if they aren't obeyed then society has the right to come up with any number of options," he said. “All of those things are irrelevant to these kids. It's got nothing to do with good or bad - they just don't see it the same way.  There is an increasing number of cases reaching the courts because we've been diagnosing this for about 20 years. Those individuals are now in adolescence and adulthood, and at a prime age for when they're going to be involved in the court system." 
Given the strict diagnostic criteria used in the studies of FAS, we are only looking at the tip of the iceberg. For every full case of FAS, there are four out there with partial effects. 
Shirley LeClaire of Social Services' Family Service Bureau says "there's been a longstanding history in our community of not giving this the attention it needs. It's one of the areas where there's not a lot of attention paid, especially fetal alcohol effects, because you don't have the physical attributes," she said. "The whole area of FAS and fetal alcohol effects is significant because the way that our system is set up to deal with kids is obviously not going to work for them."
One of the ironies is that children with FAS often make model prisoners,  because  FAS people do very well in structured environments. Often people are fooled in the early stages of treatment into thinking somebody is doing really well, not realizing that they're doing really well because all the opportunities for them not to do well are taken care of in a structured program. This, however, is an illusion. The FAS individual will fall apart emotionally.
Ignorance Will Send Your Child To Prison
Popular misconceptions about mental illness and mental retardation are partially responsible for the railroading of FAS persons through the criminal justice system. From arrest to the determination of competency to stand trial and beyond, a person's mental health affects every stage of passage through the criminal justice system.
If you doubt that assertion, simply ask yourself whether or not mentally ill people act weird, peculiar or suspicious.  Does the behavior of people with mental problems attract attention? Of course it does, and that includes attracting police attention, even if a crime hasn’t been committed.  
Untrained to recognize and handle mental illness, be it caused by exposure to alcohol in the womb or any other factor, arresting officers and other staff inappropriately assume the arrestee understands such things as their Miranda rights. Children and adults with FAS are more likely to give false confessions simply to please the police.
A Public Health Issue
Even a brief skimming of the previous pages should prove adequate to make my case: FAS is a devastating problem with dreadful impact on millions of lives, and all the pain, suffering, punitive measures, imprisonment, and fortunes spent on researching effective ways to treat FAS would all vanish in a generation if women simply didn’t drink alcohol before or during pregnancy. Not one drop. Not one beer. No loving mother would trade her child’s future for a six pack, a wine cooler or a bottle of single malt scotch.  
If you are a woman, love your child more than you love alcohol. If you are the father of the unborn child, join with the mother to shelter and protect that innocent being from the pernicious and life-long effects of Fetal Alcohol Syndrome.
	Drugs Other Than Alcohol
	Although Alcohol is the most destructive and dangerous of all social/recreational intoxicants, there are medical dangers in the misuse of even a benign medication. 
Pain is one of the most common reasons people consult a physician.  The most effective pain relief is from opioid analgesics – narcotic pain killers. . You may become physically dependent on pain killers if you take them regularly, but physical dependence is not the disease of addiction.   If you stop taking them abruptly, you may develop nausea, sweating, chills, diarrhea, and shaking. When people take these medications for pleasure instead of to reduce pain, there is a heightened risk of the disease of addiction. 
FDA estimates that more than 33 million Americans age 12 and older misused extended-release and long-acting opioids during 2007—up from 29 million just five years earlier. And in 2006, nearly 50,000 emergency room visits were related to opioids.
"Opioid drugs have benefit when used properly and are a necessary component of pain management for certain patients, but we know that they pose serious risks when used improperly—with serious negative consequences for individuals, families, and communities," says FDA Commissioner Margaret A. Hamburg, M.D.
Stimulants
Cocaine is a stimulant, as is caffeine. Obviously, cocaine is stronger. Amphetamines are also stimulants, and have proper medical uses. Methamphetamine, stronger yet, also is utilized medicinally. Recent studies shows promise in using methamphetamine in the treatment of    various conditions, including Alzheimer’s Disease.  Amphetamines are prescribed appropriately and safely for children as young as six years of age without ill effect.  As with all medicines, appropriate use a specific condition is beneficial. Misuse and abuse, however, cause all manner of problems. 
When stimulants are taken in excess for recreation, the consequences can be delusions, anxiety, hypertension, seizures, stroke, arrhythmia, chest pain, heart attack, and hyperthermia.   Long term Meth misuse can cause extreme psychosis similar to Schizophrenia. 
 Cocaine abuse is also associated with numerous detrimental health effects.. Ten cocaine-induced psychiatric disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, all of them the result of continued excessive indulgence.
Coke Bugs
Coke bugs, meth mites, and speed bugs are the common names for: the delusion that there are  bugs crawling on your skin,  under your skin, or infesting your clothing, furniture or even your pets.   Amphetamines, methamphetamine, and/or cocaine can cause the physical  sensation known as “formication” which, when combined with  the seeking, searching and exploring behavior that is symptomatic of stimulant over use, gives rise to the false belief of infestation and parasitic insect activity. The obsession or observation of non-existent bugs is called parisitosis .
With cocaine and methamphetamine, this  phenomenon occurs because the human  body can’t digest the hazardous additives, or “cut,” that were mixed in to increase the seller's profit margin.  The body  forces these toxic substances out through the pores, causing sores, acne and chronic scratching. 
Stimulants also cause your body temperature to go up, and you begin to perspire heavily. When the sweat evaporates, it removes the skins protective oils.  The combined  effects of sweating, no oil, and dehydration creates a sensation of the nerve endings which feels like  something irritating or "crawling" on or under (Delusional Parasitosis) the skin. 
 This phenomenon was first noted in the 1890's. and in all decades subsequently.  In addition, a person suffering from stimulant over-use will find their attention directed to  raised follicles or small irregularities in the skin, and they will pick or pluck at these until they have numerous scars and lesions. 
Extreme use of stimulants, and subsequent lack of sleep and nutrition, may result in someone spending hours searching through their clothes or bedding with a magnifying glass for evidence of these bugs. Some will resort to microscopes in their quest, and it is quite common for those suffering from this delusion to bring “evidence” to doctors, pest controllers, or skin specialists. Believing they have captured one or more of these bugs, they are often upset when a doctor informs them that their evidence is nothing more than a piece of their own skin, remnants of a scab, or a piece of lint.
In more advanced stages of this delusion, the person may cut their skin open to find the bugs, or pluck all the hair follicles out of various areas of their body.  I had one female patient who was convinced that not only she had these bugs, but so did her dog. The innocent creature was subjected to hour upon hour of her plucking away at it with tweezers until the poor thing was virtually hairless!
If you use stimulants, and you think that you have bugs, you have simply taken too many stimulants. Drink plenty of water, and recognize that the sensation that you have bugs is indicative of overuse. You don't want to end up like those folks who rip their flesh apart trying to get the little critters. 
Paranoia
 When people are paranoid, they distrust the behavior and motives of others. Even the most innocent actions are viewed with suspicion.   Among the drugs that can cause paranoia  are corticosteroid medications, H-2 blockers (cimetidine, ranitidine, famotidine), some muscle relaxants (Baclofen), antiviral/anti-Parkinson drugs ( amantadine ), some amphetamines (including methylphenidate, or Ritalin), anti-HIV medications, anti-depressants (Nardil). Abused drugs that can prompt paranoia include alcohol, cocaine, marijuana, ecstasy (MDMA), amphetamines (including Ritalin), LSD, and PCP (angel dust).  
A common symptom of stimulant over-use is paranoia coupled with hyper-vigilance. This is known in the drug world as tweeking. People will actually stand at the door and peer through the peep hole attempting to see if someone is sneaking up on them, or stand and stare out the window blinds as if anticipating an attack. 
While this is often described as a negative effect of cocaine or other stimulant use, research shows that some people actually enjoy hyper-vigilance and paranoid delusions.  Stop and think about this for a moment.  When you read a list of the ill-effects of using stimulants for recreation, one of the “bad things” is paranoid delusions and fear, along with elevated heart rate.  The same could be said for scary movies, and it is precisely to have these fears that some people indulge in the misuse of these drugs.
“I like being paranoid,” confessed one of my patients, “I know that my fear isn't really real anymore than the fear from watching a horror movie – I know in the back of my head that   this feeling is temporary, like the scary rides at an amusement park. Lots of folks don't like the feeling, but I do. In fact, the scary feeling is the reason I like to get high.”
Most people who have paranoid delusions, however, do not find it entertaining, and these delusions can result in violence against people whom the paranoid person imagines as enemies. 
	Marijuana

When alcohol was illegal in America, Marijuana was the only legal recreational drug available.  The roles were soon reversed, and Marijuana's reputation went into stark decline for several decades.  Today, however, Marijuana is he most commonly used drug among teenagers in America.  While alcohol is far and away the most destructive intoxicant, the combination of alcohol and marijuana is especially harmful to the developing brains of adolescents. 
The human brain will develop up to 400% more receptors for the active ingredients in Marijuana if use begins in the early teenage years, and consistent use during this critical period may give rise to various neurological and psychological issues, including problems with  verbal skills, sequential memory processing, motivation, and task completion.
Frequent adolescent Marijuana users manifest significant impairments to important cognitive brain functions, and the negative effect of Marijuana on memory and concentration is well documented.. Those who begin marijuana use at age when the brain is still developing may be more vulnerable to various neurological and psychological issues, including problems with their verbal skills.
Marijuana smokers also have a lower rate of college acceptance, and a higher rate of drop out, although poor academic performance often comes before the Marijuana use, and is one of the triggers for the onset of drug use.  Once started, however, the usage combines with collateral sociological and emotional factors,to further undermine the student's academic career.  While it is true that there are pot smokers at Harvard and Yale, these are incredibly bright achievers who were always top academic performers, and they certainly did not spend their adolescence “wasted” instead of studying.  
 Another result of prolonged use of Marijuana is reduced  sperm count,   recently verified by a study conducted by the American Society for Reproductive Medicine. "The bottom line is, the active ingredients in marijuana are doing something to sperm, and the numbers are in the direction toward infertility," said Lani J. Burkman, Ph.D., lead author on the study.
 "The sperm from marijuana smokers were moving too fast too early," said Burkman. "The timing was all wrong. These sperm will experience burnout before they reach the egg and would not be capable of fertilization."
As an addiction specialist I've personally treated patients with Marijuana withdrawal symptoms of anxiety, agitation, insomnia, and even violent behavior. These patients struggle to stay away from Marijuana with the same challenges as those who have battles with alcohol or other drugs, and their psychological pain is obviously visible,  and confirmed by the patients themselves. 
Marijuana in a pill
Medical marijuana in pill form, called Marinol, is a legal prescription medication used to treat the adverse effects of chemotherapy, and to increase appetite in AIDS patients.. The active ingredient is synthetic THC, and Marinol is  approved by the medical community and the Food and Drug Administration (FDA), the nation's watchdog over unsafe and harmful food and drug products
Why not just smoke it?
Smoking is generally a poor way to deliver medicine.  As a doctor, I assure you that is almost impossible to administer safe, regulated dosages of medicines in smoked form. Morphine, for example, has proven to be a medically valuable drug, but no responsible physician endorses smoking opium or heroin.
Another reason for not smoking marijuana for its medical properties is the issue of tar. One of the most dangerous aspect of smoking tobacco, the tar level in marijuana is 400% higher than in tobacco. Of course, even a heavy pot smoker does not smoke as pot at the same level as a tobacco smoker smokes cigarettes.  If they did, they would have far more problems to worry about than “tar.”
There are  profound reasons for addiction medicine specialists, as well as other physicians, to look askance at the current so-called “Medical Marijuana” programs in California, among other states.
Medical Marijuana
In my opinion, “Medical Marijuana” continues to make a mockery of medicine.     Let me begin with the fact that the approval process is outright laughable. Anyone with a checkbook can get a "recommendation letter" for marijuana. 
Under normal standards of professional care, a doctor performs a complete physical examination and diagnosis of the patent, and then prescribes appropriate medication. Once the medical treatment begins, there is continual interaction between the doctor and patient to ascertain the progress and efficacy of the treatment. 
In case of marijuana, there is no standard medical procedure performed, no special training for the physicians, and no guidelines. There is also no prescription written, nor are there any specifics as to dose and frequency.  You can get a marijuana card for as little as $35 dollars if your complaint is "hair pain,“ or something equally dubious. 
Anyone with any symptom can go to a " Marijuana Doctor" and can get recommendation letter stating that the person will medically benefit from Marijuana. The patient then takes this letter to a marijuana dispensary and picks out the flavor of marijuana they find most appealing. 
This isn’t a prescription such as “take 500 mg 3 times / day for a month“ and no one in the dispensary, including the patient, has no idea what it is they are getting.  
“My Balls Hurt!”
A seventeen year old patient was referred to me by a pain specialist.  The specialist was about to perform invasive surgery to deal with the patient’s continual complaint of pain in his testicles.  The specialist, however, rightly perceived the true nature of his patient’s problem: the kid just wanted to smoke a lot of pot.
He started using marijuana at typical age of twelve, correlated with poor academic performance, and finally dropped out of school completely.  He parents, however, were unaware of the marijuana use. When his father found out, the youngster cleverly explained that he had excruciating pain in his testicles that only was relieved by smoking marijuana. 
The father, rightfully concerned, made appointments for his son with all available urologists in the local area.  None of them could find anything wrong with the boy‘s testicles, or any cause for the pain.  Either the boy was suffering from a rare malady, or he was scamming his dad.  
There was no rare malady. Fully believing that his son suffered from a testicular pain that only marijuana could relieve, his father got him a “marijuana card” allowing the boy to have his pick of whatever was available at the marijuana dispensary. 
When the surgeon referred the patient to me, I did a complete and thorough medical assessment.  His “problem” had nothing to do with pain or tentacles. He simply devised a convincing deception allowing him to continue his indulgence.
.I called the boy into my office where, with the utmost courtesy, I kindly suggested that he at least think about cutting down his marijuana intake. 
“No way,” he screamed “no way in hell!”   A seventeen year old boy throwing a tantrum worthy of a two year old is not pleasant.
“The reason for the question,” I said as if his outburst went unnoticed, “is because your problem is not testicular pain, it’s your marijuana dependence.  If I were you , I would acknowledge this fact, and deal with it. Otherwise, your pain specialist is prepared to  perform a surgical procedure on your testicles to remove the source of your pain.”
Amazingly enough, the fellow didn’t need further encouragement to deal with reality. He smiled with relief as I called the pain specialist and informed him that an invasive surgical procedure would not be necessary.  
His is one of endless anecdotes of teens who suffer the consequences of the misuse and over-use of Marijuana.  Remember, I am an addiction medicine specialist and I have treated enough people with severe problems related to Marijuana to know it's true potential for  harmful medical consequences.
Sadly, you can get a marijuana card for as little as $35 dollars and bogus claims of hair pain, muscle soreness and headaches. Before you pretend that you are in the presence of medical professionals, I am telling you with absolute certainty that you are not. 
Rather than  further disgrace the medical profession with this absurd claim of “Medical Marijuana,” it would make more sense to legalize Marijuana as a recreational intoxicant, tax it, and use the revenue for education and medical rehabilitation of those who have suffered Marijuana's negative consequences. 
Just as the vast majority of people who drink are neither problem drinkers nor alcoholics, the majority of adults who smoke Marijuana are not problem smokers or drug addicts. My concerns are in two categories. First of all, because Marijuana is illegal, there are no regulatory standards of production and manufacture regarding content and potency. Hence, , one cannot state that Marijuana, “used properly” is safe, because there is no definition of “properly,” nor is there a standard “safe dosage.” Second of all, there is a predictable percentage of people who, due to genetics and other factors,will manifest the disease of addiction.  One out of six people who smoke marijuana regularly will develop problems requiring some type of medical intervention. 
Marijuana, as with all other mind altering drugs, is definitely dangerous in combination with any motor vehicle. Marijuana affects alertness, concentration, coordination, and reaction time.  Marijuana also makes it hard to judge distances. The worst case scenario is combining   Marijuana with even a small amount of alcohol. The two together is more dangerous  on the road than either drug alone.  
Benzodiazepines
Medications such as  Valium and Xanax  are some of the most commonly prescribed medications in America. . There are  numerous uses for these medications, but when people take them who don't need them, then there are problems. People at risk for addiction to these substances are also at risk for alcoholism. The combination of the two is deadly. 
Withdrawal from Benzodiazepines is similar to alcohol withdrawal, and can be a dangerous process if not done properly. One should never stop these drugs “cold turkey,” but taper off the doses as directed by a physician. 
Social Consequences
The idea that there are “social consequences” for indulging in recreational drug use has come under intense research and professional scrutiny in recent years.  In America, the biggest social consequence risk for the non-addict drug user is arrest and or coerced “treatment” for possession of a controlled substance. 
According to the National Institute on Drug Abuse, (NIDA), "Among young people in drug abuse treatment, marijuana accounts for the largest percentage of admissions: 61 percent of those under age 15 and 56 percent of those 15-19."  
According to the US Government study from which NIDA gets this figure, the majority of these teens were not in treatment because of dependence or addiction. They were given a choice of treatment or juvenile detention after being caught in possession of marijuana. There was no medical diagnosis of dependence or addiction. 
NIDA doesn't mention this fact because, as an official representative of Federal drug policy,  they want the reader to infer the admissions are due to dependence/addiction. Sadly, this is  exactly the  type of thing that causes teens to not trust anti-drug pamphlets. Once again, we see research studies used not as education, but as propaganda. While the intent may be honorable, the methods undermine credibility and perpetuate harmful exaggerations. 
Because of my role as a doctor who treats patients with the medical condition of addiction, you might think I would approve of any method that proposes to decrease drug use. Proposing isn't the same as accomplishing, and falsely labeling people as drug addicts when they do not have the disease of addiction diminishes the credibility of the condition itself and makes a mockery of treatment. 
`The respected New England Journal of Medicine  presented a paper on its Perspective page titled, Medicine and the Epidemic of Incarceration in the United States. The paper reviewed the deplorable plight of drug addicted and mentally ill inmates in our nation’s prisons and concluded,
“Locking up millions of people for drug ­related crimes has failed as a public­ safety strategy and has harmed public health in the communities to which these men and women return. A new evidence­ based approach is desperately needed. We believe that in addition to capitalizing on the public health opportunities that incarceration presents, the medical community and policymakers must advocate for alternatives to imprisonment, drug ­policy reform, and increased public awareness of this crisis in order to reduce mass incarceration and its collateral consequence.”
 A special  Designer Drug and Cocaine Conference held in Switzerland prominently featured extensive research by Peter Cohen, author of  The Social and Health Consequences of Cocaine Use.  In his final analysis, and in his words, “For all drug use and drug users, social exclusion and marginalization are the worst settings. The best harm and crime reduction money can buy is to lower marginalization and exclusion of drug users, even if this would mean that the drugs they (still) like to use have to be made available to them at acceptable costs. In my view daily and regular use .is far less of a danger to people than social exclusion.”
We must deal with what is real, and the reality is that I practice addiction medicine in the United States where the stigma against addicts is widespread, punitive legal measures are still instituted against disease sufferers, and millions of people who could avoid addiction, or be treated successfully for it, receive no help beyond a good scolding, shame, and support group meetings. 
Be reasonable. If you thought you had cancer, you would go to a cancer specialist for medical diagnosis.  You may also attend a support group for people dealing with cancer, but you would certainly pursue effective medical treatment.  It is the same with heart disease, diabetes, or addiction.  These are all chronic medical conditions with strong emotional and environmental components.  They are all also preventable and treatable. 


ADDICTION
CHAPTER FOUR
Education, Harm Reduction, and Intervention
There are key risk periods in life that increase exposure to, and use of, mood and mind altering drugs and alcohol. These risk periods are anytime there are major transitions in someone's life. For youngsters, the major transitions are school related. 
Most parents can easily recall the emotional state of their children when they left the security of the family for the first time to attend public school.  Some kids were excited, others were fearful.  The advancement  from elementary school to middle school is when the  young person encounters  new academic and social situations, and deals with a wider diversity of fellow students. This  is one of the major transitions most associated with exposure to, and use of, drugs and alcohol. 
Some children are already using drugs at age 12 or 13, including alcohol, inhalants, marijuana, psychedelics, and prescription drugs such as sleeping pills and anti-anxiety medicine  The transition from middle school to high school is another high risk period because   of additional challenges socially, emotionally and educationally,. They are also exposed to increased availability of drugs and alcohol, social activities where drugs are present, and interaction with more peers who are actively drinking and/or drugging. 
	 It is no big secret that teenagers drink alcohol.  They cannot legally purchase it from a retail outlet, nor can they consume it in a bar or cocktail lounge, but the Surgeon General of the United States reports that more than 8 percent of eighth graders, 16 percent of sophomores, and 24 percent of seniors report recent binge drinking.  One out of every ten kids between 12 and 13 drinks alcohol at least once a month. 
	Teenagers  are more sensitive to brain damage from alcohol, because their brains are still developing, and do not usually reach full maturity until around age 25. 
	 I could go on with all the terrible depressing statistics regarding the horrors of teen age drinking, but I'll spare you the specifics and cut to the important questions:
	 Why do young people drink and get drunk?
	What are we trying to prevent with prevention programs in the alcohol field?
	What are the different strategies of prevention?
	What is the evidence of their effectiveness?
What strategies are most politically popular, and how do they relate to those which are most effective?
 What conclusions can we draw for future programs and initiatives?.
These same questions were explored at great length by the Centre for Social Research on Alcohol and Drugs at Stockholm University, and I don't think their answers will surprise you. In fact, if you stop and think about it, it is pretty straightforward. After all, everyone was young once. 
The Search for Identity 
In the teenage years, young people begin their quests for identity, the “sense of self.”  Teenagers' identities are entirely dependent on how they see themselves, not how their parents see them.  During the teen years, people strive to define who they are. 
Les Parrott, Ph.D., a professor of psychology, notes that teens demonstrate their struggles with identity in five ways. 
1. Status symbols.   Adolescents try to establish themselves through prestige — wearing the right clothes, having the right possessions, from stereos to sunglasses. These symbols help form teen identities by expressing affiliation with specific groups.
2.Forbidden behaviors. They smoke, drink, drug, and have sex – all activities associated with adulthood.
3 Rebellion demonstrates separation from parents and authority figures, while maintaining the acceptance of their peers.
4. Idols.  Celebrities may become “models” for teens who are looking for a way of experimenting with different roles.  This identification with a well known personality gives teens a sense of belonging.
5.Exclusion. Teens often can be intolerant and refuse association with anyone having unacceptable or unattractive characteristics. They try to strengthen their own identities by excluding those who are not like themselves.
When we look at these five things, we see clearly that adolescence is a time of experimentation, new sensations and taking risks. Most of the behavior flirts with what teens see as “marker of adulthood.”  Among these perceived aspects of adulthood are drinking, driving, and having sex.    Drinking, however, is one of the few behaviors with intense symbolic significance because, unlike sex, it is most often performed in front of an audience of your peers, and expresses solidarity with your friends.  
What you drink, even the brand name, identifies you with a particular culture, sub-culture, and social style.  While this is also true of soft drinks – those who drink Dr. Pepper see themselves as distinct from the herd of cola drinkers – it is of greater significance to those who drink alcohol. 
We are not talking about so-called “peer pressure.”  No one puts “pressure” on teens to become intoxicated, and were that the case, it would not be considered a pleasurable experience anymore than being forced to have sex would be recalled with fondness.
 What we have all experienced is “Peer Influence”-- we we are attracted to a particular social group, and desire to participate with them in their activities. Drinking is predominantly done in groups and is incidental to other activities, such as dancing, going to clubs, partying, or following a particular music performer or style. 
For an adolescent experiencing the transition to adulthood, drinking to intoxication is more than consuming a mood altering liquid. It symbolizes freedom and autonomy, providing young people with something resembling adult status. If you doubt this, simply consider the message about drinking we most often give youngsters: wait until you are old enough. This reinforces the status of drinking as a marker or claim to adulthood, and being “grown up.”
In the context of the social acceptance of drinking among adults, youth rightly perceive hypocrisy in the message that they should act differently.  Hence, they don't act differently, and they do it consistently, undeniably, and everyone knows it.  There are also consequences, both long term and immediate. 
Long term consequences of heavy alcohol use are well documented and easily ignored by young people. Teens are not famed for their long range thinking skills. After all, it is difficult to contemplate twenty years in the future when you have only been alive for thirteen years.  
There are, for adolescents, immediate consequences for getting drunk, including alcohol poisoning in extreme situations.  The majority of current teen drinkers got drunk in the previous month,including 50 percent of the high school sophomores who drink, and 65 percent of the high school seniors who drink. 
While the U.S Surgeon General attributes five thousand underage deaths per year to alcohol related incidents, those include crashes, homicides and suicides. In the United States, 12.8% of all fatal traffic crashes were alcohol-related, and 40% of that number involved teens driving while drinking alcohol. (Source: National Highway Traffic Safety Administration)
About 1,900 people under 21 die every year from car crashes involving underage drinking. Young people are more susceptible to alcohol-induced impairment of their driving skills. Drinking drivers aged 16 to 20 are twice as likely to be involved in a fatal crash as drinking drivers who are 21 or older.
 Academic performance amongst drunks has never been exemplary. A recent government study  shows a relationship between binge drinking and grades. Approximately two-thirds of students with “mostly A’s” are non-drinkers, while nearly half of the students with “mostly D’s and F’s” report binge drinking. It is not clear, however, whether academic failure prompts drinking as a way to overcome the negative emotions associated with academic failure, or if the thinking impairments engendered by alcohol facilitate academic failure. One characteristic of alcoholic behavior is that drinking becomes the primary response for dealing with stress   Either way, drinking and good grades don't go together.  
Teens' still-developing judgment and decision-making skills may limit their ability to assess risks accurately and make sound decisions about using drugs. Drug and alcohol abuse can disrupt brain function in areas critical to motivation, memory, learning, judgment, and behavior control.  So, it is not surprising that teens who abuse alcohol and other drugs often have family and school problems, poor academic performance, health-related problems (including mental health), and involvement with the juvenile justice system. –  NIDB

I'm not sharing this information to scare you, or to bang some moral drum on the evils of demon rum. Rather, my purpose is to the lay a firm foundation upon which to raise important issues regarding the most effective ways of reducing harm and saving lives. 
 These problems are not unique to the USA.  Among those aged 15-29, an estimated 12.8% of male deaths and 8.3% of female deaths in European established market economies are attributable to alcohol (Rehm et al., 2001). 
A study in the Republic of Ireland found that for teenagers aged 15–19:
86% drink alcohol 
51% binge drink  at least once a month.
19% binge drink once a week.
On a typical drinking occasion, the average amount of alcoholic beverages consumed is 5.75 pints.
The average age for taking a first alcoholic drink is 13½.
50% have used illegal drugs at least once.
41% have used cannabis at least once.
The average age of first illegal drug use is 14½.
Northern Ireland has the highest rate of recreational drug use among teenagers in the European Union. 
Meanwhile, in the United States of America, we continue to pretend that teenagers don't drink and drug.  We pour all our efforts into telling them not to start drinking, not to start drugging,  when they already have extensive experience doing both. 
The assumption of ignorance regarding the effects of various drugs was one of the many shortcomings of DARE, Drug Abuse Resistance Education, an undisputed publicly funded failure, and many other programs and “drug education” publications that promulgate misinformation.  
 “As a result, they learn to distrust all drug education,” says the Family Council on Drug Awareness, decrying programs that send  harmful stereotypes, and self-fulfilling prophesies.
 Perhaps the most tragic example is the drug abuse prevention program attempted in Houston, Texas in which counselors and teachers  were asked to identify students they believed to be drug abusers. These students were put in  a special class for “druggies” where they received drug education, and were encouraged to explore alternatives to drug use.  
On the evening following the very first class, the students had an after school party where three of them suffered non-fatal drug overdoses on a mixture of alcohol, Quaaludes, and marijuana. Of those three, one had never used any illicit drug previously, and another had never taken Quaaludes.  At least three other students attending the party smoked pot for the first time, and even more students took Quaaludes for the first time.. The students lived up to the identity and stigma bestowed upon them by their teachers and counselors. 
We can learn from our mistakes, and the failed programs teach us many valuable lessons, including not to hold up drugs as a litmus test of character, and don't reinforce negative self images or dire predictions of self-destruction. 
 Punishment doesn't heal a chronic illness. 
Alzheimer’s disease is a  brain disorder, as is addiction, but Alzheimer's doesn't come about by any voluntary act of will. Lung cancer may result from the voluntary act of smoking, but we don't treat lung cancer patients with mockery and incarceration. 
 According to the National Treatment Plan Initiative recently released by the U.S. Center for Substance Abuse Treatment (CSAT), stigma can "cause ostracism, shame, and even denial of life’s necessities – such as employment and a place to live – for which the person in recovery is fully deserving."  Criminalizing addiction simply creates further shame, alienation, and dysfunction.
“People who are victims of stigma internalize the hate it carries, transforming it to shame and hiding from its effects,” states David L. Rosenbloom, Ph.D. “In many ways, hiding an addiction problem is the rational thing to do because seeking help can mean losing a job and medical insurance, or even losing your child when a social service agency declares you an unfit parent because you have an alcohol or drug problem.”
Addiction expert Dr. Dan Umanoff states it clearly,: “Unconscious human xenophobic instincts are at the root of our country's addictophobia and its anti-addict intellectual and academic propaganda, ideology, and social, legal, and political policies exactly as in racism, homophobia, and antisemitism. Absent a rational premise, addictophobia, as presently exists, is inevitable and inexorable.”
Perpetuating the myths of drug use  and/or drug addiction as character defects or moral flaws is not in anyone's best interest. .Honesty and accuracy are of paramount importance. Attempts to manipulate the behavior of others, even for their own good, are doomed to failure if based upon easily refuted myths, lies or false assumptions.  
Once trust is violated, it is difficult to regain.
“Modern drug education programs for adolescents are little more than warmed-over 19th-century teetotaler sermons, phony as snake-oil,” wrote Paul M. Bischke, Board Member of the Drug Policy Reform Group of Minnesota .”It's lying re-labeled as education. but lying exacts a price. After 120 years of exaggeration about John Barleycorn and the Demon Rum,  the jaded American public longer believed alcohol to be a dangerous drug.” 
When we attempt to curtail drug use by scare tactics, the results are always negative.   When we repeat myths about various drugs, we only undermine our credibility.

 Myths of Addiction
1. Addicts are bad, crazy, or stupid.
Addicts are not bad people who need to get good, crazy people who need to get sane, or stupid people who need education. Addicts have a brain disease that goes beyond their use of drugs.
2. Addiction is a willpower problem.
Willpower has nothing to do with it. The area of the brain where addiction occurs is not under anyone's conscious control.  The addict's brain is radically changed, and the ability to resist the object of their addiction  severely compromised, if not altogether eradicated.
3. Addicts should be punished for using drugs, and alcoholics should be punished for drinking. 
Impaired control is one of the basic signs of addiction.  This condition is treatable, as it is involves neurology and chemical pathology in the brain.  
4. People addicted to one drug are addicted to all drugs.
This is not true. The drug to which someone becomes addicted corresponds to that individual's particular brain chemistry. 
5. Addicts cannot be treated with medications.
Nonsense. Addicts are medically detoxified in hospitals, and there are new medications that reduce relapse and enhance treatment. 
6. Addiction is treated behaviorally, so it must be a behavioral problem.
New brain scan studies are showing that behavioral treatments (i.e., psychotherapy) and medications work similarly in changing brain function. So addiction is a brain disease that can be treated by changing brain function, through several types of treatments working together. .
7. Alcoholics can stop drinking simply by attending AA meetings, so they can't have a brain disease.
There is more to alcoholism and addiction than drinking and drugging. 
Stopping the behavior associated with the condition is not treating the condition itself.  This is why AA works for a small percentage of people, but not most. The simple reason is that meetings are not medical treatment for a medical problem. Support groups are wonderful when used in a comprehensive individualized program that addresses the underlying medical issues first. 
The myths don't stop with the general heading of addiction, there are widely spread myths about specific drugs such as crack and meth. 
Myth: Crack in instantly addicting.
Fact: Most people who try crack don't like it, and don't use it again. Over 75% of people who tried crack between 2004 and 2006 were not using it at all two years later.  15%  still smoked it occasionally, but not in a way associated with addiction. 
 7,840,000 (3.3%) of Americans have smoked crack cocaine during their lifetime. However, only 467,000 (.2%) of Americans reported smoking crack cocaine in the last 30 days. If crack were  instantaneously addictive, the number of recent users would be much larger. 
Source: SAMHSA. Results from the 2004 National Survey on Drug Use and Health: Detailed Tables.
Myth : Crack is much more addictive than powder cocaine.
Fact:  According to the National Household Survey on Drug Abuse in 2004 of Americans age 12 and older, 5.9% of individuals who had ever tried cocaine went on to be "current users" (reported use within the past 30 days). The same statistic for crack use was also 5.9%. These numbers show no statistical difference in the tendency towards the future use of cocaine and crack.
Source: Reinerman, C. and Levine H., Crack in America. University of California Press (September 1997). 2004 National Survey on Drug Use and Health: National Findings.
Myth : Crack is purer than powder cocaine, and is more potent.
Fact: There is no pharmacological difference between crack cocaine and powder cocaine. Crack cocaine is simply powder cocaine which has been converted into a solid "rock" form that may be smoked. The effects of smoking crack cocaine may be more intense, but this is a result of the mode of ingestion rather than the drug's purity. Regardless, it is difficult to rationalize the extreme sentencing disparity between crack and cocaine.
Source: Hatsukami, D. and Fischman, M. Crack cocaine and cocaine hydrochloride: are the differences myths or reality?. Journal of the American Medical Association (November 1996).
Myth : Crack use is much more dangerous than powder, and kills its users more often.
Fact: The misuse of any drug (legal or illegal) can be detrimental to your health. It is simply not true to claim that crack cocaine is a major cause of death. The percentage of deaths attributed to ALL illegal drugs combined is less than 1%.   By comparison, over 18%  is  caused by tobacco.. More people die every year from legal drugs, legally prescribed, than all illegal drugs combined.
Source: Actual Causes of Death in the United States, 2000. American Medical Association (2004).
Myth: Crack is used almost exclusively by Blacks and is a special plague of the Black community.
Fact: While often characterized as a drug of the Black community, 60% of individuals who have used crack in the last month are White. White crack users also account for 66% of individuals who have ever used crack in their lifetime. Simply stated, the majority of crack users are White.
Despite this reality, 80% of people arrested for crack offenses in 2002 were Black. Consequently, a disproportionate number of Black crack offenders face the harsh mandatory minimums associated with crack convictions. 
Source:SAMHSA. Results from the 2004 National Survey on Drug Use and Health: Detailed Tables. Bureau of Justice Statistics. Compendium of Federal Justice Statistics, 2003. Table 1.4.
Myth:  Crack use leads to violence much more than the use of other drugs.
Fact: . Research has shown that crack use does not result in violent behavior.  The violence one associates with crack is not from the effects of the drug, but rather the violence between rival criminal organizations and/or law enforcement. . 
Source: Reinerman, C. and Levine H., Crack in America. University of California Press (September 1997).
Myth: It is hard to quit crack/cocaine
Fact:  Most people who decide to stop using cocaine simply stop using cocaine.   A majority of people who misuse stimulants find it exhausting, and they literally become tired of it. The majority of crack smokers taper off their use, or stop completely, at anywhere between two months and two years, and they do so without going to “rehab.”  These people do not have the disease of addiction, nor do they have the characteristics of an “abuser” rather than a “user.”  Even former heavy users have  resumed occasional use from time to time without “relapsing” into addiction because they did not have the disease of addiction in the first place. 
Myth: Meth use is on the rise, and Meth users are harder to treat..
Fact: Meth use in America peaked at least two decades ago and has slightly declined or stayed about the same. Addiction to methamphetamine is not much different than any other drug addiction except tobacco, which is the most addicting and the most difficult to quit. When it comes to successful treatment, it doesn't matter if you're talking about meth or heroin or alcohol.
 Just as the vast majority of drinkers are not alcoholics, the majority of stimulant users are not addicts. They stop on their own, or with help from family and friends. There is that small minority of those who actually have the disease of addiction and require treatment. These are the people with whom I am concerned, and the ones who require true medical attention. 
 "Meth is a real problem for some people, but it is an over-hyped problem. All you have to do is look at the use rates and look at sentencing,” said  Jason Zeidenberg, executive director of the Justice Policy Institute. “When 100,000 people a year die from alcohol, I'm still saying that's the most dangerous drug in America." 
Thankfully, there are excellent accurate sources of information about the most common “recreational” drugs. .Drugs-forum http://www.drugs-forum.com  offers a wealth of quality information and discussion of drug-related politics, in addition to assistance for members struggling with addiction. In this capacity, Drugs-forum has proved to save lives.  Members of Drugs-Forum include researchers, drug users, harm-reduction specialists, concerned parents, officials, NGOs, lawyers, doctors, journalists and addiction specialists. Drugs-Forum provides easily accessible, free, unbiased and confidential information, advice and support. Drugs-Form is person centered, supporting users actively using and at all stages of recovery. It attracts members from all walks of life and gives people a safe space to get accurate and up to date information on a variety of substances. 
First, Do No Harm.
 If we are to truly reduce harm, we must give real practical short-term harm reduction messages that 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.  
“A youth audience will be more open to prevention messages about immediate problems in their lives than to messages about how to prevent problems which may or may not occur when they are in their 60s.” (USDHHS, 1994).
Famed comedian Amy Dresner used to “shoot Meth” – inject it directly into her bloodstream with a needle.  As she did more and more, she began having violent seizures. Amy 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 utilizing 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 realization of the need to stop the dangerous  behavior.  Amy Dresner no longer shoots Meth, and the football helmet is no longer required..   
Preventing a drinking-driving casualty can be accomplished by alerting teens of the real immediate danger of drunk driving, and by providing alternative to and from the event. 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 reality that many teens are already drinking. 
This, as international researchers have noted in their presentations, a major problem in the United States where the uniform minimum legal drinking age of 21, but the average age of when people start drinking is 13-14 years of age.  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, PhD, 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 those with a family history of abuse, a history of antisocial behavior, and those from ethnic and racial minority groups who were either “physically or psychologically beyond the reach of traditional, school based prevention programs.” 
Successful programs use  honest and effective educational programs that treat drug use as just another part of a broad health curriculum, with 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.  Make sure your school sends an honest, positive message that includes models beyond abstinence, and embraces moderation, harm reduction, and 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 school and reduce their likelihood of dropping out. 
Any program utilized 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 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.  The idea is to put a separation between the individual and harm, and society and harm.  Seat belts and airbags are harm reduction strategies, for example.  
Harm-reduction projects have aimed to reduce potential casualties, and other harms associated with drinking in bars and nightclubs.  Bars in the USA 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 their degree of intoxication will not increase. 
Taking keys away from drunks, and calling them a taxi to get home, is a major harm reduction policy that is saving lives, as is the concept of “designated driver.”
“Friends don't let friends drive drunk” is a major harm-reduction campaign in the USA, and it is having a beneficial effect.
Reducing Harms
Harm reduction is a health-centred approach that seeks to reduce the health and social harms associated with alcohol and drug use, without necessarily requiring that users abstain.
Harm reduction is a non-judgmental response that meets users “where they are” with 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 are features of harm reduction:
• Pragmatism: Harm reduction accepts that some use of psychoactive substances is inevitable, and that some level of substance use is expected in a society.
• Humane Values: The substance user’s decision to use alcohol and other drugs is accepted as his or her choice; no moralistic judgment is made, either to condemn or to support use of substances, regardless of level of use or mode of intake. The dignity and rights of the person who uses alcohol and other drugs are respected.
• Focus on Harms: The extent of a person’s substance use is of secondary importance to the harms resulting from that use. 
 Hierarchy of Goals: Most harm reduction programs have a Hierarchy of goals; the most pressing needs are addressed first.
The Harm of Social Consequences
Despite the potentially lethal damage that heavy drinking does to the body—including cancer, heart problems, and liver disease—the social consequences can be just as devastating. Alcoholics and alcohol abusers are much more likely to get divorced, have problems with domestic violence, struggle with unemployment, and live in poverty. 
Interaction with a punitive law enforcement system is also harmful. Research has shown that the harms associated with drugs other than alcohol are far less than those associated with alcohol, especially for harms associated with aggression and violence.  
The punishment handed out for illicit drug use is  more harmfull than the drug use itself.
Due to the relatively low harm potential of cannabis, one important aspect of harm reduction would be limit testing for cannabis use in those juridictions where testing postive for canibis would result in harmfull punitive actions because of existing laws.
Here is an easy to understand example: If a foreign exchange student in America under a Federal program smokes pot at a party, and his host family finds out, they are obligated to report it.  Once reported, the student is then never alllowed to pursue a college education or career in the United States, nor can they ever enter America again. 
The harm was not done by smoking marijuana. The harm was done by the punishment.
None of these long term concerns, be they consequences of health or punishment, have any meaning to a teenager who can't imagine life 12 months down the road, let alone the impact on advanced edcuational opportunities, marriage, family and employment in some distant future. 
A successful technique for reducing the risk of teen drinkers becoming alcoholics is “friendly advice” offered to the heavily drinking teenager by someone they trust. 
 It is important that advice to moderate their consumption not be confrontational or judgmental in any way. No criticism, no drama, no threats or stress.  In fact, exactly the opposite. A very brief, simple moment of advice to reduce consumption and/or moderate behavior has proven far more motivating than lectures, scolding, or threats. 
Removal of secrecy has also proven a powerful method.  When a teen is told that if they really want to drink or drug, they are more than welcome to do it right there at home, in the living room, where they run no risk of arrest, accident or harm. They mystique of substance use being a secretive or rebellious act evaporates  faster than alcohol. 


ADDICTION
CHAPTER FIVE

Family Concerns
Family members come to me saying, “my loved one is in denial. They refuse to admit that they have a problem.”   Naturally, they expect me to take their word for it.  I don't. I have not yet examined the patient or seen signs of illness.  Chances are, there is something about the loved one's drinking or drugging that has them concerned.  
The term "denial" is tossed around alot in the recovery field, is terribly overused and not always appropriately.    The term "denial" refers to the process by which people with addictions pretend  that they do not have an addiction, when in fact they do, or that their addictive behavior is not problematic, when in fact it is. Problematic. 
Denial may happen consciously, for example, when the person lies to cover up, or it may happen unconsciously, for example, when they genuinely believe that they do not have a problem.  People often deny they have  a problem with alcohol or drugs because  they really don't have a problem with alcohol or drugs. Other people may have a problem with their drinking and drugging, but they don't.
Elizabeth Hartney, PhD, a psychologist with extensive experience in research, practice and teaching in the field of addictions and concurrent disorders, notes that “denial may be partially conscious, for example, when someone admits that they drink more than is sensible, but deny that it causes them problems, when in fact many of the problems they experience are consequences of their drinking.”
The primary motivation for denial is fear, including fear of the stigma of alcoholism or addiction. This fear causes millions to live in secrecy, suffering not only the medical illness, but severe emotional pain, isolation and life threatening stress.  Stress imposed by fear, combined with that of stigma, fault finding and negativity by friends and family severely impacts all aspects of the person's health, and aggravates the disease. 
It is possible that the person accused of being in denial about their addiction is not addicted. Perhaps their behavior, including drinking or drugging, is at variance with the behavioral standards and expectations of their family.  
Deviation from someone opinion of how you should live your life is not a medical illness.  In this situation, the person's denial of alcoholism or addiction is their refutation of a false assumption made by people who are not experts in medicine, psychiatry, brain chemistry, hormonal imbalances, blood sugar issues, psychology, and/or other disciplines. 
It is simply not reasonable to assume that a layman, without any degree of  detached expertise, has the knowledge and ability to diagnose one or more medical illness impacting behavior, and prescribe the proper course of treatment.  While their concerns may be valid, and the loved one's behavior may be problematic, they have neither the medical training nor credentials to make a diagnosis.  
 Let us suppose that you have an intense pain the center of  your chest. You can feel it. It could be a heart attack, angina, damage to the aorta, the main artery supplying blood to your body, or maybe your lung collapsed. Then again,  it might be pulmonary embolism, in which a blood clot occurs in a blood vessel of the lungs and perforated viscus, in which tearing occurs in the gastrointestinal tract. 
 If you are doing cocaine, maybe you have constriction of the blood vessels and that is cutting down the blood supply to your heart. Then again, even if doing cocaine, perhaps  what you are experiencing is simply heartburn and acidity from that Super Duper Extra Everything Pizza you ate.  Or maybe you have  gall bladder problems or stomach ulcers. Those all cause chest pains. 
So tell me, based on the symptom of chest pain, what specific condition, or combination of medical conditions, are you denying by not “admitting” what's wrong with you? Perhaps the pain is the direct result of anxiety caused by people who have no medical knowledge or training  having the presumptive hubris of saying, “What's wrong with you is X. Get out of denial, and admit it.”  
The person suffering from any medical illness does not know the true nature of their condition based on their experience of the symptoms.  The person's  family, concerned as they may be, also are not qualified to diagnose medical conditions.  
To diagnose the meaning of the patient's symptoms, a medical specialist must see signs of the illness. If a person has been using drugs, the doctor must know about it because the side effects of certain drugs can mimic symptoms of various illnesses.  This is especially true with cocaine use. 
The number one cause of young people going to the hospital with heart attack symptoms is cocaine. In truth, they are not having a heart attack, although their symptoms, and the outward signs are the same. If we do not screen them for cocaine, and simply assume that they are having a heart attack, we could give them medication that endangers their life rather than saving it.
The Question of Intervention.
 The most effective and proven method for reducing harm and consequences of the adult problem drinker or drug user is the same as for a teenager: . The “friendly advice” method.  No criticism, no drama, no threats or stress.  A very brief, simple moment of advice from someone they trust to reduce consumption and/or moderate behavior has proven far more motivating than lectures, scolding, or threats. 
A person's response to this direct advice also provides valuable information on what their attitude is towards behavior change. If you come off as confrontive, they will balk and be defensive. Speak to them with words mild as milk, as if sharing a wise bit of helpful guidance, or a well-meaning suggestion. 
“A man convinced against his will is of the same opinion still.”
The accomplishment of anything depends upon a three part process of knowledge, volition, and action.   Knowing what needs to be done isn't enough. Thinking about it isn't doing it. Volition is the decision to do something, but that too is useless without action – actually doing it.  Most people never get to the “follow through” stage of action, especially when it comes to changing long-established behavior.
There are many theories of behavior change, and all of them offer useful insights. The “Stages of Change”  model  is one I find valuable, and it shows that  behavior change occurs gradually, going through progressive stages.  While the process, in reality, is a bit more complex, and the stages overlap, you can get the basic idea easily enough:
PRECONTEMPLATION: The patient is uninterested, unaware or unwilling to make a change. They are not even thinking about changing.  They may react defensively to any suggestion that they change behavior. 
It is in this stage that the process of engaging the individual in their own process of change is so important.  Enlist their opinion, value their views.  The days when patients' needs and perspectives were ignored are far behind us. Patients need to be engaged in managing their own health, and patients want to interact in a partipatory way with their health care providers. 
The increase in availability of information, developments in new technology, and changes in public attitudes mean that patients want to interact differently with their doctors.
I am reminded of the patient who, as soon as he met with his doctor, said, "I hope you're not going to tell me to stop drinking, because I love my wine."
"Of course not," replied the doctor. "You are perfectly free to drink all you want."
The doctor was telling the truth. He was free to drink all he wanted. It might kill him, but that information had not yet been communicated to him. Even then, the patient has a choice in behavior.  Once the patient was informed of his condition, and the potential or inevitable impact of alcohol on that condition, he thought it over and reduced his intake by half, and then stopped altogether. This was done without threats, recrimination, or bullying. He was engaged as a  partner in his health care. 
I had a similar situation with a woman who drank two bottles of wine each day.  I simply asked her to consider possibly reducing it a bit.  Considering is contemplating, and that is the next stage in the behavior change model. 
CONTEMPLATION:  They are considering changing. They weigh the pros and cons of the change. If they are being asked to give up something they enjoy, their sense of loss is an honest consideration. ,
PREPARATION:  They are preparing to make the change. Indicators that they are preparing to stop smoking, for example, would be switching to different brands, trying "lite" smokes, or shifting to cigars from ciagarettes.  If they are prepared to stop drinking, you may notice them consciously cutting down on their alcohiol consumption. Alcoholics, as opposed to simply heavy or problem drinkers, are unable to moderate their consumption. Remember the lady who drank two bottles of wine per day? Her first action was to reduce her consumption by half. From there, fully engaged in her own health care, she moderated her wine consumption all the way down to zero.
ACTION: . Any action taken towards the desired behavior change should be praised. 
MAINTENANCE: If they continue the behavior change for six months, that is significant.
 As addiction and alcoholism are chronic medical conditions, the patient will assuredly relapse. That's what having a chronic illness means. The disease flares up, and you have to start the process again. 
The stages of change are not always linear. They are components of a cyclical process that varies for each individual. For this, and many other reasons, invidualized care is imperative.
 If your loved one actually  has the medical condition of addiction, being angry at them is inappropriate and unfair. They are not weak or immoral or lacking willpower. They are simply no match for a medical condition that requires professional medical help.
Based up on my own experience, and years of validated research, people who are not addicts or alcoholics will seek help for drinking and drug problems on their own, or they will alleviate the problem themselves.  Otherwise, family and friends will arrange an intervention. 
Briefly, intervention is a proven, successful process which has enabled thousands of addicts to receive treatment – no matter how unwilling.  Some interventionist are remarkably honest about the true nature of purpose of intervention-- to create a crises.  
The idea is to put the person in such extreme emotional pain and stress that they only want the pain of the intervention to stop, and to get out of there as fast as possible. The interventionist offers them a way out: immediate transportation to a treatment center. 
Should the person actually refuse, the family is encouraged to make overt threats of dire consequences such as divorce, loss of child custody,  and/or court ordered commitment.
Involuntary Treatment
 Two hundred years ago, all it took to have someone involuntarily committed  was a concerned family putting forth a petition, or perhaps three  people who were not family, but took a significant interest in the condition of the individual.  The courts and asylums signed off on it, and the individual was taken away “for their own good, and the good of their community.”
Two hundred years later, the process is almost identical, except easier.  As of this writing, 38 states allow some form of involuntary substance abuse treatment that is separate from any kind of criminal issues. In several states,  you may be involuntarily committed to a drug treatment center simply because your family does not approve of your behavior.   

Are you Dangerous?
If you suffer from mental illness, or what police term EDP (Emotionally Disturbed Person), the question will be asked, "Is this person a danger to themselves or someone else?" If the answer is no, then the person is left alone.  If they pose no danger, there is no reason to take them away against their will to a psychiatric hospital.
Following intense lobbying of lawmakers, this standard is rapidly being discarded when it comes to people who drink or use other recreational drugs.   Florida's Substance Abuse Impairment  Act makes involuntary commitment for alcohol and drug use easier than involuntary commitment for mental illness.  In fact, you cannot petition to have someone involuntarily committed for mental illness if their behavior is because of retardation, learning disabilities, intoxication, or substance abuse. 
The Florida forced treatment law “enables family members to obtain help for a loved one who is unwilling to seek substance abuse services voluntarily.”  This is a very polite way of saying that you can be forced to have treatment without your consent. 
 	You can be committed  “...when there is good faith reason to believe the person is substance abuse impaired and, because of said impairment. is incapable of appreciating the need for substance abuse treatment.” (Stewart-Marchman-Act Behavioral Health Care).
In other words, believing that  you don't need treatment is considered proof that you need treatment. This, of course, is absurd.  
Florida is not the only state with forced treatment laws that read as if something from the Soviet Union in the 1950's.   In Arizona, for example, a pregnant woman may be forced into treatment merely on the suspicion that she has used methamphetamine.   Considering that the impact on the fetus of the mother using methamphetamine is no different than if the mother smoked cigarettes, one must wonder why there is not forced treatment for mothers who smoke or, far more dangerously, mothers who drink alcohol.    
The Washington state legislature approved a bill in 2010 that allows the state to involuntarily commit chronic drug and alcohol users, and force them into drug treatment programs. These people being forced into treatment have not committed any crime, nor do they pose any danger. . 
Not everyone was thrilled with this new law, including many addiction specialists and physicians. The Washington Association of Criminal Defense Lawyers sent an open letter to the Governor stating asking him to veto the bill, stating, "What this bill is in effect saying is that alcoholics and substance abusers do not understand their need for treatment and should be forced to receive it. The same argument could be made for smokers or thrill-seekers who knowingly refuse to stop smoking or endangering their lives." The Governor signed the bill.
Some states require a medical evaluation by an addiction medical specialist or other qualified diagnostician before a person can be compelled into treatment against their will, while other states such as North Carolina make it impossible to force someone into treatment unless they present a clear and present danger to themselves or others.  
The new "forced treatment" laws are seen as a blessing to those who want to force family members into treatment, and have been an incredible financial boon to for-profit treatment centers that don't rely upon, or have much regard for, actual medical diagnosis or medical treatment.  
As an addiction medicine specialist, it strikes me as more than peculiar that many advocates of forced treatment  say that addiction is a disease that requires treatment, but are perfectly  willing to leave medical diagnosis up to families, courts or police, and keep medical specialists out of the equation. 
Use vs Misuse
Mary has a glass of wine with dinner. It helps her relax, and she enjoys the effect.  That is recreational drug use in its most simple form.   If Mary drinks wine with dinner, and keeps drinking wine to the point where she argues with her husband, screams at her kids, and then passes out of the floor, that is recreational drug misuse.  
The negative consequences of alcohol consumption are from misuse, not use.  There is the argument that the  same is true whether the drug is legal or not.  As a doctor with a specialty in addiction medicine, I can't go along with that argument because if the drug is sold via a black market where adulteration of the substance is highly likely, the purity uncontrolled, and the conditions under which it was manufactured are not regulated, there is no way of knowing the quality or composition of the drug, or what a "usage" dose would be.  Hence, there are too many variables, from a professional medical standpoint, to endorse that view.  Of those who do share that view, they say that the vast  majority of people who use recreational drugs use them, not misuse them, and that only 4.2% misuse them. 
If someone is going to misuse drugs, the first symptoms of misuse typically show up within two to three years after beginning illicit drug consumption, and this misuse will last an average of four to five years before the person stops. They may stop misusing, or stop both using and misusing.  
Attempts to prevent illicit drug consumption do more harm than misuse of drugs. In the United States of America, all our past policies have been based on the false idea that using drugs is abnormal.  That is simply not true.  If you doubt it, ask yourself if you have had a soda, coffee, or tea lately. 
Any policy based on creating a 100% drug -free America is doomed to complete and utter failure because people in every civilization world wide has used, and does use, intoxicants.  Remember, tea used to be illegal because it contained caffeine. England wised up, legalized it, and taxed it. 
 Drug use is historically, clinically and statistically normal behavior. Individuals can choose whether to engage in this behavior and most who do consume legal drugs in a responsible way, and illegal or controlled substances in a manner of the least harm.  A society free from recreational drug use is not a feasible possibility, but a society that suffers minimally from drug misuse is a possibility through a program of honesty, education and harm reduction.
As things stand today in America, distraught family members or employers, concerned about someone’s drinking or drugging will often call upon the services of a professional interventionist to compel the person into some sort of alcohol/drug rehab or treatment facility. 
There is only one acceptable outcome of the traditional intervention: the person goes off to treatment immediately. 
There is no delay, no discussion. The interventionist is in complete control of the situation, the meeting, the conversation and the outcome from the moment it starts until the moment the person is delivered to the facility.  
“In its most basic format and construction,” acknowledged an interventionist, “it is simply a sales presentation where “no” is not accepted. They must buy or suffer consequences. Of course this is for their own good.”
Most treatment centers and rehabs encourage interventions, and will refer you to a trained interventionist.  The goal of a professional intervention is to have the person begin treatment immediately- this means right after the intervention is completed, transportation should already be set up, the person's bags packed, and the treatment center alerted to a new patient 
I am continually amazed at the number of people who, fearing that a loved one may have  the medical condition of alcoholism or addiction, rush them into facilities where the only thing that is evaluated is their insurance coverage. There is no doctor awaiting their arrival to diagnose their condition, and no staff of medically trained personnel.  It is big business, and I trust that the recovering addicts who work there have the best of intentions. Their heart is in the right place; the patients are not.  “Where is the doctor?”
The history of interventions in both America and the UK is stained with horror stories of unethical behavior by both interventionists and treatment facilities.  Thankfully, there are now established ethical standards for interventionist seeking to repair the damage done by “bounty hunters” who shuffled people off to inappropriate treatment for non-existent addictions.
Before you consider an intervention, you must be aware that there is always the distinct possibility that the person's extreme use of alcohol or drugs isn't alcoholism or addiction, but the sign of an untreated medical problem.  
Quite often, use of specific drugs is an indication that the person is deriving some benefit from those drugs because they are similar to, or contain properties of, the actual medication a doctor would give them.  This is termed “self-medication” . 
Someone may be using central nervous system stimulants because they actually have a medical need for central nervous system stimulants.  A medical diagnosis could result in their “drug problem” being solved in part by them being prescribed the appropriate medication to replace the illegal drug they have been buying on the street.  
Stopping the symptom is not the same as treating the illness. In many cases, the drinking and drugging are signs and symptoms, not the illness itself.  Once the brain disease of addiction has developed, however, then there is one more medical condition to address. 
The Ideal Intervention Result:
Rather than the goal of intervention being to coerce a person into a treatment center, it would be preferable if the goal of the intervention was for the person to  have an examination by a medical professional who specializes in the diagnosis and treatment of addictions with the full assurance that once the individual has a comprehensive medical examination,  the family will “back off.”  Knowing that their loved one is under the care of a medical professional gives comfort to the family, and offers safety , security and medical confidentiality to the individual. 
I have seen intervention, done properly, have life saving outcomes. I have also seen people coerced into treatment centers where they essentially were compelled to stay drug and alcohol free for a period of time,  attend meetings where their identity as an alcoholic or addict was reinforced, and then released into immediate relapse because the true nature of their condition was never diagnosed, let alone addressed. 
The American Society of Addiction Medicine has a doctor finder/membership directory feature on its website at www.asam.org.   You can search by state, country, specialty, professional interests, and addiction medicine certification. Once you have identified a physician member, you should visit the AMA website or the yellow pages to get contact information.
Even if there is not an addiction medicine specialist in your area, you can probably find an addiction therapist who will make an appropriate referral. Make sure you consult a psychologist or psychiatrist with experience in dealing with alcohol and addiction.  Most general practitioners are not well versed in addiction, so ask your family doctor for a referral to a trained professional specialist.  


ADDICTION
CHAPTER SIX
The Truth about Treatment 
	The first treatment center for habitual drunks was the New York State Inebriate Asylum, founded in 1864. Patients were both voluntary and involuntary.  Alcoholics were considered “common drunks” and “worse than thieves.”  There wasn't much real treatment in that first treatment center, and within fifteen years the facility was converted to an insane asylum.  
All in all, the attitude and approach of treating alcoholics and addicts didn't change much over the next 100 years, and there are places where the same attitudes prevail to this day.  In any given year in this country, no more than 10 percent of those who meet accepted criteria for alcohol dependence receive treatment, and these figures include persons  who merely attended self help meetings.  This is tragic.
 Meetings are not medicine, and the devastating effects of alcoholism and addiction are a major public health issue.  Twenty years ago, when support group meetings were viewed as medical treatment, and there was no comprehensive biological diagnoses of the medical condition of those entering treatment, the outcomes were predictable in their disappointment. The methods that people assumed were effective were, in the light of critical research, only of minimal value.
Although addiction is chronic in nature, it is treatable. People with this medical condition can and do lead normal lives.  It is not a hopeless condition at all. In fact, there is more hope today than a decade ago. 
I am often asked, "what about people who were heavy drinkers or drug users who suddenly stop and never need treatment?"  Yes, some people do have moments of epiphany, a spiritual awakening, or a embrace a religious/philosophical lifestyle which means more to them than drinking or drugging. They simply stop doing it.  These are the few, the fortunate, and the not-yet-addicted. 
Most people require professional help when tackling a chronic illness, be it addiction or diabetes.  I had a patient brought into ER because of high blood sugar. He never knew he had diabetes until his diagnosis. He immediately changed his lifestyle and diet and never needed treatment again. 
He was an exception. Most patients require treatment, and an ongoing process of commitment to change their diet and lifestyle in addition to appropriate medication. 
If you heard of a clinic where heart disease and diabetes patients were treated by listening to lectures, commiserating with fellow sufferers, and praying for unclogged arteries and stabilized blood sugar, you would be alarmed at the lack of proper medical care.  This is sadly the situation in the majority of drug/alcohol rehabs. 
Science and medicine have advanced to the point where there is really no ethical excuse for denying those who suffer from the medical illness of addiction comprehensive medical , behavioral, and psychological help.  Devoid of such a practical approach, the relapse of alcoholics will continue to be 50% within 12 months, and 90% in five years.  There are proven models of success, and these must be utilized to alleviate this crises in public health..  
Addiction medicine physicians understand that alcoholism and addiction are multifaceted and complex conditions.  We are as interested in why people stop using drugs as why they use them.  We know that despite the increased availability of cocaine in America over the past few decades, use of the drug has declined.  Obviously there are factors that counter balance drug use for the majority of users who are not addicts, and will never be addicts.  Understanding social and economic aspects that contribute to increased or decreased risk of alcoholism and addiction are of significant interest. 
In short, alcoholism and addiction are complex conditions comprised of biological, social, and psychological components.  Instead of arguing over the relative importance of the biological, psychological and social factors, all of these must be  taken into consideration  when designing the appropriate treatment for the individual patient. 
  The ASAM Patient Placement Criteria focus on six dimensions to define severity: (1) potential for acute intoxication and/or withdrawal; (2) biomedical conditions and complications; (3) emotional/behavioral conditions or complications; (4) treatment acceptance/resistance; (5) relapse potential; and (6) recovery environment.  Our goal is to match the patient's needs to the appropriate treatment service by assessing the severity of the addiction, as well as verification of medical diagnosis. 
As a doctor who treats people with the medical illness of addiction, including alcoholism,  I know that the most successful treatment methods are the ones that first address the biological   component, change brain chemistry and/or correct the brain's chemistry imbalance. 
Every aspect of treatment must be built upon a solid scientific foundation, and clinically proven to be effective in overcoming addiction. It is most important that all aspects of addiction treatment be under the direction of an Addiction Medicine Specialist. It is this physician who is qualified to coordinate, assess and make ongoing treatment decisions. ,
There are different modes of treatment that are of proven value in addressing specific concerns, and the Institute of Medicine uses the term “modalities” to describe  "the specific activities that are used to relieve symptoms or to induce behavior change."   In treating addiction, these activities include: 
Biomedical, which focuses on improved detoxification regimens, followed by the use of medicines to reduce cravings, block the effects of addicting drugs, managed maintenance in cases of prolonged opiate addiction, and the appropriate application of psychiatric medications. 
Psychological,  including addiction counseling, cognitive-behavioral treatment  psychotherapy, aversion therapy, and behavioral self-control training.
Sociocultural,  utilizes the community reinforcement approach, family therapy, therapeutic communities, vocational rehabilitation, various motivational techniques, culturally specific interventions, and contingency management. 
All three of the above modalities include more than one dimension in common, such as social skills training, relapse prevention techniques, self- and mutual-help programs, support groups, and chemical aversion therapy. 
The days when rehab was program driven, and all or most patients received only enforced abstinence and 12-Step meetings such as Alcoholics Anonymous or Narcotics Anonymous   regardless of their individual needs, are hopefully behind us.
. The modern treatment approach  identifies specific problems  that require specific types of attention.  This means that the patient can be placed in the least intensive, safe level of care and specifically treated with strategies selected from a wide range of effective treatments best suited to their individual condition and situation. .


ADDICTION
Chapter Seven
The Process of Effective Treatment
Before treatment begins, each and every patient needs a full medical and psychiatric diagnosis and evaluation, plus evaluation of their individual psychological and social situation.  Any and all additional  medical problems need to be addressed by an appropriate specialist . Liver disease, for example, would require a liver specialist,  bipolar disorder by a psychiatrist, and psycho-social and interpersonal issues by a psychologist. .
Once all specialized assessment and treatment are completed in an inpatient setting (detox/rehab) or outpatient setting, patients may continue treatment with one or more aftercare programs. Organized in different formats, self-help groups may also be started during treatment. 
There is absolutely no denying that addiction is a chronic medical illness that must be treated with proper medical treatment like Diabetes, high blood pressure or any other complex medical issue; therefore, I'm sure that all logical people would agree that simply attending meetings will never be the sole solution to treating addiction. You don't treat Diabetes with self-help meetings. It is treated with uniform, secular medical treatment -- this is exactly how addiction must be treated.   
I have been typically diplomatic in the past, and am on record as saying that there is a very real place for the AA 12 step model in recovery, and that role is as a self-help model. While long-time practicioners of 12-Step programs such as AA, often referred to as old timers, offer anecdotal evidence of the value of the program, and there is no doubt that any methodology that supports recovery and facilitates postitive changes in life style and human interaction is praiseworthy to that extent, we must remember that support groups are not considered professional treatment for alcoholism or addiction.
 Professional treatment is by definition offered by treatment professionals.: individuals providing treatment should be  trained within their professional discipline regarding substance use disorders and addiction.
Reid K. Hester and William R. Miller  of the Unversity of New Mexity Center for Alcohol, Substance Abuse and Addictions, Dept. of Psychology,  rated the various alcoholism treatments in their book Handbook of Alcoholism Treatment Approaches: Effective Alternatives.  A.A. 12-Step treatment scored so low, and showed up so far down on the list,  that it almost disappeared. The best treatment was Brief Interventions, and it got a positive score of 390. A.A. got a negative score, MINUS 82, way below zero.
By it's own best estimates, the A.A. failure rate is at least 95%, because 95% of all newcomers are gone at the end of the first year. Those who remain do not all stay sober, so the real success rate has to be even less. We definitely have an upper ceiling of 5% for the maximum possible success rate. But 5% is the normal rate of spontaneous remission in alcoholics. Five percent of them will quit if we send them all to A.A. and five percent of them will quit if we do nothing. That makes the real effective A.A. "cure rate" zero. 
This does not mean that self-help groups such as AA are not of value to those who use them as an adjunct to comprehensive medical care. As the old saying goes, for those who like that sort of thing, that is exactly the sort of thing they like. However, to present it as "treatment" or "the only way to sobriety" is incorrect and potentially health-endangering.
Another reason why it's critical to provide a variety of support group options as an adjunct  to proper professional treatment is to protect an individual's constitutional rights, which state that religion shall not be forced upon them. Not everyone has a belief in God or religion and ideally, if a treatment center offers  a 12 step element, or other faith-based self-help program, it should also offer decidedly secular alternatives so the patients can make the best choice for themselves. Without the option, how can any facility truly claim to provide individualized treatment?
As I have previously mentioned, not all heavy drinkers are alcoholics, and not all drug users are drug addicts.  The patient with the disease of addiction is a indeed a minority of the those who drink and drug, and an even smaller minority of the general population.
According to the Harvard Mental Health Letter regarding Treatment of Drug Abuse and Addiction, there is a high rate of recovery among alcoholics and addicts, treated and untreated. According to one estimate, heroin addicts break the habit in an average of 11 years. Another estimate is that at least 50% of alcoholics eventually free themselves although only 10% are ever treated. One recent study found that 80% of all alcoholics who recover for a year or more do so on their own, some after being unsuccessfully treated. When a group of these self-treated alcoholics was interviewed, 57% said they simply decided that alcohol was bad for them. Twenty-nine percent said health problems, frightening experiences, accidents, or blackouts persuaded them to quit. Others used such phrases as "Things were building up" or "I was sick and tired of it." Support from a husband or wife was important in sustaining the resolution. - Part III, The Harvard Mental Health Letter, Volume 12, Number 4, October 1995, page 3. 
It is those who are unable to quit on their own who are true addicts.  Addiction is a chronic medical condition, a brain disorder. Just as hypertension and asthma have biological, psychological and social components, so does alcoholism and addiction. The diabetic can live a normal life with life adjustments and the recovering alcoholic or addict can live a normal life with their own life adjustments. 
Addicts and alcoholics often misuse drugs or alcohol as a way of self-medicating themselves, both physically as well as psychologically. When a person suffers from low blood sugar, for example, they will often use alcohol or drugs to help them feel better, right away.
As a part of a comprehensive medical evaluation, a complete blood chemical analysis should be performed.  A Blood Metabolic panel is a group of chemical tests performed to measure the amount of vitamins, minerals, cholesterol, protein, blood sugar, electrolytes and other bodily requirements and functions.
An EKG, CT/MRI, or PET scan may also be utilized prior to treatment to ascertain severity of brain structural or functional damage, or other brain related concerns. After all, Alcoholism and substance misuse are diseases of the brain.  
Dual Diagnosis
Dual Diagnosis. Is also known as “co-occurring disorder.” This is when a person is suffering from both the consequences of substance misuse and a simultaneous mood disorder such as depression, bi-polar or anxiety, panic disorder, or a more severe mental condition such as schizophrenia. 
There is a difference between induced psychosis from drugs or alcohol, and psychosis as a result of mental illness. Induced psychosis is not uncommon even with perfectly legal medications that impact brain chemistry.  In that situation, the psychosis goes away as the drug’s effects diminish over time.  When the psychosis is the result of a mental illness, it does not diminsih over time. It needs specific medical treatment. 
 When a patient has both drug induced psychosis, and mental illness, there are unique challenges to effective treatment.  Even identifying both conditions presents problems. Drugs and alcohol can worsen the severity of mental disorders, and present symptoms that look like those of mental disorders or cover them up. Both severe intoxication and detox can give the appearance of mental illness, and vice-versa. 
It is so difficult to tell the difference, that only 2% of mentally ill patients with substance abuse problems were detected in a university hospital emergency room. A state hospital did slightly better, detecting 15%.
 Roughly 50 % of individuals with severe mental disorders are affected by substance abuse. Thirty-seven percent of alcohol abusers and 53 % of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 %  also have problems with  either alcohol or drugs.  If you are bi-polar, substance use problems are seven times more likely than if you are not bi polar. 
 One recent study revealed that 33.7 % of schizophrenics also meet the criteria for a diagnosis of Alcohol Use Disorder.  47 percent of individuals with schizophrenia also have a substance abuse disorder more than four times as likely as the general population.
A person with dual diagnosis needs specialized professional care, and most mental health services are not prepared for patients who also have severe drug and alcohol problems. . As a result, the individual may be bounced back and forth between services for mental illness and those for substance abuse, or they may be refused treatment altogether. 
Many treatment centers will not take a person with dual diagnosis because the treatment center doesn't have qualified medical personnel on staff to deal with mental health issues.    Then again, most treatment centers don't have any doctors on staff to deal with the illness of addiction or alcoholism. 
 A "traditional" non-medical rehab is definately not a good place for someone with a mental illness because these patients are very emotionally fragile and sensitive. Placed in a confrontive, accusatory, and coercive environment can be the worst thing for them, and for those around them. 
Many of these patients who need medication for mental disorders have self-medicated with street drugs. They go to 12-Step recovery support groups and someone will tell them  that they are not "clean and sober" if they are taking medically prescribed medication. This is not only absurd and cruel, but a direct contradiction of 12-Step publications which  specifically advocate psychiatric or psychologic treatment where appropriate.  There is an Alcoholics Anonymous pamphlet, for example, that clearly states that some recovering people can and do need special treatment, including medication.
The dual-diagnosis patient is often discriminated against by non-medical treatment preofessionals, and emotionally abused by other recovering addicts and alcoholics  who insist that all drugs are bad – usually said while consuming massive amounts of caffienated coffee.  These unfortunate individuals find themselves as outcasts from both the drug/alcohol recovery community, and from the mental health recovery community, and they are almost twice as likely to stop participating in outpatient mental health treatment as those who don't have issues with drugs and/or alcohol. . 
It is my firm and unalterable opinion as as a psychiatrist who is also a specialist in addiction medicine, that the answer lies in integrating mental health and addiction treatment in a single, comprehensive program designed to meet the individual needs of the specific patient. 
This approach is of proven value, and is endorsed by Kathleen Sciacca, M.A., the founding executive director of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction, and Alcoholism (MIDAA) in New York City
"There is a need for education that demonstrates that addictive disorders are illnesses," Sciacca writes. "Understanding mental illness as a disease that is not caused by families was necessary to successful advocacy for the mentally ill. The same advocacy must happen for those who are dually diagnosed, through a clear understanding of the addictive disorders."
It is continually frustrating to those of us who work in the fields of psychiatry and addiction medicine that there is such a gap between what we know are scientific facts, and what people beleive about mental illnesses and addictive disease.  There needs to be a major campaign of awareness to influence public opinion, and do away with harmful myths and prejudices that do only harm to those who already suffer, and society in general. 
The percentage of drinkers who are alcoholics is only 5%. That means 95% of people who drink, even problem drinkers, are not alcoholics.  The same is true of those who use other recreational drugs.  My concern is with that 5%.  Those who suffer dual diagnosis is a smaller percentage still. The smallness of the percentage belies the largeness of the number of individuals, and does not negate the importance of appropriate and compassionate care.  
Empowering the Patient
Most chemically dependent people, and those with mental disorders, feel overpowered and helpless.  They yearn for hope, and a sense of empowerment in the face of debilitating disease.  An important aspect of effective treatment includes empowering the client to see themselves in partnership with their physician, strengthening their physical, emotional and   mental health.
As the disease of addiction impacts the thought processes, an important aspect of effective treatment is individualized Cognitive Behavioral Therapy, also known as CBT.   CBT  is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.    
There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. All of these cognitive-behavioral therapies are  based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events.  Even if a situation remains unchanged, how we respond to that situation can change. We can choose our response, making a conscious decision to respond in ways that are in the best interest of our health and happiness.
In conjunction with CBT, there is another therapy proven valuable in treating adolescents and substance misuse clients. Motivation Enhancement Therapy (MET) MET has been thoroughly researched in the field of substance misuse, most especially with young people, and has proven itself as exceptionally effective at enhancing an individual's motivation to make positive changes in their behavior.  
An effective treatment must help clients address, identify, and describe the personal meaning of their addiction. Are  they self-medicating, filling up an inner emptiness, numbing out feelings related to a trauma, or all of the above?. Unless clients understand what they are actually doing on a deep level, they will chronically relapse. A responsible comprehensive treatment program takes all aspects into consideration for the ongoing health and well being of the client. 
Severe Intoxication and detoxification
The American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: (1) “to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free”; (2) “to provide a withdrawal that is humane and thus protects the patient’s dignity”; and (3) “to prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs.”
Detoxification or those in severe intoxication because of alcohol, opiates (Heroin and pain killers), stimulants ( cocaine, meth), benzodiazepines ( Xanax, Valium), and/or barbiturates can be fatal, and each patient must receive personalized medical care. Opiate withdrawal is very physically uncomfortable. Seizures, while common in the withdrawal process , are not usually fatal. 
Extreme stimulant intoxication can precipitate symptoms similar to those of heart attacks,  cause strokes, seizures, arrhythmia, or life threatening hyperthermia.  Non medical use of methamphetamine has severe destructive potential for the brain, including micro strokes, neurotransmitter disregulation, and death of brain cells. The long term psychosis resultant from extreme and continued non medical use of methamphetamine is often misdiagnosed as Schizophrenia. 
There are no life threatening withdrawal considerations when someone stops using stimulants, although there is a "crash" period of exhaustion, lethargy, and depression. 
Treating the Unique Addict/Alcoholic  
All addicts and alcoholics think they are unique. In a very true medical sense, they are absolutely correct. No two are the same, and each  must receive thorough medical evaluation in order to provide the appropriate medical care in a compressive program incorporating all the therapeutic and/or curative methodologies available.
It is interesting that people with a "drug misuse" history can take prescription medications of high misuse potential and not misuse them.   I usually avoid prescribing mood altering  medications  because they may trigger relapse.  In selected patients, however, it is both prudent and necessary to use  benzodiazepines in sever bipolar patients. I also will treat patients who have uncontrolled anxiety with other psychiatric medications. 
We usually avoid giving patients stimulants unless it turns out that they have undiagnosed ADD. In the majority of those cases, once they are prescribed the most effective stimulant, their life is changed, and their drug misuse ends.  There are some patients with legitimate ADD diagnosis who also have developed a non-medical stimulant dependence for whom even prescription stimulants trigger a relapse.
The point is this: physicians need to keep open minds, and provide individualized treatment. The old belief that individual addicts are not unique, one from the other, is completely wrong. No two are exactly alike, and there is no one universal treatment that is appropriate for all patients. To overlook the individuality of the patient is a gross violation of both ethics and professional responsibility. 
Variations in Intoxicated Behavior.
An interesting variable that is almost universally recognized is different people act differently when intoxicated.  People often ask me why some people become rude and abusive, even violent, under the influence of alcohol. 
 The reasons for emotional rage, especially when under the influence, are complex.  Comprehensive research regarding anger found that there are medical underpinnings to compulsive, repetitive outbursts of anger, even when not accompanied by ingestion of alcohol, and the brain imagery of those afflicted is indicative of the physical disease of addiction, along with other medical illnesses..
Researchers at Ohio State University found that men and women with higher levels of hostility also showed higher levels of homocysteine -- a blood chemical strongly associated with coronary heart disease. It is medically correct to say that extreme and repetitive anger can cause heart attacks and strokes. There is an ongoing discussion, and considerable research concerning hostility and anger because they are not only sit may be three things at once: a symptom of disease, the cause of disease or, in cases of compulsive rage, a medical condition of addictive nature.
Dr. Jill Bolte Taylor,  a trained and published neuroanatomist, garnered acclaim for her specialized postmortem investigation of the human brain as it relates to schizophrenia and the severe mental illnesses.  According to Dr. Taylor, all emotions, including anger, have a chemical component.  Once triggered, the brain releases that chemical, and you experience the corresponding emotion.  The chemical associated with anger, insists Taylor, is completely dissipated from your blood stream in 90 seconds.  She asserts that if your anger lasts longer than 90 seconds, it may be that you are self-perpetuating, or self-triggering, the chemical for much the same reason as a heavy drinker keeps ingesting the alcohol. 
 As a specialist in addiction medicine, I see individuals come to me with highly complex problems involving more than one diagnosis. They may have heart and liver problems, brain dysfunction, addiction, ulcers, plus psychiatric and psychological problems. They may also have any manner of ailments engendered by, aggravated by, or marginally correlated to their compulsive use of alcohol and/or drugs.
Because of both complexity and individuality, there is no simple “one answer fits all”  to the question regarding why we have “The Angry Drunk.”  There are, however, some recent interesting insights into the phenomenon.
An experiment at Canada’s University of Waterloo in Ontario was conducted during which volunteers were to press a particular button when prompted by computer.  These same volunteers were  also instructed to not press the button if there were a bright red light.  There  were some participants who , when given alcohol, would become defiant. Despite the bright red light, they would smack the button with outright aggression. This is similar to the drunk who does something despite being repeatedly told not to do it. 
Now, consider the results of the following study in light of the one you just finished reading: Research in the US has found that a percentage of  people who believe that they are drinking alcohol  will behave as if they were under the influence, including some who became aggressive, hostile and even easily sexually aroused despite not really having any alcohol whatsoever. 
The reason I put those two studies back to back is to raise the obvious question: is the aggressive and defiant behavior the result of alcohol, or the result of what people believe about the effects of alcohol, or is it indicative of another, more subtle medical condition?
There is not one absolutely correct answer under all circumstances, but we do know that in cultures where alcohol consumption is not associated in any way with aggressive or hostile behavior, the behavior of those who drink is not hostile and aggressive. 
The appearance of hostility when drinking is a  manifestation of a physical disorder other than alcoholism, even if alcohol addiction is also present.  A person who becomes  insulting, aggressive,  hostile and/or abusive when drinking, even if they rarely touch alcohol, is exhibiting a known symptom of one or more medical conditions other than alcoholism, all of which require comprehensive care by a trained physician. 
The implications for successful treatment of the angry alcoholic are clear – more than the physical illness of addiction must be addressed.  There will be more than one diagnosis, and personalized treatment is of paramount importance.   As with the alcoholic, solemn oaths to use willpower, the use of support groups, counseling, and the best intentions are, for the most part, useless. Yet, without fail, and despite repeated failure, addicts continue do more of what doesn’t work.
Symptoms indicate illness, but symptoms don't diagnose the illness anymore than the existence of clues is the answer to the mystery.    One symptom or characteristic of addiction is self-stimulation.   
 If an alcoholic has one drink, it stimulates a biochemical and emotional chain reaction triggering the compulsion to keep drinking despite any unpleasant outcomes.  As alcoholism is a medical problem with a biological component of approximately fifty-percent, to ignore the physical illness would be irresponsible. Hence, simply not drinking is not a medical treatment, although it certainly is a beneficial change in behavior.
If someone is going to assert that anger itself is an addiction, or that there are “Adrenalin Addicts,” then the people so afflicted should certainly seek the help of a specialist in addiction medicine. Much to my personal shock and dismay, I have seen so-called anger addiction  treatments where there are encouraged to become angry, express anger, and “get it all out.”
  If you were treating alcoholics, I doubt you would buy the alcoholic a case of beer, a large bottle of Scotch and several wine coolers, and then have them drink to “get it out of their system.“   No responsible person involved in the treatment of addiction would tell a drug addict or alcoholic that they need to drink or drug as much as possible as a way achieve health and sobriety.  Telling someone with a negative and destructive behavioral addiction to not only continue, but amplify that behavior, strikes me as both absurd and irresponsible. After all, with any addiction, the continuation of the behavior ignites a self-stimulating, self-perpetuating system. The more you do, the more you want, even if every indulgence in the addiction brings more pain.
As mentioned early on,  more people believe in demons than believe in germs, and  were you to tell me that there is a treatment center putting leeches on alcoholics, or practicing blood letting on hemophiliacs,  I wouldn't be surprised. Dismayed, yes; Surprised, no.
Compulsion.   When compulsion replaces control, the disease of addiction has taken over. There are short episodes of abstinence as a result of coercion and/or feelings of guilt, shame or remorse. Those same emotions, however, provide the stress that triggers relapse into active addiction.  
“Addicts will try anything to solve the problem except to stay away from the substance or behavior that triggers the addiction. Once the compulsion is triggered, all efforts at control fail.” -- Newton Hightower,

When you have an addiction, you look for opportunities to live your addiction. When the addiction is to alcohol or other drugs, seeking and procuring the drug is part of the obsession, use is the compulsion. For the person with an “anger addiction,” it is easier to live the addiction than if they were shooting heroin, snorting cocaine or drinking vodka. As long as they have  yourself, you have your own full time bartender and drug dealer.  With an internally stimulated and self -perpetuating rage altered brain chemistry,  all the addict requires is an insult, real or imagined.  A medical diagnosis, however, would reveal a significant biological factor to the rage issue, in addition to medical problems engendered by the anger itself. 
Obsession is when you can only think of one thing at a time, and it is the same one thing all the time.  Anyone who has experienced obsession understands that it is an: irresistible force of thought that pushes everything else aside.  Obsession is, hopefully for the addict,  followed by consummation in an unending repetition.   Stalkers are obsessed. Fanatics are obsessed. A person in active addiction is obsessed with living their addiction,  
One psychological attraction of addiction for the intelligent and well informed, is the delightful prospect of not being in control. These are people who, due to their important positions of responsibility in life, wish to take a vacation from being in charge, and place themselves in a subservient position.  Of course, as with the person who pays to visit a dominatrix, they are only pretending to not be in control. In truth, they are in charge of the entire scenario.  Sadly, when true addiction manifests itself, the game of “playing a drug addict” is no longer a diversionary vacation, but a tragic health crises.  
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in person’s pathologically pursuing reward and/or relief by substance use and other behaviors.
The transition from casual substance use to addiction can be seen in changes in the chemical substances found in the brain known as neurotransmitters, which transmit messages within the brain’s reward system.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Special Considerations for the Opiate Addict. 
Managed Maintenance is a program with proven success in restoring health, life and hope to those unique individuals who, because of either systemic or acquired medical conditions, have become completely dependent on opiate pain relievers  These special cases are  patients with ten to fifteen year addiction histories, medical conditions such as  Hepatitis C, HIV, heart problems, and/or psychiatric complications. These cases are  not the norm, but not being a “normal addict” is no reason to be denied effective life saving, health restoring treatment. 
Without Managed Maintenance, 80% of these extreme cases immediately fall right back into dangerous addiction. An addiction medicine specialist knows the proper and effective way to replace dangerous and illegal substances with FDA approved  Suboxone, a prescription medication also used in detox that keeps patients from experiencing life threatening, debilitating withdrawal, and allows them to remain physically stable. 
Suboxone,  a once-a-day tablet that easily dissolves under the tongue, is a “partial opiate,” meaning that it gives the brain something similar to what it is used to without the dangers associated with full opiates. Suboxone contains a combination of two ingredients, buprenorphine and naloxone.  Buprenorphine is an opioid medication. Buprenorphine is similar to other opioids such as morphine, codeine, and heroin however, it doesn't produce the “high” of those drugs, and is therefor easier to stop taking. This is offers advantages over Methadone, although some patients with an exceptionally high degree of addiction are often better candidates for Methadone, a medication used effectively and safely to treat opioid addiction for more than 30 years. 
Heroin Treatment and Harm Reduction
   The Heroin of today is so potent that many patients can't stay away from it even when under treatment with Suboxone or Methodone. This is why nations who adopt a true harm reduction model of treatment, such as Switzerland, have authorized managed maintenance utilizing actual Heroin, medically supervised and dispensed.  This reduces both medical harm and social harm by reducing crime and illness   As we do not yet have this harm reduction model in America, Suboxone is rapidly becoming medication of choice for managed maintenance for the majority of Heroin addicts in the USA. 
 Another advantage of Suboxone is that there is no tolerance developed, but there is a ceiling on the drug's effect. In other words, if you take more than your required amount won't get more “high.”   Suboxone is available only by prescription, and administered by a physician. 
 Perhaps an easy way to understand the use of Suboxone in Managed Maintenance is to think of training wheels on a bicycle. Training wheels provide physical balance while promoting personal assurance and confidence during the learning process.  In time, the rider balances perfectly on their own. 
 For the extreme opiate dependent patient, the managed use of Suboxone makes it possible for them to acquire the life skills and personal balance to ride “the bike of life” without crashing. It is wonderful to see the transformation of opiate addicts into healthy, happy, stable individuals free from cravings, illegal drugs, and life threatening behavior. When they have internalized and integrated the therapeutic tools given them , the patients recognize the “right time” to taper off the use of Suboxone until it is completely discontinued.
  Remember, we are dealing with a physical disease in much the same manner as we treat heart disease, diabetes, or high blood pressure. Whether or not the patient should take medication for their condition, what medication would be most effective, and how long that medication should be administered, is a matter best determined by the treating physician in consultation with the individual patient.
Treating Teenagers and Young Adults
Teenage  experimentation with alcohol and drugs, no matter how much we pretend otherwise, is normative.  In other words, it may not be healthy behavior, or behavior of which parents approve, but it is normal behavior.  
There are teens with excessive drug and alcohol use, but actual teenage alcoholism is a rarity.    There are 13 and 14 year old kids experimenting with all manner of mood altering drugs, but they are not drug addicts. They may be at risk, or have the potential for the disease of addiction, but they don't have it yet.  It is as if the child has high cholesterol, but not heart disease.   It is possible to prevent the onset of alcoholism or drug addiction in someone who has the tell-tale risk factors.  
The risks of becoming an alcoholic increase with binge drinking, especially in the formative adolescent years.  As biology forms up to 50% of one's propensity to develop drug or alcohol addiction, a family history of alcohol or drug misuse is a major red flag.
Other risk factors risk factors for teenagers developing drinking problems include low levels of parent supervision or communication, family conflicts, inconsistent or severe parental discipline, problems managing impulses, emotional instability, thrill-seeking behaviors, and perceiving the risk of using alcohol to be low. 
Girls whose mothers have drinking problems are at severe risk of alcoholism, as are those who begin drinking prior to age 14.  Family relationships, part of the social aspect of contributing factors, indicate that a 16-18 year- old is less prone to excessive drinking if they have a close relationship with their mother..
The treatment appropriate for a binge drinking teen, or a fourteen year old who was caught experimenting with cocaine, must be entirely different from the treatment given to a middle-aged alcoholic with decades of continual consumption, or a thirty year old heroin addict with hepatitis C and HIV, or the bi-polar twenty three year old who snorts Ketamine on the weekend.   
The most common reason  teenagers end up in rehab is that they got into trouble at school or home because of their use of alcohol or drugs.  Their behavior could range from normal teen experimentation and recklessness, to blatantly extreme intoxication and dangerous behavior.  
Although drinking does not equal alcoholism, and drug use does not equal drug addiction,  there is significant pressure to treat the drinking/drugging teen as an alcoholic/addict who must, for their own good, be sent off to rehab, even if that treatment be coerced.  A current advertisement for a drug/alcohol treatment center in California states: “Even if you have to admit the teen into the facility against their will, it will be best for them to be there.” 
A 1979  U.S Supreme Court decision gave parents power to commit their children who are under age 18 without judicial proceedings.   This has been a gold mine for private “treatment centers,” private mental health care facilities, and lawyers specializing in helping parents have their children involuntarily admitted to rehab centers or mental hospitals. 
In the past few years, several states have revised their involuntary commitment laws making it very easy to have loved ones treated for substance misuse, even if they don't want to be treated.  Insisting that you don't need treatment is simply proof that you don't realize that  you need treatment, according to new state guidelines. 
	 This approach has been hailed by concerned parents as a blessing because it allows them to get their kids, or other family members,  the help they need.  There is no recognized definition of  “the help they need,.”  and many doctors who treat alcoholism and addiction share serious concerns regarding the ethics and wisdom of the state being permitted to institute preventative therapeutic programs against a citizen's will
Setting aside the ethical issue of coerced admission, there is documentation that drug and alcohol treatment may be equally effective whether admission to the ;program  was voluntary or not.  The educational and empowering experience of appropriate treatment can be of significant value in helping the teenager consciously choose what behaviors to continue, and which ones to abandon.  
 If the treatment experience only serves to reinforce an “addict/alcoholic identity,” and  continually places them in both emotional and social proximity to those with more advanced drug usage, the risk of actually becoming an addict or alcoholic in their adult years increases.
A “teen only” facility also has its challenges. Recent  research cautions grouping high-risk teens in peer group preventive interventions. Such groupings have been shown to produce negative outcomes, as participants  reinforce each others drug use. As teens in treatment are beyond “high risk” for drug usage, the negative potential is obvious.  This must be taken into serious consideration when structuring the interaction of patients at an inpatient treatment center.
  The most common drug/alcohol treatment for teens, and everyone else, is a 28 day program. There is no mystical or medical reason for 28 days, it is simply the number of days that most insurance companies will cover without objection.  When a treatment center advises you that they offer immediate evaluation, they don't mean diagnosis of the patient's condition. If they meant diagnosis, they would say diagnosis.  By evaluation, they mean evaluation of your insurance coverage. . 
 Once in a drug/alcohol treatment center based upon the assumption that you are an addict or alcoholic, you are regarded as such, and any protestation to the contrary are deemed denial.  This approach is most common at 12-Step based programs, or facilities that have a one-size-fits-all concept of treatment. 
There was a famous experiment conducted by David Rosenhan in which  a group of graduate psychology students signed themselves into a mental institution, reporting that they were suffering from psychotic symptoms. Once on the psychiatric wards, they behaved in completely normal ways that betrayed absolutely no psychotic symptoms. The medical staff did not notice that these people were normal and, in fact, made notes about their behavior indicating psychoses.  
Having been “sent off to rehab,”  teenagers return home to discover that they are now negatively labeled.  Post rehab self-consciousness and depression, accompanied by strong bouts of shame over being such a “loser,” causes extreme emotional stress.   The post-rehab teen always has one group ready to accept them – those who drink and drug. 
 “ My parents sent me to rehab when I was thirteen  for issues that could have easily been solved with therapy, family therapy and time,” commented a young woman in an on-line forum. “After I got home from rehab, at age fourteen, I felt like a huge outcast and was suspended from a school because parents found out I went to rehab.”
The True First Step to Teen Treatment:
Before a teenager is compelled into rehab, the parent or guardian should consult a physician specializing in addiction medicine, and engage the individual in full participation with the physician.  Consultation and diagnosis by a medical professional is always the best idea.   If the kid isn't an alcoholic or an addict, the doctor will say so, and advise the patient regarding whatever medical issues are involved, and how to decrease the risks of chronic illness. . If the teen is an alcoholic or addict, an addiction medicine specialist is best qualified to recommend the treatment regimen best suited to the individual patient. 
 Not all teen drinkers will become alcoholics, but all teen drinkers are at risk for a wide variety of health problems and legal sanctions for dangerous behavior. The most comprehensive approach to the reality of teen drug and alcohol use is short term harm reduction and common sense preventative measures to reduce risks of alcoholism and addiction.  






The Future of Alcohol /Addiction Treatment

In the next decade, we should witness a number of medical advances in addiction treatment and diagnosis from a purely medical/biological standpoint.  Behavioral interventions will continue to be necessary, not just to increase the likelihood that patients will take effective medications but also to assist them in improving their interpersonal, educational, and vocational skills so as to develop positive rather than just negative reasons for wanting to stop drug use.
In a landmark study, researchers at the University of Virginia Health System have tested a genetically targeted medication to treat alcoholism with remarkably promising results.  For the first time in alcohol addiction research – and a first in the entire field of addiction treatment -- UVA investigators have successfully treated alcohol-dependent individuals with medication that is tailored specifically to match their genetic profile.
“Our findings suggest a new paradigm for the treatment of alcoholism, as well as a major breakthrough in individualized medicine for predetermined genotypes,” says Bankole Johnson, MD, PhD, study leader and professor and chair of the UVA Department of Psychiatry and Neurobehavioral Sciences.
“By being able to do genetic screening beforehand, clinicians can eliminate a great deal of the trial and error approach to prescribing medicine,” Johnson says. “Personalized medicine allows them to better predict a successful treatment option, as well as reducing both premature medication changes and simultaneous multiple medication regimens.”
 “Although this treatment approach accounts for nearly one-third of patients with alcohol dependence, more research is needed to identify alcoholics with other genetic variations who will respond significantly to alternative medications,” says Johnson. “Our findings, however, are a major step into the forefront of modern medicine.”
Other advancements include advanced treatment for opioids and stimulants. . For opioids, this will include long acting injectable or implants of the antagonist naltrexone, injectable or implants of the partial agonist buprenorphine, and innovative detoxification methods using buprenorphine. In addition, there should be much wider office based prescribing of buprenorphine for maintenance as financial, stigma, and numerical prescribing barriers are overcome.
Possible new developments for cocaine dependence include vaccines that provide either active or passive immunization;. agonists that could decrease craving without producing euphoria; blocking agents that do not block normal pleasures; and CRF (corticotrophin releasing factor) antagonists which could decrease both craving and relapse. In the short term, medications currently marketed for other indications that show promise for cocaine include modafinil, tiagabine, topiramate, and disulfiram.
Biological and genetic factors contribute up to 50% in the addiction formula, but there is also the generational transfer of emotional pain. Drugs and alcohol become the unavoidable coping mechanism of choice for those in emotional pain due to economic and social despair. These people are at exceptionally high risk for addiction and alcoholism. Untill these economic and social factors are addressed, half of the addiction prevention and treatment formula remain unchanged. 
Brain Change Methods
One promising avenue of research involves a new technology, known as deep brain stimulation (DBS), which may one day alter our approach to treating addiction. DBS involves the insertion of a series  of electrodes into specific targets deep within the brain.  The effects of DBS are far-reaching, since neurons in one part of the brain typically influence the activity of neurons in many other parts.  
Memory Training in Addiction Treatment
People who are addicted to stimulants tend to choose instant gratification or a smaller but sooner reward over a future benefit, even if the future reward is greater. Reduced value of a future reward, called "delay discounting" by neuroscientists, is the major challenge for treatment of addiction. 
New ethods are being developed that offer therapeutic strategies for rehabilitating the addicted human brain. The results of a series of experiments presented good news: neurocognitive training of working memory can decrease delay discounting.
The researchers conclude, "These changes in executive function are consistent with the notion of neuroplasticity and suggest that at least some of the neurocognitive deficits related to addiction might be reversible."  They suggest future research address the durability of memory training, the ceiling effects of training, and the extent of improvement in treatment outcome.
The future is filled with hope, but there is hope for the addict/alcholic in the present as well.  There are  effective medicines for treating alcoholism and addiction that are of proven value when utilized in a comprehensive plan of individualized treatment. ..
If  someone you love is having drug and/or alcohol related issues, take the initiative to encourage them to have friendly visit with a doctor or therapist who specializes in alcohol and drug issues.  Addiction is a disease that can be prevented. It can also be treated. 
We have specialized cancer clinics, yet specialized addiction clinics are a rarity. Rehabs are, for the most part, still operating on approaches devised in the 1930's that overlook  50% of the addiction equation. In most cases, they simply assume someone is an addict or alcohilic upon admission. 
Failure to address medical/psychiatric realities dooms a person to unncessesary consequences. There was a patient of mine who had been active in Alcoholics Anonymous for many years. He would stay sober with little or no difficulty for ten months, and then relapse. This pattern continued for years. Finally, he sought medical help.  As it turns out, he had bi-polar disorder with a ten month cycle. Every ten months, he would enter a manic phase during which he would relapse.  All it took to rectify this long standing problem was a daily dose of a readily availble prescription medicine.  
If this man had been medically and psychiatricaly diagnosed in the first place, years of dissapointment, and feelings of failure, could have been avoided. 
As with heart disease, diabetes and asthma, addiction is a chronic medical condition best addressed, first and foremost, by medical means.  Support groups provide support, but medical care comes from trained medical professionals. 
If you cannot find an addiction specialist or addiction therapist near you, there is a list available online by state at http://www.healthline.com/doctors/addiction-medicine-specialist 



 Real Questions and Honest Answers
Here are some questions recently asked at an addiction information symposium. The answers are, to the best of my knowledge, factual.
  Q:  Doctor,  I like the "brain change" of getting high, but my drug of choice is illegal and I never know what I'm getting when I buy it, plus I have to deal with "criminals" in order to get my drug of choice.  Is there a way that a person can achieve a brain change "high" without the dangers associated with illegal  drugs?
A: The brain change you are talking about is your experience of a high impact on the pleasure/reward pathway of the brain.  The intensity of the high is due to the extreme effect on your brain by the drug..  It is similar to having pummeled your ears with loud noises,  making it difficult to enjoy subtle sounds. If you give your brain a break from the over-stimulation, in time you will appreciate the true pleasures life has to offer.  Allow me to explain what this “over-stimulation” means, and how it works.
When you do something pleasurable,  it affects the amount of a substance called dopamine   If there were a “pleasure impact scale” based on dopamine,  eating food and  drinking water rates a 2, sex rates 4,  cocaine rates 8, and methamphetamine scores a 12. It's interesting that amphetamine and cocaine both drugs increase the amount of dopamine in the synapse. However, cocaine achieves this action by preventing dopamine reuptake, while amphetamine helps to release more dopamine. So, these drugs with similar effects produce their actions through entirely different processes. In turn, addiction to the two drugs may call for somewhat different types of treatment. To answer your question more directly, the answer is no, you will not find an intense high to equal or rival the one from over stimulation, but as you pleasure/reward center returns to normal, you will experience simple pleasures that were unavailable to you while using the drugs.
Q:  I've been in so many rehabs, it has almost become a life style. One rehab after another. I wonder If I may be relapsing just so I can go back into rehab where I feel supported and cared for. Can a person become addicted to going to rehab?
A: If you continue relapsing immediately upon leaving treatment, take a serious look at the type of treatment you are receiving. A proven clinical approach utilizing modern medical methods should alleviate this “revolving door” syndrome. If, however, you are relapsing on purpose so you can live in the sheltered environment of the facility, you must seriously consider finding a program that offers comprehensive individual care that prepares you to live happily outside of the treatment center environment. 
Q:  I really don't want the cost and aggravation of using drugs -- and while I am not "out of control" I like to use drugs once a week because I enjoy the experience. Plus, I worry that I may suddenly "cross the line" and become an addict.  I don't want to go to AA or NA and call myself an alcoholic or drug addict all my life when I'm not an addict. Any suggestions?
A: Your concerns show impressive insight and maturity. I think you know the answer to your question. When the concerns outweigh any “benefits.” it is time to set the behavior aside. The way to never cross the line, is to not approach it in the first place. As you rightly perceive the potential for problems, the most wise and prudent course of action is to use a technique called “DSEI” – Do Something Else Instead on that one night a week that you used to use drugs. If the problem was fishing, I would say you caught your limit.  If your family has a history of alcoholism or addiction, you have even more reasons for concern.  For the sake of your personal happiness, follow  the logical conclusion of your question : You have rightly concluded that the drug use period of your life is over, and you have moved past it. 
Q: Are doctors such as you and your associates actively working to stop the exploitation of addicts and alcoholics by non-medical rehabs who prey on the family but don't really do anything medical for these people?

A: I wish I could give you an emphatic “YES!” to your question, but society is so influenced by misinformation regarding addiction and alcoholism, and addiction medicine as a specialty is so new that those of us who are addiction medicine specialists have our time dominated by actually helping people afflicted with this illness. As the truth about the medical nature of addiction become more well known, exploitation will be greatly reduced. Believe me, we are all doing what we can with the resources available.
Q: I'm in my forties, and getting drunk and getting into bar fights just isn't a very adult thing to do. My girlfriend is getting fed up with me.  I only go out drinking once a week, but it never ends well. I love to drink, but I don't like what happens when I do. What can I do?
A:  You can stop. That is the easiest way to put the problem to rest.  Obviously, the outcome of your drinking is not good. Continuing behavior despite negative consequences is one sign of addiction. If you can't stop even if you want to, I urge you to seek professional medical help before your drinking causes the loss of your relationship, health, career or worse.
Q: It seems to me that if addiction is a medical problem, it should be treated by doctors. Why are non medical people allowed to diagnose addiction and run treatment centers if it is a real disease?
 A: That is a very good question! I know of no other medical condition of the brain, be it Alzheimer's or Parkinson's, that has amateurs diagnosing and treating it.  Addiction is a proven medical condition best addressed by medical professionals.  If you can't find an addiction medicine specialist, at least consult a psychologist with experience in treating addiction and alcoholism. In the near future, quacks and charlatans will hopefully be expelled from alcohol and drug treatment just as they have from the treatment of other chronic illnesses. . 
Q: Is addiction in the drugs, and alcoholism in the alcohol? If so, why aren't all drug users addicts and all drinkers alcoholics? What if we did away with all drugs? What about people with gambling addictions or junk food addictions?  How can these different things give rise to the same medical condition?
A: You are correct: addictions, including alcoholism, are not caused by the drink or the drug. Addiction is primarily the result genetics and over stimulation of the pleasure/reward pathway in the brain.  Moderation in all things would be a major step towards reducing addiction, but seeking intense experiences is also symptomatic of people with a genetic predisposition to addiction.  The expression, “nothing exceeds like excess” is certainly true when it comes to obsession, compulsion and addiction.
Recent scientific research shows that the process of addiction is related to over stimulation of the brain's reward pathway. . A study recently published in Science Daily  states that what happens in addiction to drugs or junk food is lethally simple. “The reward pathways in the brain have been so overstimulated that the system basically turns on itself, adapting to the new reality of addiction, whether its cocaine or cupcakes.”
This understanding also goes a long way towards understanding gambling addiction, which is not actually an addiction to the act of gambling, but rather to the extreme emotional stimulation of losing. Once again, it is the over stimulation that results in  progressively deteriorating chemical balance in reward brain circuitry.  For that small percentage of people on the planet born with a predisposition  to addiction, awareness of the importance of balance and moderation in all things is imperative. 
Once the “brain change” has taken place, medical treatment coupled with intentional behavior modification can help restore balance, and in some cases, actually repair damage to the brain's reward circuitry.   To keep things really simple, here is a perhaps over simplified yet useful formula: 
GP+ES= A
Genetic Predisposition (GP) + Excessive Stimulation of Pleasure/Reward Pathway (ES)= Addiction. (A)
For someone with genetic predisposition to addiction, a most effective preventative measure is a diversity of pleasures, none of them to excess.  Knowing that too much pleasure repeated too often, especially from a singular source, is a major factor in addiction, the wise person practices moderation, and enjoy a variety of different activities, and guards against overdoing any one thing.


The American Society of Addiction Medicine provides both the public and medical professionals valuable information, guidance and research on addiction. Here is a somewhat shortened version of their most recent definition of addiction.
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.
Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.
Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;
Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);
Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;
A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and an apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.
Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs. While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”--but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal. Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.
 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.
As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.
Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.
The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to:
Decrease the frequency and intensity of relapses;
Sustain periods of remission; and
Optimize the person’s level of functioning during periods of remission.
In some cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives 
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. 
Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

 



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