Excerpts

CHAPTER 1 THE DISEASE OF ADDICTION "Every day I thank God for inventing the blackout, without which I would have drunk myself to death." --ANONYMOUS I DROVE HOME one cold November night through the mountains of Vermont. My moment of spiritual awakening came like Bill W.'s, the cofounder of Alcoholics Anonymous, who describes his moment of spiritual awakening in the form of a bright white light--only for me the light was blue and in my rearview mirror. When the rookie cop got out of his patrol vehicle and walked up to my car, I thought I recognized him. He could have been a pediatric patient of mine, now grown up in jackboots and a Smokey hat. He told me that I had been wandering between the lines. I said, "Well, I thought that's where I was supposed to be--between the lines, that is." I then did what any other red-blooded American alcoholic might do having the time, knowledge, and inclination: I blew out the side of my mouth so his Breathalyzer test wouldn't work and so I could buy myself some time. On the way to the police station, I faked a hypoglycemic attack to bring out the entire rescue squad so they would become witnesses who could help explain my behavior. This would look good in court, I told myself. Then I hired a detective. We went back to the scene of the crime and videotaped all the stripes on that highway and saw that some of those stripes wiggled and varied, a scenario that could give rise to the theory that it had only been an optical illusion that my car had been weaving. It also pointed to the possibility that the Vermont road crew who painted the lines was loaded at the time. As if that weren't enough, I hired a chemist to refute my blood alcohol level reading by explaining that at that temperature and at that time, in the middle of the night, and given the toothpaste I was using, all tests were, in all probability, invalid. After examining the arrest record of this young cop, the detective and I determined he was probably a stalker who had followed many a bar employee home, stopping them and forcing them into DUI checks. I was just another victim. So we amassed a lot of evidence, and I spent a fortune because there was no way a guy like me was going to go down. I was a doctor with the gift of defiance and grandiosity, the perfect storm for an alcoholic. We were preparing for trial when my lawyer said, "Hey, Doc, before we go to trial, would you like to see the videotape?" "What videotape?" "The videotape of your arrest that was made by the chief of police who was training the rookie cop. The chief, who's known you for 30 years and could have stopped the arrest, thought it was time you got a little help." "Has anyone else seen this videotape?" I asked. "Yes," he replied. "Just the state medical board and the district attorney." A MATTER OF CHOICE? We can define disease as a loss of function of an organ or organ system that produces a set of symptoms with a known or an unknown cause. For example, diabetes has a target organ, the pancreas. We know the cause, which is a dysfunction in insulin production or in insulin's action at the cellular level. And the effect is that the body becomes glucose intolerant, which results in high blood sugar levels that, over time, damage organs with small blood vessels, including the eyes, the kidneys, and the heart. Diabetes is a chronic, lifelong, incurable disease that is absolutely treatable. A patient with diabetes follows dietary, exercise, and medication instructions to attempt to normalize blood sugar levels. But if left untreated, diabetes takes its toll on the body. Chronic elevated blood sugar levels cause the small blood vessels in the peripheral nerves, eyes, heart, and kidneys to thicken, eventually occluding proper bloodflow. This can result in pain, numbness, and tingling in the lower extremities; destruction in the retina; early susceptibility to heart attack; and, most especially, renal failure--the awesome consequences of a disease run rampant. Are these consequences preventable? Often, the answer is yes. If the diabetic follows a daily treatment regimen, she can live to be 100. Left untreated, diabetes is a fatal disease. That is, it must be treated one day at a time. You don't get credit today for the insulin you took last week. Multiple sclerosis (MS) is another example of a chronic, lifelong, fatal disease, treatable but not curable. The target organ system for MS is the brain and central nervous system. It is a chronic, organic disease of the brain with a relapsing and remitting pattern that may come and go with devastating symptoms. For many years, alcoholism and drug addiction were considered a weak person's inability to control desire. Most people believed that drinking was simply a matter of choice and that anyone with a drinking or drug problem was reckless, self-absorbed, and irresponsible. Research dating back to the 1950s, however, has led most medical professionals, myself included, to understand that addiction is not a moral issue but a disease-- a brain disease to be specific, and one that has genetic links. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) continue to do important research on the complex genetic disorder known as addiction. We have proof. Addiction is a disease. So why do most people, including addicts and their family members, find this fact difficult to accept? Perhaps it's because addicts and alcoholics seeking their drug of choice have done some pretty bad things, transgressing the boundaries of society and the law. No doubt, an addict's behaviors can be intolerable. Living with an addict can bring family members to the brink of insanity. But addiction is a brain disease with signs and symptoms manifested in part as behaviors. And like diabetes or MS, alcoholism and addiction have a target organ, a cause, and an effect, which we call symptoms. THE TARGET ORGAN OF ADDICTION The disease of alcoholism and drug addiction affects one of our more precious organs: the midbrain (more appropriately called the survival, or reptilian, brain), an area located just below the upper, or thinking, brain. It is called the reptilian brain because it is the only brain that reptiles have and the only brain they have ever needed to survive for hundreds of millions of years. The midbrain dictates survival behaviors: to move away from danger and toward food; to breathe in and out; to eat and to rid the body of the waste products; and, of course, to procreate. These survival behaviors require reinforcement so that they're repeated over and over again by generations to perpetuate the species. That reinforcement comes in the form of dopamine, a neurotransmitter that, when released by the brain, simply makes us feel great. When we're parched, we seek water, knowing how good those first gulps of cool water will feel. When we experience orgasm through sexual intercourse, we're encouraged to procreate. These pleasurable feelings are directly related to the midbrain, which encourages us to repeat behaviors that feel good and to avoid those that don't. Drugs of abuse affect the midbrain by causing it to release 2 to 10 times more dopamine than natural rewards do. If we're smoking or injecting our drug, the effects can be immediate and long lasting. At first, the "high" is bigger, better, and stronger than the natural high most of us get from pleasurable activities. Our brain rewards us for using drugs, and, drawn to the dopamine, we do it again and again. Over time, our brain, overwhelmed by repeated surges in dopamine and other neurotransmitters, adapts. It either produces less dopamine or reduces the number of receptors that can receive dopamine signals. Our natural supply of dopamine plummets, and we have a hard time feeling pleasure from normal activities. At this point, we need to take drugs just to feel normal. If we want to feel the high we once felt, we need to take larger amounts of the drug than we first did--an effect known as tolerance. The result is addiction, a condition that keeps us drinking and drugging even after our behavior has started to make us feel bad and negatively affect others. THE CAUSE OF ADDICTION Disease (excluding infectious disease) is often based on genetics, inherited traits passed down from generation to generation through DNA, and addiction is no exception. The disease of alcoholism and addiction is about 60 percent genetic; the other 40 percent is environmental. What do I mean by that? To experience addiction, we must first trigger the expression of our addiction genes. This is where environment enters the picture. Even if we carry the addiction genes and drink or use drugs on occasion, we may never become addicted to drugs or alcohol. Someone who has inherited the genes and grows up in a healthy environment with little or no exposure to drugs and alcohol, and who doesn't experience any major traumatic life events, may never manifest the disease. Are they still genetically an addict or an alcoholic? Yes, they have those chromosomal traits. But the environment has not supported the disease's development. Conversely, someone with very little genetic contribution--three or four generations without a case of addiction or alcoholism in his family--who grows up living over a bar in an inner city, next to a crack house, and hanging out with a gang that's manufacturing methamphetamine and amphetamine has a pretty good chance of developing the disease of addiction primarily because of his environment. One way to trigger addiction is to experience stress. Stress causes the adrenal glands to release the hormone cortisol. The stress could be good or bad--marriages or funerals, births or deaths, letters from the lottery commission or letters from the tax collector--it doesn't really matter. All events of significance will stimulate the release of cortisol, which has the effect of raising the dopamine requirements in the person who has the addiction genes--1 in 10 people in the United States. Puberty, as luck would have it, is a stressor in and of itself. And we all go through it. Our bodies may differ from our peers in growth and maturity rates, causing us to feel awkward or like we don't belong. We may feel too young for this group and too old for that group. It's during this awkward, stressful stage that many of us are introduced to drugs or alcohol. When using for the first time, we may experience a warm glow or feel our inhibitions replaced by false courage. If we are among the 1 in 10 who are genetically predisposed to addiction, this can be a life-changing event-- many alcoholics and addicts will tell you that the first time they had a sip of alcohol at age 12 or 14, they felt heavenly, normal, and comfortable in their own skin for the first time. We might not develop alcohol or drug addiction in these adolescent years or even in our twenties, but at some point in the future, under specific stressful circumstances, the relief of anxiety and discomfort through alcohol or drugs will be a remembered and welcome event. The disease of addiction is very patient. Many who have had this type of euphoric experience with drugs or alcohol go through long periods of training, schooling, and employment where outside factors keep their disease at bay. The same people who say they will never drink before 5:00 p.m. or will never have a drink at lunchtime may find that when their life circumstances change due to financial difficulties, job loss, or the death of a spouse, the floodgates suddenly open. Even retirement can be a trigger: More and more people of retirement age find that their drinking or drugging patterns change dramatically when the structure and constraints of their work life are no longer present. Once we establish high dopamine requirements, normal pleasures--a day with the kids, a beautiful sunrise, a painting, or good music--don't seem to satisfy the midbrain's requirements for reward. Something that has worked in the past, such as a surge of dopamine from alcohol, cocaine, methamphetamine, or an opioid, may serve the purpose. I like to think of the carnival game where you hit a block with a big hammer, causing a weight to fly up a cable and ring a bell. Imagine that the bell being rung is a dopamine bell and ringing it on a regular basis is a requirement of survival. We have no choice. We must breathe. We must eat. And we must have reproductive activity to keep ringing the bell. Then a drug like cocaine comes along, causing a surge of dopamine that raises the bell 10 feet on the cable. Suddenly, the hammer, or those things that have caused pleasure in the past (good food, good sleep, sexual activity), isn't effective any-more. A bigger hammer is needed. Like heroin. Like opioids. Like cocaine. Like alcohol. The addictive substance trumps the normal behaviors that ring the bell and becomes a requirement for the bell ringing. In other words, our midbrain sends out cravings for the substance that it deems necessary for survival. The midbrain will require us to seek out the same substance, over and over and over again, until the cycle is broken. THE SYMPTOMS OF ADDICTION When we have a disease, we call certain traits symptoms, not behav-iors. Addiction has its own list of physical symptoms, but it also claims a host of symptoms that affect behaviors. The symptoms of addiction are biological, emotional, social, and spiritual. In the field of addiction, we sometimes call them consequences. Biological consequences (of alcohol). All drugs take a toll on the body, but alcohol affects you from head to toe. .The brain may shrink or atrophy, like the brains of those with Alzheimer's disease. It's difficult to distinguish between the MRI of an Alzheimer's patient and the MRI of a chronic alcoholic. (Amazingly, brain damage caused by alcohol can often be reversed in recovery, and the brain regains its former size.) .The digestive system becomes red or raw and may even bleed from the caustic effects of alcohol. .Elevated liver enzymes give rise to fatty liver disease, which may progress to cirrhosis. The liver, shrunken and scarred from cirrhosis, causes a backup of bloodflow that results in varicose veins forming at the bottom of the esophagus, leaving the alcoholic more susceptible to internal bleeding. If internal bleeding does occur, the damaged liver is incapable of producing the blood-clotting factors it's responsible for, so there's nothing to stop the bloodflow. It's not uncommon for the terminal alcoholic to suffer a grotesque form of death--bleeding out through his mouth. .The spleen becomes enlarged, which compromises the immune system by destroying valuable disease-fighting white blood cells. This increases the alcoholic's susceptibility to infection. .The heart's muscular wall may thin and become flabby, causing the heart to overexpand and pump ineffectively, eventually leading to heart failure. .High blood pressure, common in alcoholics, further damages the heart's effectiveness. Excerpted from Being Sober: A Step-By-Step Guide to Getting to, Getting Through, and Living in Recovery by Harry Haroutunian All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.