Why Do Some People Get Addicted?

Please be aware that this podcast has reference to drug and alcohol use and paraphernalia and may not be appropriate for some people in early recovery. Hello everyone. My name is Dr. Majibine Islam and I am Dr. Ketley Daniels. And you want to thank you for listening to our Tree Dediction podcast. The information in this podcast cannot replace your seeking a treatment provider which you can easily do at SAMHSA's national helpline at findtreatment.gov or 1-800-622-4357. That said, I got to tell you, developing this podcast has been so much fun that I think I could stand to quit my day job. Our focus today is going to be on the inevitable or perpetual question of why and the impact of addiction in the United States. In many illnesses, people often ask themselves, "Why me?" But with addiction before sobriety, the person often blames themselves. And after sobriety, they find themselves asking why they were so stupid or why did they keep going along that path, knowing what they know now. Maybe you can tell us, at least tell our audience, and what you learn and what you've read and what you've seen. Why do you think people get addicted and others don't? That really is, you know, Ketley, quite the million dollar question. And I hate to say it is complicated. And before we talk about the research, I want to share my personal experience because you'll notice that with our diseases, we tend to either follow one parent or the other. And I've noticed that my genome or my diseases or disorders are like my mothers. But it's really very interesting that she has spinal stenosis and has been prescribed per cassette when she gets very severe pain. And her experience is very different from mine because when I had a c-section and I was prescribed per cassette, I was in Florida and I was hallucinating and the hallucination was not a pleasant one. So I just didn't enjoy it at all. But when she has severe pain, she will say that why don't you give me per cassette? And I'm like, okay, and then I can see, I can see her possibly even nod a little bit and she has the intoxication. So even though everything or disorders are very similar, but in this situation, her opioid receptors clearly like the per cassette and my receptors do not. So though genes play a large part, the individual differences, I think we really have to keep in mind. So what do you, Dr. Daniels, how would you explain the master chemical in all this? Well, studies of the brain have provided insights onto the role of what we call the master gene in this addiction podcast called dopamine. Dopamine is a key chemical in the brain and it wears many different hats. It plays a role in movement, in memory, in attention, and the mood. But importantly for us, it's the pleasure center of the brain, which is why we call it the feel-good hormone. And reinforcing effects of the drugs of abuse are based not just on the dopamine, but how quickly the dopamine increases in the body. The faster it increases, the more intense the high. And once it's on, the chase is on. And people find themselves always trying to recapture that first high. It's different when the addiction has become long term, isn't it? And that's really what's very interesting is that on the one hand, it is the pleasure chemical. But when something becomes chronic, it becomes, it's very, very different. Because with long term use, dopamine does not work very well because there's a reduction in the number of dopamine receptors and also how well the receptor works. Before we go on, people, you know, we, us addiction specialists always like to talk about receptor receptor. So it's important to explain what a receptor is. And it's basically made up of protein in the brain and that it has a channel that transmits the chemicals. It transmits the dopamine or the other chemicals. So normally dopamine receptors in the frontal regions of the brain stop the person from doing impulsive things. But when drugs have been used for a while, this inhibition or prevention of impulsivity goes down. So it's a kind of like a paradox which we've just got to try and understand. And this shows itself as a loss of control and it goes on to compulsive use, which we know as addiction. But that's not all there is to it, is there? I look at the fact that once the chase is on, it's on. The individual who becomes habituated to this drug, they find themselves not only craving, but seeking the substance irrespective of the consequences, which just boggles my mind. It doesn't matter if they lose their jobs. It doesn't matter if they lose family members. It doesn't matter if they get arrested. The chase is on. I remember one individual and I couldn't even imagine living that lifestyle. Every morning, she and her mother, they were addicted together. They would get up and go to all the area bars to collect bottles and cans, to take to Michigan to recycle, to bring back to Ohio so that they can use the money to buy their drugs. The chase is real. NIH has funded studies trying to figure out why addiction is as it is. But one of the main things I've discovered, it is a long-lasting, complex brain disease. But the good news is treatment does work. Unfortunately, even when successfully treated, many individuals relapse, which is so tragic. And I think some of us may remember the actor Philip Hoffman, he played in the Hunger Games. Sober for many years, he relapsed, he overdosed, he died, tragic. And so we can put a face with a name with this popular individual. But this death and dying, it's happening every day right here in our community. But repeated use of these drugs, it causes damage to that frontal, prefrontal cortex. This area of the brain that we use for judgment, for insight, for guiding us. This area once damaged, it doesn't matter now, whatever happens happens. You just don't care. And I think it's very sad. I'm picturing this one, a young man that I know is a distant family, friend. It's incredible what he has lost over the years. But yet he keeps going back. He was sober for the longest about maybe nine months. He was in a treatment program. He looked human again. I mean, literally, he looked great. He was discharged from the program. He went right back to using, again, the damage to that prefrontal cortex. The frontal cortex, it's the intellectual center of the brain. And it's really, really key when it isn't working properly. And it doesn't, when it has been damaged by long-standing drug or alcohol use, people can't make the decision to stop, like we mentioned, stop taking the drug. Even though they see the price that it's taking out of their lives, like they're going to lose custody of their children or end up in jail, the high or the chasing the dragon phenomenon that we discussed is so significant that the person still takes the chance, even though the risk is so high, like we were talking about how, when car fentanyl came out, I was listening to this report about how you have to be so masked and gowned and gloved and all that, because the smallest amount can cause death. But what did patients think? Patients wanted to use it. Because the high is so intense. The biological basis of addiction helps to explain why people need much more than good intentions or willpower to break their addictions. And when drug or alcohol use becomes an addiction, it crosses over into the realm of a chronic disease. And when society thinks and does not realize that it's a chronic disease, they feel that good intentions or discipline or pulling yourself up by the bootstraps should work. I mean, why don't you have willpower? That's really the question of society that doesn't, that because they don't understand that it's a chronic disease. And the person kind of, the receptors kind of like just latched on to the drug. But really, it's medication assisted treatment. Actually, and that's really the push or the thrust of this podcast by a physician combined with counseling that can really, really change lives. And I always say that, you know, I love practicing family medicine, but the effect that family medicine prevention does is in decades, but with addiction medicine, we can make a difference within three months. And the reason that the brain is so, so important in all of this is it actually changes with addiction. And it takes a good deal of work to get it back to its normal state. And the more drugs or alcohol you've taken and the longer you've used them, the more damaging it is to the brain, which is such a, you know, kind of like a sad, sad situation. It's like a negative loop they get into, negative loop. And I'm picturing, um, there was a, a news program, I want to say it wasn't CNN, but they were talking about addictions. And it doesn't seem to make sense to those of us who do not have the disorder. When you have a product that can cause you possible death, that you say, damn, that must be some good stuff. Right. I suppose to, this is not a good thing. Maybe it was just the away from this. Yeah. And there was an article that came out and they showed a picture of some of the crosses of when the tissue begins to break down from people injecting. And they showed the arm of this individual that looked like an alligator arm. Guess what their reaction was? Damn, that must be some good stuff. Yes. Yes. So, you have to understand that once that prefrontal cortex area has been damaged, they're not going to respond like those who do not have the same issue. It's affected now. Yeah. And it's caused kind of like a burnout kind of a situation that while it dealt with the high or the pleasure, now it's really preventing the impulsivity, you know. And so many people continue their use, at least in my experience in my office, they continue using just to feel normal now. Exactly. Exactly. Just want to feel normal. People think that, you know, addicted patients are having a wonderful time. And I always try to tell people it was wonderful for them for the first time. But after that, all that they're trying to do is get back to some minimal semblance of normal, normalcy. They just don't have that anymore because of its drawl from opioids and certain other drugs can be very, very intense. So, you're going to talk about how it runs in some families? Yes. And it does. The genetic studies have shown that there is a propensity, a likelihood that it can run in some families. But it doesn't make the understanding of it any greater because I've seen a number of individuals who come into my office for treatment of their mood disorder. And when you get a family history, they have a family history of depression, I mean of drug addiction, but they don't. So why? We don't know. There are many other factors that can also influence the development of the disease. Growing up in an alcoholic home, so your product of your environment, being abused as a child, because they use that to help them cope. Life stressors can lead to it. And also starting drugs or alcohol at a very young age. It's incredible when I have someone tell me, they tell me things like how old were you? I will ask them when you first started using. And they'll say, well, I was eight years old or I was nine years old when I consciously was using. And I'm thinking to myself, I can't picture an eight year old rolling a joint, smoking it, but they do because they were introduced by other family members. So all of those variables affect why people develop drug addictions. And you know, they develop a, there's a circuitry in the brain. And just like an eight year old trying to roll a joint, I had a patient who was injecting heroin in the veins of her feet. And then she came into treatment. And when she relapsed and she couldn't obtain the heroin, she was just using a dry needle to just mimic that pleasure circuitry. It is, it becomes so embedded in the addicted brain that they just want to reproduce it. And, and you know, the frontal cortex is so, so important, especially in teens because teens are especially vulnerable because their brains are not fully developed. And the frontal cortex cannot stop their impulsive behavior. And they are not able to assess the risk. So you just see the impulsivity and, and the, the complete confidence that teens have that they can conquer the, the world. And the pleasure circuits and adolescent brains also operate on overdrive and make drug and alcohol use even more rewarding and enticing. But then again, even though we've been through quite a few sort of issues, there's much more to addiction than even this, isn't it? There's, there's, there's so much more. But as you were talking about the teenagers, something popped into my mind about how, how sad it is. One of my favorite saying is, you don't know what, you don't know until you know it, but then it's too late. So you have these young adults, these teenagers, you know, at the cost of emancipation, they start damaging their, their brain. They don't realize that this is a forever disease. Yes. And if you try to tell them, you can't because they know it all. Yeah, yeah. Teens always know it all. Yeah. But like you said, though, addiction is quite complicated. We have the environmental factors. The parental attitudes, peer influences, lower education, unfortunately, is a factor, drug availability. And sadly to say, you know, alcohol is very, very much a legal product that we can all consume. And now we have a new, I was going to say new sheriff in town, but it's a new beast in town. We have cannabis marked my words. You heard it here today. I said it. It's going to be a problem in our community. It is already a huge problem. But it's now legal. And so we have that factor. We have the biology. We have people who have depression and anxiety in their self-medicate. And many people who have alcohol tendencies tend to report having had anxiety, symptoms, panic symptoms that abate when they, when they drink or use a substance. We also have the drug properties. How it makes you feel because some drug make you feel euphoric, some calm you down, some make you feel low, you know, low chilled. The way it makes you feel determines also the tendency towards becoming more addicted. The route of administration. So the faster it gets to your system and gets going, the more dicting it is. So you have those who take an IV or under their skin, they call it skin popping, or they dissolve it under their tongue, or they swallow it, or they have patches on their skin. And so there are many ways that this addiction is propagated. When you listen to the different stories, you realize how patients develop an interesting degree of expertise. They could they could teach us a thing or two. And though statistics are really boring, but I think they really give perspective and we would not be fair to our audience if we didn't give them an idea as to the enormity of the problem that that we are dealing with. So half of people, 12 and older in the United States have elicit, have used elicit drugs at least once. So if you extrapolate and see, the current US population is 333 million. Half of that. I mean, just imagine. And these, this is based on 12 and older. Somehow the other, you know, we think of adults, but this is involves 12 and older. So it's really something to think about. Drug overdose deaths in the United States since 2000 are nearing one million souls. And for me, to conceptualize it, I pictured the population of Toledo, Cleveland, Columbus, most of Ohio, most of Ohio Toledo, Cleveland, and Cincinnati because Columbus alone, Columbus had become very large. So Columbus, like almost a billion people. So I think it's really important to kind of concept make a visual that all of these people have died and the problem. And we still don't have our arms around this problem. And 141,000 Americans die from the effects of alcohol in an average year. And 10% of the population or one in 10 Americans. So if you take a crowd of people, one in 10 Americans over the age of 12 have alcohol use disorder. And in a couple of our future episodes dedicated to alcohol use disorder, we will explain the pervasive damage that alcohol causes in our bodies. And it kind of like reminds me of diabetes. I tell patients, you know, that if I was given a choice that you're going to get diabetes, or you will get curable cancer, I will choose curable cancer because diabetes involves every, every essentially every part of your body. Every part. Similarly, alcohol is like a little sister to diabetes in that it affects so many parts of our bodies, so much of its functioning, that it is kind of like mind boggling even for, you know, us professionals to read about. And the it's really very interesting that we have 385 daily deaths in America from excessive alcohol use. But just like you mentioned, you know, the, the The second monster in town is going to be marijuana, but society has accepted the legalization of alcohol, and there has become a misconception. People think that if marijuana is legal, then it's not damaging. If alcohol is legal, it could not be damaging, and that nothing could be further, further from the truth. And cigarettes. Exactly, exactly. It's interesting. I was thinking of a gentleman. It just popped into my mind. When they come to see me, their social history, I ask about substance use. And he was a smoker two packs a day. So I said, "I always ask, have you considered stopping?" And he said, "No, thank you. I'm not gonna." I said, "Well, thought I'd put it out there. So fast forward maybe three or four years into treatment." He comes in and he was diagnosed with lung cancer, and he says, "Doc, you gotta go somehow." I said, "But not that way, you know, not that way." And so now he's in treatment, and I'm having some side effects with the chemotherapy. He's still, you know, puts things about. And I think to myself, "But why? But why?" And so they make these choices, they live with the consequences, but I wish people would just not start some of these things. And you know, cigarette smoking, I tell my patients that it's one thing to have diseases, a lot of diseases we do not have control over, we develop them. But if there is a disease that is within your hands to create, which is smoking, smoking creates a bunch of diseases, and dying of the consequences of cigarette smoking, it's not just lung cancer, but dying of COC lead in which you cannot breathe out. It's like slow suffocation, that is something that one should prevent, and you know, going back to the teens, I tell my patients that, "Please, we still consider marijuana the gateway drug." And actually, I consider smoking the gateway drug. Don't let your child smoke, don't let your child use marijuana, because you don't know if the receptor is going to like it, they're doomed. But some parents actually use with their kids, they smoke with their kids. And that's the sad part, yes. And the stories we hear are hair raising. Like I told you about that little child, the two-year-old who was running around drinking after her parents, she was two. So we have another issue with methamphetamines, huh? There are so many substances in our culture that are not being addressed because of the larger than life opioid crisis, right? But over the last few years, cocaine has increased fivefold. The use of methamphetamine has increased 14fold from 2011 to 2021. We're going to talk some more about the effects of these drugs on the brain. But it's incredible what's out there that are preventable. Yes, yes. Preventable. And, you know, going back to marijuana, 55 million American adults use marijuana currently. And this, you know, whenever it comes to teenagers or high schoolers, your heart just melts. 24% of 12th graders have used marijuana in the past, in the past, that's the key piece. And we will dedicate at least one future episode to marijuana, but like with alcohol and it promoted by the marijuana lobby, people think like I just mentioned that legalization of a drug means it's not harmful. And nothing, nothing at all really, and I can't stress it more, can be further from the truth. Because marijuana now is purer than it used to be. And using it continually increases the risk of psychosis. It is so hard for me. It makes me very sad. And I guess that's why all of the passion comes out. It's hard for me to forget two patients in my practice, young brilliant men, boys actually, who despite my pleading with them, and just like you mentioned, this other patient that you about the lung cancer one, very kind of like it was almost prophetic. I, when I look at my notes, a year previously, I kept telling him, don't use marijuana. And he was using it with methamphetamine. Don't use them together. You'll develop psychosis. I would just tell them. But for them, it's just like, it's not going to happen to me type feeling. And sure enough, he developed psychosis. And there was no family history of schizophrenia. He developed schizophrenia. And he couldn't handle the voices, the auditory hallucinations, he committed suicide. And there was a similar patient, you know, same age group, same situation. So this is a reality just because of the marijuana lobby. This is, you know, capitalism gone awry, that we must take anything that has the potential for money and run with it. There's so much money in marijuana. Absolutely. It is capitalizing and destroying people's lives. So why should Michigan just get all the money? There you go. Exactly. Yeah. Exactly. Yeah, very sad. I had a young man similarly. I saw him only one time, no, twice. And he came in because he was agitated and easily bothered and the mother came with him. He was about maybe 16. And incidentally, he was also prescribed medicinal marijuana that he was using for his migraine headaches. This young man was so paranoid. But of course, when you're delusional, by definition, you don't know you're delusional. So there was no way of connecting with them because it was everybody else, not him. Right. He was lost to follow up, but he was using cannabis, not just the gummies or any other sub mutations, but he was using pot three or four times a day for his migraine headaches. I said, right, all righty then. I have a patient who has persistent vomiting. And being the primary care provider that I am, we become very thorough and comprehensive and we worked it out. I worked it up, could not get to an answer and finally referred him to GI. And he had, he was using marijuana excessively and had cyclic vomiting syndrome. And even now, till today, even though he has been diagnosed with that, he won't stop. You know, full of complaints and it's like, it's very difficult when that kind of transaction happens. It's very, very hard. And you say, all righty then. Yes. Exactly. So most of us have, and actually the reason, I think, for this, you mentioned it very well, this huge issue of the opioid epidemic that is taking so many lives is the primary reason for the podcast that 136 people die every day, every day from opioid overdoses. And since, in 2022, 108,000 people died. Over 10 million people misuse opioids in a year and opioids are a factor in seven out of 10 drug overdoses. It's just so much to deal with. And I think sometimes we get disensitized when we hear these numbers. And I think sometimes we just not as affected by them anymore, like the war in Ukraine and Gaza. And then we just go, oh, okay, what's for dinner, you know, we just keep going. But people are dying, not just from opioids, they're dying from alcohol use. They're dying from cocaine was the thing I remember years ago when that was the beast in town. Exactly. Remember, and now it's morphed. Every few years it morphed with something else and they met and said, I mean, we've had a block of time when that was the issue. Now it's opioids. It's going to cycle back again. But people are dying and we need to do more than. And people are dying and the opioid overdose because fentanyl, first we had the, they had painkillers, then they had heroin and now we have fentanyl. And the fentanyl becomes more and more concentrated and then previously the addiction is so intense that I still remember that I had a patient who used to make these, what a business to create these underwater lighting for little lakes in front of businesses. And she had a business of the generated $250,000 a year and she lost it all behind oxycontin. And then on the, and while that is there, which is like a, you know, I'm never, those stories can be with clashing but at the same time treatment is so effective that you see these, what I call turn around and remember patients who this particular one was homeless and after treatment, he got a house, a car, and then one day came and said, I have a pension plan. I was like, whoa, okay. So a little bit about the opioid epidemic and our audience, if they don't know already, will be very surprised to know how it all started because it developed before you're in my very eyes because it's in very recent memory, right? And it wasn't as though someone published a research article in the New England Journal of Medicine, it was just a letter. And the letter said contrary to what we had been taught in pharmacology, it said that opioids are not addicting and Purdue, pharma and the Sackler family took it and ran with it and the development. oxycontin and out of all in my career, out of the substances that are very, very addicting and very difficult to get rid of from your life are is liquid injectable oxycontin, heroin and cocaine. So they massively promoted the oxycontin and then they created the thing that we all experienced in the emergency departments treating pain as the fifth vital science in the North would always come and ask you she take your regular vitals and then she'd ask you about pain and there would be these little smiley faces on the walls and you could like if you were challenged in terms of one to five one to ten you could use the you know the smiley face and then like everything in medicine there's compassionate prescribing like people come in and they say oh you know I have this pain and I have many pushover colleagues in medicine who in town who I get referrals from and they prescribed the pain killer they prescribed an opioid and then there was greedy prescribing and then there was the development of oxycontin pill mills and so if you took a map of the United States you would see that it would be dotted all over the big concentration in Florida of oxycontin pill mills in which you never saw the physician you just basically were given something across a window you gave the cash and it was given across the window then the government finally woke up and decided that this oxycontin is causing a huge number of problems so they insisted that Purdue pharma changed the formulation so they changed it and now if oxycontin is heated it becomes concrete so you can't inject it but of course capitalism gone awry if you don't have oxycontin then you just go on to heroin and then from heroin you just go on to fentanyl you know just just simple that that's basically how the opioid epidemic developed based on the greed of the Sackler family and one letter in the New England Journal of Medicine and unfortunately you know we're all complicit from the manufacturer to the distributor the producers you know the prescribers the users everyone has a role to play and we all need to recognize it and to our part to stem this tide in the book Dreamland by Sam quinones it's very well described and the audience may do well to take a look at that and also to follow and review the role of Purdue pharma in the Sackler family as portrayed in the in painkiller the series but even as we do this let it not be just an intellectual exercise but also how can we be part of the solution indeed and not to forget dope sick dope sick Michael Keaton's role in that was just phenomenal and and they portrayed just the way that we saw it develop happened right in front of our eyes so we really hope that our audience enjoyed this episode our next episode will deal with the important issue of opioid addiction and the very successful life-changing treatment options that are available we really hope that our information today will propel you to listen to our to our next podcast I want to thank my co-host Dr. Ketley Daniels for a great conversation today I'm your host and producer Dr. Mahjuddin Islam and I am your co-host Dr. Ketley Daniels and our executive producer is Chris Piper if you have any questions or comments or you just want to listen again go to WGTE.org/treetedictus or wherever you get your podcasts until the next episode I do want to instill this little life skills piece because it's so helpful do remember patience in difficult times and gratitude always always see you sir WGTE voices around us WGTE is supported in part by the American Rescue Plan Act funds allocated by the City of Toledo and the Lucas County Commissioners and administered by the Arts Commission