I used to believe that addiction was a character flaw, and that the drug fiends I treated on the streets of Hartford were there due to their own poor choices.  That doesn’t mean I treated them badly. I have always tried to treat all my patients as if I were treating members of my own family.  That said, like anyone I have good days and bad days, and don’t always live up to my expectations.

The older I get the less judgmental I am.  I guess I have seen people go through hard times over the years, and am more sympathetic.  I view the drug fiends, as I called them, differently now for two reasons.

One, I know people can stumble, they can make mistakes and they can have bad luck.  Not all roads traveled lead to good ends.

Two, science now makes a compelling case that addiction is a brain disease. Hard core addicts are crippled in their thinking in much the same way that people with heart disease have diminished cardiac capacity or diabetics have problems regulating their sugar.

I advise all to read the chapter on THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION  from the just published Surgeon General’s report Facing Addiction in America.

Here’s the jist:

Use of opiates causes neuroadaptations in the brain’s structure and function that impair logical thought and breed abnormal behaviors.  These neuroadaptations can persist long after a patient has gotten clean and cause them to relapse.  People with substance addiction are damaged in the same was as people with heart disease, COPD or diabetes have damaged hearts, lungs, and endocrine functions.  People with opiate addiction have damaged brains.  This can be seen on MRIs.  We can’t expect them all to sudden act rationally in the same way we can’t expect someone with a heart transplant to run a marathon, a COPDer to climb Mount Everest or a diabetic to live without insulin.

This from the Surgeon General’s report:

  • Well-supported scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease that has potential for recurrence and recovery.
  • Well-supported evidence suggests that the addiction process involves a three-stage cycle: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation. This cycle becomes more severe as a person continues substance use and as it produces dramatic changes in brain function that reduce a person’s ability to control his or her substance use.
  • Well-supported scientific evidence shows that disruptions in three areas of the brain are particularly important in the onset, development, and maintenance of substance use disorders: the basal ganglia, the extended amygdala, and the prefrontal cortex. These disruptions: (1) enable substance-associated cues to trigger substance seeking (i.e., they increase incentive salience); (2) reduce sensitivity of brain systems involved in the experience of pleasure or reward, and heighten activation of brain stress systems; and (3) reduce functioning of brain executive control systems, which are involved in the ability to make decisions and regulate one’s actions, emotions, and impulses.
  • Supported scientific evidence shows that these changes in the brain persist long after substance use stops. It is not yet known how much these changes may be reversed or how long that process may take.
  • Well-supported scientific evidence shows that adolescence is a critical -risk period for substance use and addiction. All addictive drugs, including alcohol and marijuana, have especially harmful effects on the adolescent brain, which is still undergoing significant development.

* Well-supported: when evidence is derived from multiple rigorous human and nonhuman studies; Supported: when evidence is derived from rigorous but fewer human and nonhuman studies.

Our job in EMS it to keep these people alive and help steer them toward recovery. We can do it by reversing their overdoses, by guiding them to treatment and treating them like fellow human beings.  We are all in this human journey together. Let’s help each other out.

Peace to all.

Graphic from Facing Addiction in America.



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