Understanding Addiction

Our sponsor is the brain, of course. So, before getting to Part 2, here’s an important message, also excerpted from the final chapter:

The term neuroplasticity has been bandied around a lot in recent years, but it’s been understood for at least a century. In Donald Hebb’s (1940s) memorable words: What fires together wires together — neurons that activate each other become more strongly connected — through adjustments (increased efficiency) in their synapses. Neuroplasticity is the brain’s natural starting point for any learning process. This includes the development of addiction. But is it also the springboard to recovery?

Neuroplasticity is strongly amplified when people are highly motivated. Which is why all learning requires some emotional charge, and entrenched habits like addiction grow from intense desire. Clearly, the desire to recapture a potent experience of pleasure or relief is the motivational on-ramp to addiction. But does desire also cultivate recovery?

In The Woman who Changed her Brain, Barbara Arrowsmith Young describes the many cognitive exercises she devised for herself, in order to overcome her very severe learning disabilities. She practiced these exercises prodigiously. As a result, she went from a high-school student who could not comprehend history, who even had a hard time understanding simple sentences, to a writer and teacher who has set up roughly 70 schools for learning-disabled children across North America. I met this remarkable woman in Australia, at a book fair, and I became convinced that her intuition, creativity, and determination to triumph over her learning disabilities were precisely the means by which addicts recover. I also learned her delightful phrase for the neuroplasticity needed to replace bad habits with good ones: What fires together wires together, and what fires apart wires apart. In other words, new mental patterns can fashion new and divergent synaptic avenues.

In 1993, Mogilner and colleagues looked at the brains of people plagued with webbed fingers. That means that some of their fingers were connected and could not operate separately – they functioned in total unison. After surgery was performed to allow the fingers to move on their own, these authors looked at changes in the (somatosensory) cortex. What they found was that clusters of neurons that had always fired together now fired partially independently.

The presurgical maps displayed shrunken and nonsomatotopic hand representations. Within weeks following surgery, cortical reorganization occurring over distances of 3-9 mm was evident, correlating with the new functional status of their separated digits.

So the brain adjusted its wiring, breaking down the coherent habit it had assumed, based on the details of repeated action patterns, and replacing it with new habits, based on novel action patterns. In fact these changes were observable just weeks after the change in action patterns took place! Might recovery work the same way?

Just in case you think the webbed-finger analogy is far fetched, you should know that it’s not an analogy. That’s exactly how neuroplasticity works, whether dealing with severe learning problems (which no doubt involve the prefrontal cortex) or reversing a physical anomaly that took hold during prenatal development (involving the sensorimotor cortex).

When people recover from strokes or concussions, the same sort of rewiring takes place in many regions of the cortex. Even language, one of the most basic human functions, can be relearned after it has been demolished by brain damage, through the synaptic rewiring of cortical regions that previously took care of other business. Thus, neuroplastic change can and does occur, in real life, with a speed and vigor we rarely imagine.

Back to addiction. People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of that plasticity. As if their fingers had become attached together, they can no longer separate their desire for wellbeing from their desire for drugs, booze, or whatever they rely on. Then, when they recover, whether in AA, NA, SMART Recovery, or standing naked on the 33rd-floor balcony of the Chicago Sheraton in February, their neuroplasticity returns. Their brains start changing again—perhaps radically. Just as in Mogilner’s study, their brains begin to grow new synaptic patterns to allow for those distinctions, to hold onto them over time, and thereby acquire new vistas of personal freedom and extended wellbeing.

The take-home message here is simple: Recovery involves a major change in thought and behavior, and such changes require ongoing neural development. Without developmental adjustments in synaptic patterns, we would stay exactly the way we are. Which raises the question: If the high-beam of desire is what drives the synaptic shaping of addiction, is it also the necessary ingredient for finding the road out?

Just finished day 1 at the Mind and Life conference. What a beautiful building this is for a conference. The corridors seem to echo with the shuffling feet of Christian monks. But now, in our modern age, there are a lot of shaven-headed guys with orange robes walking around. It’s strange to see them in the washroom with everyone else, shaving, brushing their teeth. Very corporeal. But most people here are young scientist types, assistant profs or post-docs in psychology or neuroscience, but incredibly friendly and warm-hearted. And a few old guys, like me, except that they look like they’ve known each other for decades. It’s weird to meet a guy with a name like Saul Weinstein who turns out to be an expert on meditation.

Today the talks were on heady Buddhist topics, loaded with Sanskrit and Tibetan words for different traditions. I had to struggle to focus. I’m still a bit jet-lagged and my mind is buzzing with worldly things. In fact today’s meditation session was a total write-off.  Tomorrow’s talks will be on neuroscience. That should wake me up.

What’s most strange about this event is that I’m staying in a small room with another guy. Two beds side by side, and four tiny shelves for our stuff. I haven’t shared a room with a stranger since boarding school. He’s a prof in religious studies at a university in Pennsylvania. A nice guy, actually. Still, he’s very close.

Anyway, not much more to say for now, so what I’ll do is post the second half of an article I just wrote for the Mind & Life newsletter.

To prepare for the meeting [with the Dalai Lama], I’ve been trying to think like a Buddhist for the last few months. And what strikes me most is that the Buddhist perspective on personal suffering, based as it is on desire and attachment, captures addiction surprisingly well. So well, in fact, that addiction comes off looking like a fundamental aspect of the human condition.

Buddhism sees attachment, craving, and loss as a cycle — a self-perpetuating cycle — in which we chase our own tails and lose sight of everything else. What Buddhists describe as the lynchpin of human suffering, the one thing that keeps us mired in our attachments, is exactly what keeps addicts addicted. The culprit is craving and its relentless progression to grasping. First comes emptiness or loss, then we see something attractive outside ourselves, something that promises to fill that loss, and we crave it. And the next thing we do is grasp — reach for it. Grasping leads to getting: a brief moment of pleasure or relief that reinforces the attachment. But it’s never enough, we crave more, and that’s what keeps the wheel going round. Whether the goal is success, material comfort, prestige — the more respectable human pursuits — or whether it’s heroin, cocaine, booze, or porn, hardly seems to matter. Either way, you’ve locked your sites on an antidote to uncertainty, a guarantee of completeness, when in fact we never become complete by chasing after what we don’t have. And, incredibly, the pursuit itself is the condition for more suffering. Because we inevitably come up empty, disappointed, and betrayed by our own desires.

Now that sounds a lot like addiction to me. Yet the Buddhists are talking about normal seeking and suffering. Isn’t addiction something abnormal? What about all those brain changes I mentioned? [which took up the first half of the paper.] Those brain changes suggest to most scientists and practitioners that addiction is a disease — an unnatural state. But a Buddhist perspective might cast it quite differently, as a particularly onerous outcome of a very normal process, a sadly normal process: our sometimes desperate attempts to seek fulfillment outside ourselves.

So what about those brain changes?

It turns out that the brain is designed to change.  Every advance in child and adolescent development requires the brain to change. The condensation of value and meaning in adolescence corresponds with the loss of about 30% of the synapses in some regions of the cortex. As with addiction, normal development involves a lasting commitment to a small set of goals: I’m going to make money, I’m going to live in a secure neighborhood, I’m going to find a life partner. And that involves the formation and consolidation of new neural networks at the expense of older ones. In fact, every episode of learning, whether to play a violin, move in a wheelchair, or see with your fingers after going blind, requires the growth of new synaptic networks. Such cortical changes ride on waves of dopamine, in normal development as in addiction. Gouts of dopamine, with its potency to narrow attention and grow synapses, are highly familiar to lovers and learners alike. That palpable lurch for sex, admiration, or knowledge is always dopamine driven. The brains of starving animals are transformed by dopamine, when, as in addiction, there’s just one goal worth pursuing. And successful politicians achieve dopamine levels that would make an addict swoon. The brain evolved to connect desire and acquisition, wanting and getting, and that connection depends on the tuning of synaptic networks to a narrow range of goals with the help of dopamine.

For both normal development and addiction, desire acts as a carving tool, collapsing neural flexbility in favor of fixed goals. So our understanding of addiction may benefit more from a Buddhist-style perspective on normal development — with its tendency to become fixated on attractive goals — than the disease model favored by Western scientists and doctors. Yet the Buddhist perspective offers another advantage: an emphasis on the value of mindfulness and self-control to free ourselves from unnecessary attachments.

On that note, I’ll end by touching on a provocative experiment recently published in PLOS1, a prominent scientific journal [and brought to my attention by Shaun Shelly on this blog]. It’s well known that cocaine addiction causes reduced grey matter (GM) volume — thought to represent a loss of synapses — in certain regions of the cortex. But these researchers found increasing synaptic thickness in cocaine addicts who had abstained for several months: and the longer the period of abstention, the greater the growth. Most striking of all, the new growth wasn’t simply a reversal of what was lost, like a pruned bush growing back its leaves. Rather, synaptic growth was observed in new areas — areas known to underlie reflectivity and self-control. In fact, this growth surpassed levels reached by “normal” (never-addicted) people after a period of 8-9 months, indicating the emergence of more advanced mental skills. If these results are replicated, they’ll provide solid evidence that recovery, like addiction, is a developmental process, which may benefit from the advanced cognitive capacities facilitated by mindfulness training.

Based on studies such as these, and filling in the blanks with subjective accounts, addicts, scientists, and contemplatives have a lot to learn from each other. I hope that this theme will help guide the discussion with the Dalai Lama in October. Ater all, addicts and meditators make use of the same brain, with all its vulnerabilities and strengths. It makes sense that the brain changes underlying suffering and healing have much in common, whatever their source.

…by Nick Jaworski…

After nearly 80 years, addiction treatment in America is slowly warming to the idea of multiple pathways to recovery, after viewing the 12 steps as the only “real” way to recover. MAT (medication-assisted treatment) is among the most promising.

This is a guest-post by Nick Jaworski, owner of Circle Social Inc., a marketing and consulting firm specializing in addiction treatment. (See bio information at bottom)

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Quite recently, MAT has gained recognition as the gold standard for care in treating opioid use disorder (OUD) among researchers, legislators, and even the general populace. But the acceptance of MAT by the professional treatment community has not been nearly as fast.

Many providers I speak with are still very reluctant to accept MAT in their centers or as a viable component of treatment within the field in general. Even if facility leadership is on board, there’s a good chance staff or referral partners won’t be.

Other providers, such as Hazelden, were also reluctant at first but looked at the  research and made their own determination that they had to change their approach (other providers, even today, still look down upon them for it).

Congress and many States have also recognized the efficacy of MAT and so have begun to pump serious money into programs that offer it (like this large grant from SAMHSA). Insurance providers often prefer MAT as well.

Cost is a very significant factor for legislators and insurance providers. MAT protocols can be provided to those struggling with opioid addictions at a fraction of the cost of a residential program ($4,000 or less a year versus $28,000 a month for your average residential program).

Since the majority of those struggling with addiction lack resources or are on Medicaid, MAT also opens the doors for the demographic with the greatest need to access care.

There are two additional drivers of the increase in the use of MAT in the US — Wall Street and parents.

Wall Street has seen great opportunities because the opioid crisis is constantly in the news and the addiction treatment industry has an estimated market cap of at least $35 billion per year. These investors come from outside the field and do not have the same biases. They look at the data and see what’s effective and where trends are going.

And then there are the parents referring their adult children into treatment. Many parents, especially mothers, have become completely disenchanted with the addiction treatment industry as it has existed since the late 1990’s.

Their Children Are Dying from Overdoses, and Parents Aren’t Taking It Lying Down

The bottom-line is that length of care is one of the highest predictors of success for treatment, so any 28- to 90-day program has very slim chances of success for the first round or two of treatment, regardless of what model they are using. To move away from abusive substance use requires extensive development of new neural pathways that drive new habits and patterns of thought.

As outlined in my article on a Brief History of Addiction Treatment Marketing, it was not uncommon for these young adults to go through 10-plus rounds of treatment. My team and I actually just interviewed a client who was currently on his 27th round of treatment!

As you can imagine some parents have become extremely skeptical after 10-plus rounds of failed treatment (not to mention that they’re paying as much as $30,000 a pop). But, more importantly, many parents have lost children to opioid overdose. The 18-26-year-old age demographic has always had the highest prevalence of drug and alcohol abuse. Most of the time, this is alcohol or marijuana, with smaller percentages using meth, cocaine, and other substances.

However, with the rise in availability of opioid-derived prescription pills, more young adults were switching to these painkillers, which have a high potential for overdose when mixed with other drugs. A subset of these users would go on to heroin, especially when prescription regulations reduced the availability of legal drugs. As most readers know, the extremely high overdose rates of the last few years have been driven primarily by fentanyl-laced (or -replaced) heroin. Unlike in the past, when young adults using drugs or alcohol mostly survived to go on and live normal lives (probably like most of those reading this blog), these kids were dying instead.

So parents were sending their children to multiple rounds of rehab, paying tens of thousands of dollars, and then losing their children to overdose anyway. As you can imagine, this created a lot of anger and resentment.

But that was nothing compared to the anger many parents felt when they learned there was this option called MAT that decreased overdose deaths by roughly 40-60% and they had never heard about it! It’s not uncommon for parents who have lost a child to overdose to tell me that the first time they’d heard about MAT was after their child’s death.

Imagine how you would feel if you sent your child to the hospital and you weren’t even told of a readily available and cost-effective method of preventing your child’s death because the doctor personally didn’t care for the treatment.

This is the kind of anger we see from parents such as Gary Mendell, who created Shatterproof, or Justin Phillips, who created Overdose Lifeline. Parents are simply giving up on the traditional rehab industry as a whole because they feel lied to.

American Addiction Treatment Perspectives Are Shifting, But in What Direction?

All of this has started to open the window to different conversations surrounding effective addiction treatment. Programs relying solely on 12-step and abstinence-based models are regularly being called into question.

However, I am not yet seeing an attendant shift in the disease model of addiction. Conferences premised on non-disease models are still small, and advocates of this approach are still few and far between.

I am on the board of Above and Beyond Family Recovery Center in Chicago, one of the most innovative treatment programs in the country. We focus on providing free, high-level outpatient treatment to Chicago’s homeless and disadvantaged, but we have had a hard time gaining the support of other treatment programs in the city because we do not focus solely on 12-step programming or disease models of treatment (although these are offered alongside our other programs).

Americans have a long history of deterministic thinking when it comes to human behavior. Starting with Calvinistic predeterminism in colonial America and then evolving into Eugenics, the American view of genetic influences rarely goes beyond a limited and simplistic notion of Mendel’s pea experiments (perhaps a topic for a future blog post).

With this misconception, most Americans still view addiction as some kind of genetically predetermined disease, one that is chronic, progressive and incurable.

In the context of our conversation here, MAT is seen as some kind of fix for an ingrained defect, one that perhaps rebalances out-of-whack or deficient neurochemicals in the brain. What most Americans have not yet grasped is that MAT, or any other substance that alters the brain’s neurochemicals, simply combats symptoms, which is not so different from how cold medicines alleviate symptoms rather than cure the actual cold. The key difference here is that OUD symptoms induce so much suffering that users are often driven to continue using. Opioids are of course the best (if not only) way to control opioid withdrawal symptoms. In this respect, relieving symptoms, though not a cure, can change behavior patterns that exacerbate the underlying problem.

In order to truly find recovery, you must rewire the neurological pathways in the brain, which will, in turn, drive changes in neurochemical balances. Just as one cannot lose weight or get fit by taking a diet pill, individuals cannot overcome addiction by taking a prescription. The pill can help, but lasting behavioral change requires focused effort over extended periods of time, as Dr. Lewis has often pointed out.

It is only through an accurate understanding of the interplay between genes, environment, and human experience that we can create effective solutions which help individuals and communities. It’s a goal I strive towards every day and I hope others reading this will do the same. For a much more in-depth discussion on how unconscious processes involved in learning and development (rather than genes or choice) drive addictive behaviors, see my article You’re Thinking about Addiction and Choice All  Wrong.

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Nick Jaworski is an internationally recognized executive in the field of behavioral health marketing and operational consulting, with experience building organizations world-wide. As the owner of Circle Social Inc., he has helped healthcare organizations perform turnarounds and accelerate growth. He and his team spend most of their days in and out of treatment programs across the country. They do extensive analysis of trends, observe programs, interview patients and families, and analyze data from marketing campaigns. Nick is an advisor to the board for The Behavioral Health Association of Providers, and is also on the board for one of the most innovative treatment programs in the country – Above and Beyond Recovery.

If you read my blog you know that I try to post smooth, polished pieces. I try to produce something coherent, even conclusive. This one’s different: a bunch of notes that I recently found in a forgotten file from five years ago. The notes pose questions that intrigue and trouble me as much now as they did back then. I don’t even remember writing this stuff. Probably much of it landed in previous posts and articles. But anyway, here are the questions. Still without clear answers.

I’ve annotated the text and filled in a few spots that would be completely incomprehensible otherwise. I’ve also added tips to more recent work and inserted several links. But the text I started with remains relevant, at least to me. Things don’t change very fast, and I think these are hard questions.

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My drug use began with psychedelics. Then came heroin. They’ve always seemed like diametrical opposites. This is where I get my intuitive feel for whether drugs are good or bad. Psychedelics open you up, heroin shuts you down. But I dropped acid roughly 300 times in my late teens and early twenties. I shot heroin about 30-40 times. Why do l assume that heroin is addictive and LSD is pure sunshine?

The one wedge nearly everyone agrees on is whether a drug is addictive or not. If only it were that simple. Is addictiveness really a feature of the drug? Or a feature of the person and the social surround (Rat Park)? When you take the addict as the unit of analysis, you place him in a cage, and then analyze his interaction with this or that drug. How stupid. How is it that scientists and doctors have become the priests of such stark distinctions?

The boiled-down argument re drugs and addiction: think about Percy Menzies [see his guest-post here] and the idea of chemical hooks (in Percy’s view, the only real cure for heroin addiction is OST, opiate substitution therapy, and he especially likes naltrexone: kill the good feeling and they’ll stop). [The idea of opiates as chemical hooks is also pitched in Dreamland, by Sam Quinones.] Then along comes Carl Hart (High Price) who says “addiction” is just a label used to badmouth drugs, and our only responsibility is to educate drug users. [In his new book, Drug Use for Grown-ups, Hart argues that all drugs, including heroin, can be taken recreationally, and  it’s repressive for governments to ban any drug for personal use by normal, sane adults.] And along comes Johann Hari (Chasing the Scream), who says that the opposite of addiction isn’t sobriety, it’s human connection. All very liberating. But what about addiction?

Addictive drugs: are they neurochemically distinct? Do addictive drugs mimic natural neuromodulation (opioids, dopamine, etc)….vs nonaddictive drugs (like LSD, psilocybin?) that effect perspective change? [But let me add this: last year I went to a neuroscience conference and learned that baby zebrafish will swim toward water laced with Vicodan, an opiate painkiller. I doubt they’d swim toward an LSD solution.] Mind-altering vs. mood-enhancing. Is that what decides? (Though SSRIs are mood-enhancing…and guess what, they’re addictive…sort of.) But behavioural addictions are just as serious, aren’t they? (Gambling addicts can destroy their lives as effectively as any crack-head) Can behaviour also be divided into mood-enhancing vs mind-altering? Probably not. Maybe there are just good and bad addictions…in life, love, and drugs. Oh, and in products. Where do we stop?

Why do we value control so much? Is control the wedge? Or is harm the crucial marker? Control vs harm and the history of antipsychotics…that increase control and kill the soul. Drugs that harm: don’t they require harm reduction? Or is it happiness, well-being, that’s key? Then why prescribe SSRIs when you could prescribe opiates for emotional pain? If you value control, then get this: drugs are a way to control our thoughts and feelings. Yet self-medication often leads to self-harm. How do we weigh the goodness of drugs when control, well-being, creativity, awareness and harm are all simultaneously changing variables?

Drugs and therapeutics…. Psilocybin vs. depression and anxiety. If that’s okay, why not prescribe opiates for those who crave them? The duplicity built into psychiatry: we want what’s best for you. Oh really?

Patches to move us from moralism to relativism:

Individual differences  — genetics are the simplest exemplar, but different life experiences matter hugely. Trauma leads to drug-use, not the reverse. Yet, the research shows that kids who never try drugs do worse than kids who do. How do we explain that?

Developmental differences  — the wrong drug at the wrong age might become the right drug at the right age.

Societal differences  — my undergrads at Nijmegen [a rural region of the Netherlands] still see addicts as a different species; in Amsterdam students don’t see it like that. Let’s send Mr Hazelden to an ayahuasca ceremony and see how/whether he evolves.

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A sort of summary:

Why would anyone put ayahuasca in the same category as heroin…isn’t there something intrinsically valuable about perspective change, for its own sake? And what’s the difference between methadone and SSRIs when it comes to allaying depression (yet one is for disgusting addicts and the other is for normal healthy people, like Aunt Mary). But I so disagree with Carl Hart when he says that when your teenage kid wants to try meth your only duty (and your only right) is to educate him/her about safety issues. Are the distinctions between good and bad drugs in the drugs themselves (as we often think reflexively) or in the relation between the drug and the user? We have to really get individual differences. And developmental differences. Binge drinking at 16, not so good…social drinking at age 28 can really help people connect. And what I learned from [my good friend and courageous colleague] Shaun Shelly: Isabel and I often reflect on his description of the unemployable/sidelined teens in Capetown smoking (not shooting) heroin…for social cohesion and a little pleasure. So, put it all together: look at the relationship between the person (of a certain age) and the drug, in the context of the social group and the society at large.

Coda: What makes drugs bad? Is there something simple and primitive like the idea of being too attracted?

Conclusion: I don’t know.

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A number of you posted very helpful comments about what you’d like to see in future posts. We’re working on it. Next, Eric Nada, a past contributor to the blog, will post a piece on psychedelic therapy for addiction. Given the above, I’m aware of possible ironies.

Point of clarification: I didn’t mean to imply that people who take opioids for reasons other than physical pain are to blame for the opioid “crisis” or the overdose epidemic. Let me retrace my steps.

I recently pasted and posted my article, published in The Guardian, arguing that opiates prescribed for people in pain are wrongfully blamed for the overdose epidemic. All true. But I also stipulated that the illicit use of pharmaceutical opioids was a link in the chain to opioid addiction and, in the current fentanylized environment, to the overdose epidemic.

So what does that say about us former and still active opioid “abusers” and addicts? I have a pretty good sense that most of my readership, like me, went down the path of pilfering …e.g, stealing, buying, faking, or otherwise getting pharmaceutical opioids that weren’t prescribed for our physical pain. We found those pills any way we could, because we needed them to soothe another kind of pain.

I thought, since sharing my article with you, that you might feel I’m pointing the finger of blame at “you addicts” who’ve found a loophole in the prescription opioid cycle, who’ve found a way to acquire pharmaceuticals “illicitly.”

No way. Having had two spinal surgeries in the last seven years, I’m definitely attuned to the pain relief issue. In fact, though my back’s been in quite good shape since the surgeries (praise be to physio, Tai Chi, and a great healthcare system here in the Netherlands), I had a horrific episode a couple of years ago. I was attending a conference in Geneva (focused on addiction, somewhat ironically) and my back went into gridlock spasm. The pain was so intense that I literally couldn’t move, couldn’t walk, couldn’t sit. Loud noises came out of my mouth that I seemed unable to control. I had people coming up to me while I stood rigid, paralyzed, in the middle of a busy hotel lobby between session, and carry or drag me to the nearest sofa (it was a pretty plush hotel). And even sitting, I could not unspasm; my body seemed like a lighting rod that would not stop zapping. People I didn’t know — strangers — found me a wheelchair, wheeled me to the elevator, got me down to the street level and called a taxi to take me to the hospital. And the next day, at a doctor’s office near my own hotel, I was howling so bad that the doctor and his assistants dragged me out of the waiting room because I was scaring the other patients. They then lifted me into a taxi — back to the hospital again. When all I really needed was a shot of morphine or a substantial dose of oxycodone. Getting high was the furthest thing from my mind.

So why couldn’t they provide that? Even at the hospital, I had to lie on a gurney intermittently screeching in pain for over an hour before the morphine came. People passing by had pity written all over their faces. Has the opioid scare infested Europe too? Not as much as the US, but yes, seemingly, to a degree.

So physical pain is one thing, and I have immense sympathy and empathy for those who experience it regularly. (For me, thankfully, this was a rare episode).

But I’ve also experienced the other kind of pain, the overwhelming darkness that invades your thoughts and feelings to such an extent that you are paralyzed in another way. You can’t think, or feel, or communicate, because it hurts so much just to exist. Opioids can provide enormous relief from that kind of pain as well. But of course no doctor will prescribe opioids for your depression, unless you’re getting methadone or Suboxone because you’re a “registered” addict, whatever that happens to mean in your corner of the world. Maybe just lining up at some seedy clinic, maybe being sneered at, maybe not being able to get a job, maybe having your license revoked…hell, in the Philippines it means being lined up and shot.

When we’re in that kind of pain, and if we’re pretty sure that opioids can help relieve it, we’re trapped. We can’t get an opioid prescription for emotional relief.  (Don’t get me started on “antidepressants” — SSRIs — which are so much less effective than hoped, which carry their own batch of side effects, and which require as much tapering as opioids to minimize withdrawal symptoms.) So we buy, borrow, steal, forge, or do whatever we have to do to acquire the medication that can bring us back to some semblance of normality, of peace.

I just want to clarify that I don’t see you, me, us addicts — former or “active” — as villains in this scenario. Yes, we do “divert” pain pills to deal with our (sometimes enormous) psychological vulnerabilities. But we only do that because our back is against the wall. Only because there’s no other choice.

That struggle was not the point of my article, and you (us) were not the audience I was targeting. But I am so with you, you don’t even know it. And if your diverted pharmaceuticals have led to (or replaced or complemented) heroin, which might have led to fentanyl, which might kill you, I see that as a shameful tragedy. But I don’t blame you. I blame the system that has vilified, isolated, and abandoned you. I don’t blame you. In fact, the risks you (we) face are so very grave, simply because we can’t (through normal channels) get the pharmaceuticals that can help us, we move to the front of the line of sufferers.

If I had to choose between battling emotional anguish and physical pain, I’d be hard pressed to decide which to try first.

There is no reason why either kind of pain should be left untreated in this age of pharmaceutical evolution. But I’m not going to be able to convince the head of the DEA, the governor of Maine, or Donald Trump that both kinds of pain qualify for care. I’m just starting with the most obvious.