they activate the autonomic nervous system. The autonomic system is the part of the peripheral nervous system responsible for regulating involuntary body functions such as blood flow, heartbeat, digestion, and breathing. This system is further divided into two branches: the sympathetic division regulates the fight-or-flight response, while the parasympathetic division helps maintain normal body functions and conserves physical resources. So the autonomic nervous system governs functions like your heart rate, pulse, temperature, and blood pressure (the so-called vital signs). Substance withdrawal causes an autonomic nervous system disturbance, which results in physical shaking, elevated blood pressure, and elevated temperatures and can be very, very serious. It causes activation of the thalamus (a structure in the limbic system that connects areas of the cerebral cortex that are involved in sensory perception and movement with other parts of the brain), the locus coeruleus (LC), and the frontal cortex (FC).
Returning to the subject of neurotransmitters and brain structures, let’s look at the example of an Asian-American male, age twenty-three. He started using tobacco at age thirteen and cannabis at age fifteen. This is not unusual. He didn’t like alcohol because it caused facial flushing (redness of the face). Asian people often lack aldehyde dehydrogenase, one of the enzymes that break down alcohol, and they get especially unpleasant side effects from drinking. On weekends he started snorting heroin, gradually progressing to using it three nights a week. Subsequently, he added crack cocaine to his using regimen, which caused rapid deterioration in a number of areas in his life. This is not an atypical progression for an addicted person.
He began to engage in low-level drug dealing to help support his addiction. Increased availability led to escalating use, and he began injecting opiates and cocaine. He was then admitted for treatment. From the standpoint of the neurotransmitters, the available supply of dopamine has been depleted from the repetitive use of stimulants. The patient had become irritable and depressed, anergic (lacking energy), and anhedonic (unable to experience pleasure), because his dopamine was so depleted. Basically, he ran out of gas and was operating on empty. The patient’s increased impulsivity, and, to an extent, his depression, were manifestations of the depletion of serotonin.
Moreover, his use of opiates resulted in his brain putting a hold on its production of endorphins (the body’s naturally occurring pain-relieving chemicals). Depleted endorphins cause poor sleep, anhedonia, and decreased pain tolerance. With a minor pain, a normal person may take a Tylenol or a Motrin. In contrast, a person addicted to opiates/opioids may end up at urgent care or in the emergency room pleading for Vicodin. This can certainly be a form of drug-seeking, but it also reflects a phenomenon known as opioid-induced hyperalgesia. When you’re on opiates for a long time it changes your perception of pain. You actually become more sensitive to pain rather than less sensitive. For people who are on opiates/opioids, including prescription pain medications, for a long time, even little things hurt like crazy. Thus the twenty-three-year-old male patient’s addiction can be traced to the action of neurotransmitters interacting with certain structures in his midbrain—the biological underpinnings of addiction.
Certain drugs are used for specific effects in particular circumstances. For instance, a lot of serious substance abusers and practicing addicts drink alcohol, smoke pot, and take benzodiazepines or opiates to bring them down from stimulants, from the “speed rush” or the “cocaine high.” Brain chemistry also appears to play a role in what types of mind- and mood-altering substances people prefer, insofar as certain groups of people seem to gravitate toward certain classes of drugs. In my experience, depressed patients seem to be attracted to depressants, including alcohol. Many patients with bipolar disorder seem to love stimulants.
Patients with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) often seem to like stimulants, too. And the curious thing about stimulants is that when “normal” people ingest them, they get stimulated, but for people with ADHD who take stimulants, the effects are paradoxical—stimulants seem to calm them down. Addiction treatment professionals sometimes hear patients say, “Whenever I did coke or meth it made me feel more normal. It leveled me out.” Sometimes the use of stimulants is a form of self-medication for ADD/ADHD.
The neurochemistry of these individuals is different from that of other people. This is why psychostimulant medications such as Ritalin and Adderall are prescribed for kids with ADHD. Now, ADHD is overdiagnosed and these medications overprescribed, but there are many kids with ADHD who have great difficulty sitting still in a classroom without Ritalin or Adderall. Paradoxically, these stimulants calm them down and help them concentrate.
People with psychotic disorders frequently use a tremendous amount of nicotine and pot. If you’ve ever worked in a psychiatric hospital or with people who struggle with psychotic disorders like schizophrenia, you’ve observed how many cigarettes they tend to smoke. Somehow, this fits with their brain chemistry, and the action of smoking and the effects of nicotine and marijuana are subjectively soothing to them. By the way, intoxication can be confused with psychiatric conditions. When somebody comes in to the emergency room wired and manic from using large quantities of meth or cocaine, even an experienced psychiatrist cannot distinguish that drug-induced state from a psychiatrically-based manic decompensation.
However, the average person with an addiction problem who goes to a treatment facility will receive treatment primarily from addiction counselors unless he or she is in a state of acute intoxication, requires medically supervised detoxification, or has a co-occurring psychiatric condition that requires medication. It’s important for addiction therapists to understand that they are going to treat the vast majority of addicted persons, whereas physicians will be involved in the treatment of a relative minority of them—though there will likely be some gradual shifts as more pharmacological options become part of the addiction treatment continuum.
As I’ll cover in detail in later chapters, there are an increasing number of approved medications being made available for use in addiction treatment and there are many more in the research and development pipeline. The development of these medications is an exciting innovation of which addiction counselors need to be aware. Although addiction counselors can’t prescribe these medications, they nonetheless have a responsibility to let clients know that these medications are available and have the potential to be beneficial. Addiction treatment can take a variety of forms, and there are many paths to recovery. Irrespective of one’s personal position on the issue of medication-assisted addiction treatment and medication-assisted recovery, withholding this kind of cutting-edge information is a form of malfeasance on the part of therapists. It’s as if a patient were to see a therapist for depression and the therapist treats the patient month after month through psychotherapy, without ever informing the patient that there are antidepressant medications that might also help. It’s unethical for addiction therapists not to let clients know what all of their options are.
Medication is certainly not always necessary, but sometimes it can make the difference between someone improving or not. I once saw a patient who went to a therapist for many years for treatment for her depression. The patient’s depression became progressively worse until she became practically vegetative. She was extremely lethargic, to the point that she wouldn’t move. She had to be psychiatrically hospitalized, at which point we did some basic blood tests and found that she had severe hypothyroidism, a condition characterized by abnormally low thyroid hormone production. We prescribed her thyroid supplements and within a few days she was significantly improved. She would not have gotten better no matter how many years of psychotherapy she underwent. It’s not that the therapist in this case was “bad,” but she didn’t have a comprehensive-enough knowledge base and didn’t think in terms of potential physiological explanations for the patient’s distress and the possible need for medical care.
One question that arises often is, is it fair to tell patients about medications that they can’t get due to lack of insurance coverage? Therapists have a responsibility to let their clients know that these resources exist. Hopefully, with the implementation of the Affordable Care Act in the United States, more people will have access to more and better insurance coverage and the care it pays for. Ideally, in
