WHERE DO WE GO FROM HERE?

WHERE DO WE GO FROM HERE?

There is an ongoing debate in the United States about the legalization or decriminalization of drugs by society. Several states have either passed laws or are considering laws that allow the use of marijuana for medical and possibly recreational purposes, but these laws are still controversial, and there is the additional problem that these state laws can be in conflict with federal laws. As a result, no one knows what the outcome will be even though it appears that federal officials are beginning to limit some prosecutions.

A number of prominent Americans—including the conservative Repub­lican senator Rand Paul—have concluded that the War on Drugs is leading to injustices. As this is being written, Senator Paul and Democratic senator Patrick Leahy want to change the law and have introduced the justice Safety Valve Act, which will allow judges more discretion in sentencing.

On the other side, many people believe that any effort to reduce the pressure on drug users and dealers will result in a flood of illegal sub­stances that, in their worst nightmares, will become readily available to children. Unfortunately, drugs are already readily available to anyone, including children, from all economic levels. So that nightmare is here right now.

To reduce demand, we need to increase education. As we have said elsewhere in this book, effective drug education is not just a matter of exhortations to refuse all drugs, because many individuals believe that the drugs they use are harmless. It is a matter of teaching the basic science that can help us appreciate what complex and delicate organisms our brains are, how body chemistry may vary from person to person, and how little we know about the many ways, both positive and negative, short-term and long-term, that the powerful chemicals we call "drugs" can affect us. Good education is expensive, but with it we will be healthier, and as a society, we will save the enormous costs of lost wages, law enforcement, and prisons that drugs have brought us.

PATTERNS OF USE: ARE YOU A JUNKIE?

PATTERNS OF USE: ARE YOU A JUNKIE?

Many people use opiates occasionally for the high. They take a pill, drink cough syrup, or inject heroin or fentanyl, for example. Some people develop a habitual pattern of daily use that accelerates over a period of time and then stabilizes at a certain level. These people take opiates every few hours. After the first week or two, they are tolerant to many of the effects of the drug; every time the drug wears off, withdrawal signs begin and the cycle of use starts again.

What pattern of use defines an addict? Can a person be addicted after the first dose? The answer for opiates isn't very different from the answers for all of the other drugs we discuss. It is not determined by whether a user injects drugs, or uses them only on weekends, or has never shared a needle, or has ever blacked out. The answer is that he's addicted when he has lost control of use: when he must continue to pursue whatever pattern of use he has set. For some, this loss of control might come from taking oxycodone pills or smoking heroin; for others, injecting or snorting her­oin; and for still others, even drinking codeine-containing cough syrup.

Is a person an addict if he goes through withdrawal? Or, conversely, if he doesn't go through withdrawal, is he not a junkie? This is a common rule that many people use. As we have said, an opiate user will go through withdrawal if he has been taking the drug regularly enough that his body has adapted to it. This is a clear indication of tolerance. Usually, such adaptation means he is in a regular use pattern, but a user can be addicted before he has taken the drug long enough to show strong withdrawal signs. Conversely, a pattern of use might be compulsive but low, and the withdrawal might be so mild it isn't noticeable. Withdrawal happens also in patients who take opioids as prescribed for pain if they take the drug for a period of days or weeks. This doesn't mean they are addicts—just that their bodies have adapted to the opioids.

The National Institute on Drug Abuse has accumulated statistics about "addiction careers," or the typical drug-use pattern of people who are addicted to opiates. Usually, use begins with occasional experimentation and then gradually accelerates over a period of months to continuous administration at intervals of four to six hours. The surprising part about opiate addiction careers is that they often end. Many opiate users follow this pattern for about ten to fifteen years and then quit, often without pro­longed treatment. The reasons are not entirely clear but probably include a host of social and physical factors.

HOW HALLUCINOGENS WORK

HOW HALLUCINOGENS WORK

Neuroscientists know less about stimulants than most other psychoac­tive medications. To some degree, this is on account of mental trips can be contemplated most accu­rately in people. Nobody would volunteer for the watchful mind injury contemplates that can figure out where basic medication impacts live, however imaging examinations in living people have demonstrated helpful. Also, we do have a considerable measure of data about the neurotransmitter frameworks required from examines in creatures. Since there are such a variety of stimulating medications, it will not shock anyone that there are a few diverse neurochemical courses to hal­lucinatory states and that each medication creates a to some degree particular state caused by an unmistakable component of activity. 

LSD, PSILOCIN, MESCALINE, AND DMT 

The doubt that medications like LSD have something to do with the neu­rotransmitter serotonin (5-HT) has been common since researchers initially depicted the similitude of the synthetic structures of LSD and psilocin to serotonin in the 1940s. It has been a long and convoluted street from this ini­tial doubt to an atomic comprehension of what these medications do. Sero­ton in is an essential neurotransmitter that manages rest, tweak eating conduct, keep up a typical body temperature and hormonal state, and maybe restrain powerlessness to seizures. Medications that improve the greater part of the activities of serotonin are valuable for treating sadness and sup­pressing gorging. How, at that point, can drugs that influence serotonin deliver such odd consequences for observation without disturbing a number of these different activities of serotonin? 

Some portion of the trouble in understanding drugs originated from utilizing LSD as a test psychedelic drug. The greater part of the early test frameworks included organs other than the cerebrum. For instance, serotonin can make the core of a mollusk beat quicker, so these hearts were an early most loved test framework. Researchers would hang the shellfish heart from a wire joined to a pen that would move if the heart muscle contracted. At the point when serotonin was trickled on the heart, it contracted. LSD kept the impacts of serotonin on shellfish hearts and other test frameworks, and for a considerable length of time it was felt that drugs acted by keeping the activities of serotonin. At the point when more advanced trial of serotonin activity in the cerebrum ended up plainly accessible, they appeared to help this thought. Researchers measuring the rate at which serotonin neurons were terminating demonstrated that LSD restrained their terminating. Notwithstanding, this didn't bode well, since closing down the serotonin neurons so significantly ought to have influenced the greater part of alternate procedures that depend on serotonin, however I,SD did not deliver such impacts. Besides, mescaline did not have an indistinguishable impact from LSD in these sorts of investigations, but since the structure of mescaline, not at all like alternate medications, did not look like sero­tonin, researchers were ready to expect that mescaline was working in some extraordinary way. The response to the subject of what psychedelic drugs need to do with sero­tonin needed to sit tight for researchers to find that the neurotransmitter sero­tonin follows up on various distinctive receptors. No less than thirteen sorts of serotonin receptors are currently perceived, and we realize that some appear to have particular impacts on conduct. Just a single of these (as we officially depicted) can trigger mind flights. The thirteen receptors can be gathered into huge classes (1-7), which themselves are subdivided. For all intents and purposes all serotonin-like drugs are agonists (they empower) at two sub­types of the 5-HT2 receptors (5-1-IT2a and 5-HT2c). Analysts feel that the psychedelic action comes about because of the incitement of 5-HT2a. Up until this point, each trial medicate tried that empowers the serotonin-2a receptors causes mental trips. We don't know how this happens, yet we are almost certain that animating these receptors can do it. The greater part of these receptors are in the cerebral cortex, where we think drugs have 

their real activity. 

One puzzle that remaining parts about serotonin drugs is the reason the antidepres­sant drugs that expansion the measure of serotonin in the neural connection (see the "Cerebrum Basics" section) don't for the most part cause mental trips. These medications increment serotonin wherever in the mind, including destinations that have 5-HT2a receptors, yet in spite of the fact that an uncommon patient taking one of these medications encounters mental trips, when the 5-HT2a receptors are animated in adjust with the greater part of the other serotonin frameworks, there are for the most part no 

stimulating impacts.

ADMINISTRATIVE SUPPORT

ADMINISTRATIVE SUPPORT

By now it is probably apparent that the activities described herein require substantial administrative support from the treatment facility. Many of the points below are enlarged upon in Chapter 16.

Principle 20.. The treatment agency. must have flexible policies to allow therapist flexibility. The most obvious example of this principle concerns therapists' working hours. Families, especially those with low incomes and/or multiple problems, cannot always get time off to engage in treatment during the 9 to 5 workday. In addition, the working member(s) are sometimes on an evening or night shift, further complicating the scheduling problem. Berg and Rosenblum' ' found that the "work schedule- was the most frequently given reason for the father's failure to become engaged in treatment. These authors also obtained a positive correlation between the per-centage of families successfully engaged and the lateness of the hour the therapist was able to see them. They state, -Family therapists must be more flexible in the hours that they see a family and the agency for which they work must accommodate this flexibility-(p. 91). We feel this is even more crucial for the recruitment effort. When trying to engage a family, there is even greater need to meet them on their turf, and be able to contact them when they are available, usually at night. Consequently, the agency must not only allow, but must encourage late, long, and irregular hours if family enlistment is a goal.

There are other ways in which the agency can be flexible. For instance, simply allowing therapists easy access to the telephone can be important, since this is such a crucial instrument in the recruit-ment effort. Regular consultation time from supervisors can be help-ful, especially when a therapist has reached an impasse or is trying to figure out ways of obtaining leverage with a family. As before, permitting staff to function in the dual role of therapist-drug coun-selor may also be pivotal. Finally, flexibility in the kind of services offered, such as job counseling, may be necessary to allow the thera-pist to make commitments to the family during the goal-tailoring process.

Principle 21: The treatment agency must be willing to back up the recruitment effort through commitment of tangible resources.

While related to Principle 20, this goes beyond flexibility, per se, and refers to the allocation of real monies and related resources for recruitment. It is not enough to tell a therapist to -do your thing," since his time also costs the agency money. The therapist must be given clear indication of the importance attached to recruiting, so that he is not, for example, penalized on his caseload quota while trying to engage a particularly resistant family. Nighttime hours must also be rewarded. A possible way of handling this is to count recruiting time as patient contact time, and unsuccessful attempts to reach family members as -treatment backup- time. Another option is to credit evening hours as compensatory time. In addition, coverage of travel expenses for home visits may be necessary. Other areas for commit-ment of agency resources have been mentioned earlier, such as the provision of incentives for successfully' recruited cases, the use of

beepers during the engagement process, and payment to families for

parking expenses.

DISCUSSION

EFFECTIVENESS OF ENGAGEMENT

It is beyond the scope of this chapter to give data on the success of each of the recruiting principles. Only overall results will be pre-sented. It is worth noting that Black families were more difficult to recruit, and that the recruitment effort—including those successfully and unsuccessfully engaged—required a median of 5.4 direct contacts (telephone or face-to-face) over a median of 20.5 days. A more detailed analysis of the factors leading to successful recruitment, and the cost-effectiveness of our efforts, has been published elsewhere.'69

For the present purposes, the term -engager- will be used to denote those families who participated in the initial Family Evalu-ation Session. The term -refuser- will refer to families in which one or more family members refused to participate in such a session. Out of a total sample of 92 eligible families, we were able to recruit 71% (i.e., there were 65 engagers and 27 refusers). An important variable was whether the IP gave us permission to contact his family directly (Principle 4). As noted in Chapter 3, in the 74 cases where such permission was granted, 88% of the families were successfully en-gaged. Put another way, two-thirds of our failures occurred when we could not get past the IP. The reasons why we think this occurred have been presented earlier in this chapter. Sager et at 26 experienced similar difficulty with single persons, and recommended spending -a great deal of time working through individual problems with the identified patient so that he does not experience family therapy as an attempt to return him to his original difficult family situation-(p. 720). These authors also noted that patients who had difficulty accepting the importance of their families in their problem were also more likely to drop out of treatment prematurely.

The dual role of having therapists also serve as drug counselors deserves special mention. Before this procedure was implemented our recruitment success rate was 56%. Afterward the rate rose to 77%. Under the dual role, therapists required fewer contacts (mean of 6.4 vs. 7.2), a shorter period of time (median of 17 days vs. 33 days),* and fewer home visits (11% vs. 48% ) in order to get families into treatment. More important, our datai69 document that recruiting families under the dual role was more than twice aS cost-efficient than when both a therapist and drug counselor were involved in the recruitment process.

The rate of success with which these families were engaged in treatment is considerably higher than other reports in the literature with similar clients. This is especially true considering (1) the clients' predominantly lower socioeconomic status,[26- 1" (2) the severity of their addictive problems, and (3) the fact that, unlike nearly all of the earlier studies, we considered a case to be successfully recruited only if both parents or parent surrogates appeared together at the treatment site; most other studies satisfied themselves with one parent or a spouse. These results, then, offer general support for the aforemen-tioned principles, as well as for the effectiveness of the major effort applied to recruitment.

CUCUMBERS AND PICKLES: CHANGES IN THE BRAIN

CUCUMBERS AND PICKLES: CHANGES IN THE BRAIN

So what changes between the fifth time that you get your muffin and the time that you waited at the bakery door until opening time each day, neglecting your job or forgetting to take your children to school? You do this even if the muffin tastes lousy. It is this sort of compulsive, repetitive involvement in drug taking despite negative consequences that most experts view as addiction.

Use of addictive drugs can be viewed in a similar way. Many people drink alcohol occasionally, or even sometimes use cocaine at parties. However, for some people, the first social experiences with drugs gradu­ally evolve into more continual use. Alcohol use provides an example. While 50 percent of the adult population of the United States drink alco­hol occasionally, of these about 10 percent drink heavily and about 5 per­cent engage in addictive patterns of drinking.

Clearly, something happens in addicts that makes the need to consume drugs so great that they will go to extreme lengths to obtain the drug. What changes in the brain explain this? We have heard recovered addicts compare the change in their behavior and lives to the change from a cucumber to a pickle. Once a cucumber is turned into a pickle, it cannot

be turned back. Is this a real analogy? If so, then the Alcoholics Anony‑ mous approach of lifetime abstinence from drugs becomes a convincing solution to alcoholism.

Most scientists think that changes gradually occur in the reward circuit of the brain as it adapts to the continuous presence of the drug. However, we don't completely understand exactly which changes are the most important for addiction. The simplest change is easy to understand: with daily stimulation by addictive drugs, the reward system comes to "expect" this artificial stimulus. When people stop using drugs abruptly, the reward system is shut down—it has adapted to the daily "expectation" of drugs to maintain its function. We know of one biochemical change in the brains of all addicts that may explain this result. The brains of alcoholics, meth-amphetamine addicts, heroin addicts, and even compulsive eaters show a common biochemistry—they have low levels of one of the receptors that normally receive dopamine. This makes sense—in response to a constant barrage of dopamine, the cell that receives it is just trying to shut down. Recovering heroin addicts often report that every time they inject heroin, they are trying to recapture the feeling of their early experience with the drug, which gave a pleasure that they never quite reached again. People who are in a stimulant "binge," taking hits every few hours, can have the same experience. They respond by "chasing the high," taking the drug every hour or so to recapture the first rush. Only when they stop taking the drug for a while does their initial sensitivity return.

Some recovering cocaine addicts say that they do not feel pleasure in any­thing for a while after they stop using cocaine. Imagine how difficult it must be to stop using a drug that gives incredible pleasure, when even things that are usually enjoyable give no pleasure during withdrawal. This inability to feel pleasure may be one of the powerful reasons why people have great diffi­culty giving up cocaine. If there is a substance at an addict's fingertips that can make him feel better immediately, clearly the impulse to take it can

become overwhelming.

Some of the changes in the brain of a person who uses addictive drugs repeatedly are just a result of normal learning in the brain. Let's go back to our bakery one more time. As our imaginary muffin addict approaches the store each day, he remembers the route and looks forward to the smell of newly baked muffins wafting down the street. Pretty soon, the smell of the bakery alone can cause an intense longing for the pastries before he gets there. What happens when our muffin addict decides that the daily search for muffins is taking too long, or when the bakery raises prices so much that he won't pay? If he goes "cold turkey" and quits muffins alto­gether, he had better find another way to go to work, because he will find that the route to the bakery, the smell of the muffins, and many of the experiences associated with going to the bakery will cause an intense longing for a muffin. This type of longing has ruined many a diet, and this type of learning plays an important role in addiction as well. Simply showing a former cocaine user a photograph of a crack pipe will trigger a strong craving for the drug, and recent studies of brain activity show that areas of the brain involved in memory are activated while he looks at these pictures.

There is another kind of "learning" that happens in the brains of addicts that makes it hard for them to stop using drugs. This is the part of the brain that plans for the future. Under normal circumstances, if an animal or person finds a reinforcer, her brain remembers where and how it happened and plans to check back the next time she needs food or sex. This ability to plan for the future is perhaps the most sophisticated thing our brain does. However, in a crack user, what this part of the brain focuses on is finding crack—the repeated stimulation with this one rein­forcer can also "hijack" these planning centers in the same way. So it isn't simply the pleasure the drugs cause that motivates drug use but our abil­ity to remember and plan for future pleasure. This may be one of the most long-lasting changes that happen in the brain.

New research shows that there is a final step in addiction: when taking the drug becomes as automatic as tying your shoes. Scientists have shown that another part of the dopamine system that is important for the transi­tion of this learning to something automatic gradually changes, too, but more slowly. Eventually, hitting the bar to get an injection of drug becomes a habit. This behavior has become an automatic and controlling part of your behavior.