What’s Wrong with Zero Tolerance
Addressing addiction from the public health perspective. 10th in a series.
by Kim Hancey Duffy
This is Part II of an interview with Kevin McCauley, M.D., on understanding drug and alcohol addiction as a disease. Part I (December 2007) can be read at catalystmagazine.net
You've said that anxiety and depression can play a role in a person becoming addicted. But once the person is in the throes of addiction, what part does stress play then?
Stress causes relapse. Without good stress coping tools, the person will continue to relapse. Most of the research right now is focused on the stress caused by the drugs and the elevated stress hormones caused by drug use which change the dopamine system (the pleasure system) in the brain. But many addiction experts think that if that stress can be there with drug use, why can't it be there before drug use? We're learning so much about when people are traumatized, or what happens to the fetus when mothers are traumatized during pregnancy. We're learning a lot from people coming back from Iraq and the cohort of 9/11 first responders in New York City. Stress matters, and it changes the brain. Severe and chronic stress breaks the brain. And that's what addiction is. So an absolutely critical part of managing addiction is (a) getting the drugs out of the picture because they perpetuate this problem in the dopamine system and (b) getting the addict to create a bag of coping tricks. When they develop stress coping tools, the relapses start to peter out.
What happens in the brain during craving?
This is an area of intense study, which I'm simply translating; I'm not doing this research. New neuroimaging techniques, like functional magnetic resonance imagining (fMRI), actually produce a kind of movie of the brain's activity, seen in real time. In addicts' brains, during craving states, the midbrain lights up like a Christmas tree – far more than the average person who is just hungry. These are intensely active areas in the brain. But what's interesting during this, is that area in the frontal cortex – specifically the area which is necessary for assessing consequences – drops out. So not only do you get this activity in the survival midbrain, but you get this selective dropping out of very key areas in the judgment parts of the brain.
Why does that happen – does it just get elbowed out of the way by the limbic system?
I can speculate. When you look at it from an evolutionary psychology perspective, at this point the midbrain must do whatever it can. It thinks that this stress is an actual threat to existence. This is not about partying, it's about getting through the next 15 minutes alive, and it's on the unconscious level, too-a very old part of the brain. The frontal cortex is standing in the midbrain's way of getting what it needs, which is the drug. The midbrain has to secure survival and, as far as it's concerned, the frontal cortex (which is the person's morals, values, the things they find meaningful, their spiritual life) is a liability. So it shuts it off. That's a very scary state of being. And there's no doubt about it, the person in that craving state will mobilize whatever they need to get drugs – at great social cost, with criminal activity involved. But the real requirement for proving guilt in court is something called mens rea [guilty mind], which you have to prove to get a conviction. Well, what's interesting about these scans is that they show the areas that form intent are not on. That person is doing terrible things and should be dealt with, but they don't have the same level of intent as someone who actually planned out how they were going to come to your house and steal your tv.
Isn't that kind of like the "Twinkie defense"?
It's more sophisticated than the Twinkie defense, because that was sort of a legal trick. This actually has some science behind it. That's why a lot of people find it scary, because they fear it's going to be used to get off. It doesn't necessarily have to go that way. What this science gives us is a much deeper understanding of what happens when we make a choice. When we scan this person's brain – and we are coming to this point – we can see that they're just not at the same level of consciousness as a sociopathic criminal is.
Or a non-addicted person.
Right. That doesn't get them off; it diverts them into drug court. It says that this defendant has committed a crime, but rather than throwing them into prison, which will just make the problem worse, we can send them to treatment.
What has to happen to reduce the link between cravings and relapse? Cognitive behavior therapy?
Yes, that works. For instance one could say, "I'm having a craving now, but it doesn't mean I have to act on it." That's a major statement. Other things like being around people who no longer drink or use drugs. For young people, sometimes just changing their peer group helps them get sober. Get them in young person's Alcoholics Anonymous (AA), or send them to a therapeutic boarding school. What it takes is practicing this over and over again, so the person finally realizes, "Yes, I'm having a craving but there are things I can do about it. I can go to a meeting, call another alcoholic, or take this new medication that my doctor gave me to take the edge off." It's not one thing, but a bag of tricks. When the person gets practiced at this, they might get terrible cravings but not automatically cascade into relapse.
And if they do relapse, you don't punish them, but encourage them to brush themselves off and start over again?
Yes, but you want to find out what caused the relapse. Are they hanging around drug users? Are they still getting drug tested? A mechanism should go into place the minute that positive drug test comes in to get that person back on the horse and supervised. This is what we do with a diabetic. If I diagnose a diabetic and give them the tools, show them the insulin, and send them to the diabetic nurse to learn how to use it – then six months later they go into diabetic coma, I don't just say, "Try harder!" I find out what isn't working. That's the scrutiny diabetics get. If we were to give that same treatment to addicts, the problem could be taken care of.
Don't a lot of patients with diabetes and high blood pressure fall off their regimen?
Sure, and if you want to see truly revolting symptoms, spend a little time around a diabetic foot. This is medicine. Symptoms are not pleasant; patients are not at their best when they're sick. But we don't punish or categorize them based on whether they have pleasant symptoms or not. The person doesn't have a "diabetic personality." And if the patient says they're not going to follow the regimen, we don't just throw up our hands and say, "Oh well, that's the end of it." We work with them, and it's in the quality of the interaction that they eventually come around and realize they need to manage their disease.
We talked about 12-step meetings in the last interview. I have another question about their method. In the AA community, when an alcoholic relapses, they are warmly welcomed back with no judgment or stigma. What does that accomplish, and what if this were practiced in the public sphere?
What it does is maintain contact with the person at all costs. It would be nice if teenagers didn't have sex, but they do. So what are we going to do about it? A major tenet of public health is get the person to some kind of care. You may not be able to change their behavior right away, but you might be able to teach them one thing to lower their pregnancy or STD rate. At all costs, make sure it's easy for the patient to come into the clinic. The opposite tactic is zero tolerance. It would be nice if 767 captains didn't binge drink to the point of blacking out, but some do. If you want to have a zero tolerance program, fine, but unfortunately that makes things worse because the pilot who needs help isn't going to come in. However, if you create a policy that says, we know this happens, we don't like it. But please, come to us. We won't fire you, we'll get you treatment, we'll keep you with your job, your family, and the things that are meaningful.
So when a community says, "Keep coming back," and a person can come in and say, "I drank last night," and everyone remembers when that happened to them, so they say, "We know what that's like. Keep coming back" – then that person is much more likely to stay engaged.
My mom, who is an obstetrician, gave me this example: Suppose there's a 14-year-old woman/girl in the next room, dilated and ready to deliver a baby, and screaming her lungs out because she's scared. What are we going to do? Go in and say, "You shouldn't have gotten pregnant. What's the matter with you?" No, we go in there and help her, put our moral judgments aside for the time being to fix the problem at hand. That's the challenge we face – are we going to take the law enforcement approach, which is necessary for burglary or assault, or do we want to fix this problem? I think the public health attitude is more suited to addiction. It's a risk management mentality which is very different from the political angles like "Tough on Crime" or "Zero Tolerance." I understand that we don't want to give people mixed messages. But it doesn't work. I wish it did, but it doesn't. It makes things worse.
Dr. McCauley's website is addictiondoctor.com. Kim Hancey Duffy is a freelance writer in Salt Lake City, and is also a member of Salt Lake City Mayor's Coalition on Alcohol, Tobacco and Other Drugs: slcpreventioncoalition.org.