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Addiction (transcript)
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(Peter) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, but you'll be able to better take charge of your own health care. I'm your host Dr. Peter Salgo and you've already met our special guests who are joining our cast of regulars; Primary Care Physician Dr. Lisa Harris and Communications Expert Kathy Cole Kelly. Now no one on this team has ever seen the case except me so let's get right to work. I can tell you a little bit about it. We have an interesting case today which concerns Diane. Diane is a forty-seven year old Nurse Practitioner. She's been seeing the same Primary Care Physician Lisa for many, many years. She's in the Primary Care Physician's office today asking for an early refill of her Fiorinal. What's Fiorinal?

(Lisa) 
Fiorinal is a narcotic; a weak narcotic at that and she's asking for an early refill so that sends up a little red flag for what's going on. There's something else going on.

(Peter) 
Well I can tell you because she says that she's been using Fiorinal. Sometimes Fiorinal with Codeine for sixteen years and she's been using on average two hundred tablets a month and she's been going up recently from there. She says that she's been under a lot of stress. She was given these pills for headaches. She says you know if I get my headaches I can't work. Any concerns here?

(Dr. Lisa Harris) 
First that she's asking for an early refill, second that she's self medicating with a narcotic for a condition that she shouldn't be utilizing that medication for.

(Peter) 
What do you mean by that?

(Lisa) 
What I mean is that Fiorinal is not indicated for headaches. Migraine is something that I do quite a bit of in my office and a weak narcotic such as Fiorinal which can cause specifically a lot of addiction and abuse shouldn't be used for migraine headaches.

(Peter) 
Does anybody else catch another red flag that I think I? Go ahead.

(Kathy Cole Kelly) 
She says that she has a lot of stress going on in her life and that would be the other thing that I'd hope the Primary Care Physician as I'm sure Lisa does would be to refer her for psychological help to see someone else.

(Peter) 
I guess the other red flag is that she was using it for stress, not for headaches.

(Lisa) 
Exactly right.
(Gloria) 
I want to know though, is she going only to Lisa or to other Primary Care Physician's doctor shopping?

(Lisa) 
Right, exactly. She probably would have to. I can't imagine that she would get two hundred pills a month from one doctor, so she might be going to the Emergency Room or calling an on call service at night or someplace like that.

(Peter) 
Let's put this cap on the table over here. You think she's got a drug problem; a dependency problem. Is that what I'm hearing?

(Lisa) 
That's one of the things I think is going on.

(Peter) 
But she doesn't look like a drug addict right? She used middle class; she's got a steady job.

(Lisa)
What does a drug addict look like?

(Peter) 
She's functioning; now Bill you look not like a drug addict to me but you've got a story for us.

(William Moyers) 
I'm a recovering alcoholic and was actually was very good at manipulating my Primary Care Physician, my Psychiatrist, and all the other people who knew more than I did except when it came to the issue that I was battling which was a dependency on those substances.

(Peter) 
It was Cocaine? Were you using Crack?

(William) 
Cocaine, Crack, alcohol, Valium; whatever it was that would take me out of my reality and put me into a position where I didn't have to feel.

(Peter) 
You do not look like the Crack house habitant; the person that we see on the evening news, the person doing the perp walk being lead into the police station.

(William)
Well I've been clean and sober for thirteen years Peter. I look a lot better now; at least I hope I do more than I used to.

[Laughing]

(William) 
But there was a time when I was homeless, I couldn't work, I lived in the streets of Harlem, New York. I was a liar, I was a cheat; I was all those things that happen to somebody who becomes addicted to alcohol and other drugs.

(Dr. Gloria Baciewski) 
Well this may have occurred to Bill that he was homeless and a liar and a cheat and so forth, but clearly this patient is functional. She is a Nurse Practitioner, employed and many, many people are functional when they are using drugs.

(Peter) 
We've been throwing a word around here we haven't defined. What's an addict?

(Anna Rose Childress)  
Someone for whom the pursuit of the drug has really begun to consume many areas of their life right so that's it's using the drug, the affects of the drug itself, getting over the withdrawal affects of the drug, taking up a lot of time and energy so that their normal ability to work, love and play is really impacted.

(Glenn McGee)  
It's not just the perp walk that people used to talk about with addiction but now when we talk about addiction we mean a loss of self awareness. Picking that up I think is very, very difficult, especially when it comes to the primary care.

(Peter) 
Let me parse this out if I can once more. There are plenty of people who need drugs and I'm using drugs in the global sense whether it's Dilantin or its Insulin; they're dependent upon drugs. What's the difference between dependent and addicted? I think we really need to nail that.
 
(Anna)  
Well one way of thinking about it is that you know physical dependence just means that your body will really notice if you stop your Insulin right and so that there will be a reaction in your body because in fact your body has depended on this drug for functioning, but addiction really has a behavioral definition. It means that you're using this drug on which you may have a physical dependence to the extent that it's really beginning to interfere with really critical functions in your life. I think an old way of thinking about addiction is that you had to have a really colorful withdrawal syndrome when you stopped the drug and that was a drug that you really had to watch out for.

(Glenn McGee)  
The notion that withdrawal really defined addiction is so, so important because today we don't just talk about addictions to medications, we talk about addictions to sex, we talk about addictions of a variety of kinds; work, we use that word to talk about our whole lives so it's very, very difficult now to parse that.

(Peter) 
How big a problem is this in the United States globally?

(William) 
Well the Federal government estimates that there are roughly twenty-two million people in this country right now who struggle with addiction to alcohol and other drugs so it's just a terrible problem. I think roughly one in ten Americans.

(Peter) 
That's thirty, forty-five million people if your numbers are in the ballpark.

(Dr. Lisa Harris) 
It's very interesting you know I'll see patients that come to the office and they'll have Hypertension for example and they don't want to take an anti Hypertensive because they don't want to become addicted to that but they may be abusing alcohol or marijuana and I sit there totally dumbfounded and say okay but you're using, you smoke two blunts a day and you're drinking you know a couple of pints a day and that's not a problem but with this Hypertension you don't want to take a medication that's going to help you.

(Peter) 
But that brings us to this whole perception issue right? Which is the American Medical Association has defined addiction as a disease. There's a real problem with addiction being a disease as opposed to a failing, a weakness.

(Anna)  
There's a disorder and in the grips of this disorder people do things that they wouldn't normally do that other people really disapprove of that can be hurtful or harmful. People don't look necessarily at drug use as just a manifestation of a disorder and try to understand it as that. They think this is a willful misconduct, this is bad behavior.

(Kathy Cole Kelly) 
It's so hard for families because families continue to see it as purely behavioral and not as a disease and I think families can then say you're making a choice and can't understand the depth of the addiction.

(Peter) 
If it's a disease of the brain, convince me, what's the science here?

(Anna)  
Well one way of thinking about this is that you know that there is a big genetic component. When we look at twin's studies we can see that the hereditability for the bone ability addiction is somewhere in the fifty to eighty percentage.

(Peter) 
When you say Twin Studies, let's make that clear.

(Anna)  
Twin Studies meaning that if you have a twin who is your identical twin, you're likelihood of having an addiction if your twin has one is higher than if you have a twin who is just your fraternal twin. That tells you that genetics are playing a significant role.

(William Moyers) 
And I'm glad that my colleagues here can explain it from a scientific or the medical perspective. I can talk about addiction without question being a disease because who aspires to grow up to be an addict and an alcoholic? I certainly didn't do it. I innocently experimented with Marijuana when I was sixteen growing up in the quiet suburbs of Long Island, New York. Never could I have imagined that my innocent use of Marijuana at sixteen or the legal use of alcohol at eighteen would lead me down this path that would lead me lying on my back in a Crack house in Harlem, New York in 1989.

(Peter) 
What does a brain on a scan look like under the influence of these drugs? Can you spot an addict if you scan their brains?

(Anna Rose Childress)  
One thing that we can see is that when you take pictures while people are looking at things that remind them of their preferred drug.

(Peter) 
You mean scanned pictures, you don't mean, you don't mean a little bitty photograph.

(Anna)  
I'm talking about for example an active brain, a functional MRI scan. You can see that the circuits that have to do with really basic rewards like food and sex are very activated by these cues. It's our primitive and very important go system. It's the system that keeps us going as a species right? It gives us a reason to pursue reproductive opportunities, good chocolate. This system is activated by drugs of abuse but in a hugely powerful way.

(Peter) 
Let's stop for just a minute. We've covered a lot of ground. Let's sum up where we are before we continue. Addiction affects millions of Americans. It's not simply a failure of will or character. It is a disease of the brain. So let's go further. Let me tell you a little bit more about Diane. The doctor does a physical exam, her blood pressure is one twenty over seventy, her other vital signs are normal. Her other complaints are chronic heartburn, poor sleep, poor appetite, she's down to one hundred twenty-two pounds and she's five foot nine. She blames all of this on the stress in her life and she says again, Fiorinal helps me cope with those symptoms. So let me throw the question out, is Diane an addict?

(Lisa) 
Yes.

(Peter) 
A simple yes. Do you want to vote on this? Does anybody disagree?

(Lisa) 
Yes she is.

(Peter) 
Are you as definitively yes as she is?

(Anna) 
Well I'd want to talk more right? I'd want to ask a person more questions.

(Gloria) 
I think we haven't proven yet that the patient is an addict because we don't have a full chemical dependency history.

(Peter) 
Is she pre-wired? If she's an addict and I understood the science, is she pre-wired to just spring for drugs? Are all addicts pre-wired? Are they all; is there some internal architect in their brain that says yes I need these drugs?

(Anna)  
Probably.  One of the things that we've begun to understand is that even though we all are owners of these wonderful reward systems, one very important part that we haven't talked about is the stop system, of the brain so while we all own a good reward system; we have to or we wouldn't be here. We may differ in our ability to put on the brakes with regard to good chocolate, good sex or powerful Cocaine and it seems from brain scans that we have that can tell us about our stop circuitry that there are people who do walk into the world with breaks that aren't so good.

(Peter) 
Wait a minute. You're an addict recovering?

(William Moyers) 
I've been in recovery for thirteen years now.

(Peter) 
Thirteen years. In the context of this pre-wiring; that brain systems that may be pre-wired that make people addictive personalities or have addictive brains. What happened the first time you tried Crack? Describe the sensation.

(William)
Well the first time I tried Crack was just fifteen years into my active use of those substances. I mean it was the all consuming drug. It's where I think I crossed the great divide between wanting drugs and needing drugs.

(Peter) 
So intellectually you know the consequences, you understand what you're doing but you don't care.

(Anna) 
One of the really interesting things...

(William) 
Can I just say something about this? It's not that I don't care; it's that I can't stop.

(Peter)  
Assuming let's say that your brain is pre-wired.

(William) 
Which it was; there's no question. I take responsibility for a piece of that. I'm the one who experimented but I don't take responsibility Peter for the fact that alcohol and other drugs did for me what I couldn't do for myself. They'd turn on the light switch in my brain which I developed this baffling inability to just say no and turn off on my own. That's not to excuse my behavior. Nobody forced me to do that but I've got to tell you I grew up in the sixties and seventies and eighties and there was a lot of use and abuse back then. I used and abused a lot of people, none of whom became addicts and alcoholics.

(Peter) 
Alright so why don't we take Diane in whom we have some doubt whether or not she's an addict. Lisa writes her, not a prescription for Fiorinal, but a script to go to a brain scan and we'll see if she has the addict's brain scan. Can we do that?

(Anna Rose Childress) 
Well first step, I would send her to Gloria first.

(Kathy) 
I'd want her to get some Psychiatric or Psychological evaluation because I want to know what is going on in her life. What are the stresses? What is contributing to the issues?

(Peter) 
But why do we care? If she's got the brain of an addict and she's taking drugs, the rest of it is immaterial. Gloria are you going to send her for a scan?

(Gloria) 
No, no I'm not going to.

(Anna) 
Not at this stage, no. It's very important to say that scans are not being used to diagnose addictions.  They are hopefully helping us understand underlying mechanisms for vulnerability.

(Peter) 
So they're research tools?

(Anna) 
So they're research tools for understanding what may make one brain more vulnerable than another; very important and for helping us find tools, behavioral and medication. But no, we go to Gloria and find out if we meet criteria and then basically try to get this person toward treatment.

(Peter) 
So Gloria if you're going to make a diagnosis with an interview, what sort of questions would you be asking? This is out of the Psychiatric interview book right? That DSM IV thing?

(Gloria) 
That history of which substances they've used, when they started the substance, how much of the substance they have used, what the substance does for them, have they ever been able to abstain on their own? How do they get the substance? Do they do illegal activities to get the substance? Maybe they trade sex for drugs, things like that.

(Peter) 
Just between you and me, can you really spot an addict by his scan and what does the scan look like?

(Gloria) 
Not yet. The scans are not available clinically yet. Maybe someday we will have scans.

(Anna) 
We're very close at being able to say, if you send me two scans and I know they've both see Cocaine cues one of them is seeing a brain that's really on fire and very alight with excitement, the other one is I could tell you that that person has a Cocaine history but I don't have to do a scan to determine that as a diagnosis.

(Peter) 
But there's something on the scan?

(Anna) 
But there's something very important on the scan which says that there is a brain system that's extremely, extremely aroused by the sight of things that are Cocaine related and there's going to be vulnerability for that person.

(Peter) 
Is it possible for someone without this hard wiring, without this scan issue, someone who does not have apparently the genetic potential to become an addict with a small trigger, can that person be a drug addict?

(Anna Rose Childress) 
I think we know that there is some part of the variance that's still unexplained meaning that you know if a big chunk and the fifty to eighty percent range is biologic, then we know we've got to look to the brain for part of this for understanding how you get into it and how to get out of it. That still leaves a big chunk that's not explainable.

(Peter) 
Alright let's stop for a minute and sum up what we've been discussing so far. By the way, great discussion so far. Addiction is a serious problem but I want to be clear, not everyone who takes drugs or drinks alcohol is going to become addicted. Not everyone with the addiction gene apparently becomes an addict. Genetics and environment have to work together; they play a role. Is that fair?

ALL: 
Yes that's fair.

(Peter) 
Alright let's go forward. I'm going to tell you a little bit more about Diane. The doctor ordered some lab tests. I'm trying to figure out what he did. He discussed the possibility of doing some imaging for her headaches now. You want to know what else he did; refilled her Fiorinal.

(Gloria) 
Oh yes.

(Peter) 
But he says come back in two weeks.

(Lisa) 
Yeah she'll be back and it'll all be gone.

(Peter) 
Is this a reasonable follow up? Do I need to ask this question?

(Lisa) 
Absolutely not.

(Peter) 
Why is it not or why is it? Is it so impossible that nobody's speaking?

(Lisa) 
He's absolutely fed into her problem. He hasn't addressed the main problem which it really sounds like depression and some other stresses or anxiety and hasn't addressed that at all.

(William) 
You know surprisingly for a lot of addicts and alcoholics, they're just waiting for somebody to confront them with an offer of help.

(Peter) 
Do docs do that or are we as doctors in America falling down on the job?

(Dr. Lisa Harris) 
Of course we do.

(William)
Well I don't know if doctors do it to the extent with the disease of addiction as they do with other illnesses in part because I, unless something's changed in the last ten years, I don't think docs are getting the kind of training in medical school to help them recognize what, that Diane's problem is exactly what it is.

(Lisa) 
Well I think they get more and more of this training in medical school. There are many models of this training like the Ask, Advise, and Assist Method where you ask the person about the problem then give them some direct advice like why I think you may have a problem and you may need to stop this Fiorinal. It's something very simple that can be done in a Primary Care Doctor's office and then assist them with finding a program.

(Peter) 
Well Diane got sent home with a refill but her supervisor at work confronts her. It says here in the chart that a co-worker reported Diane was smelling like alcohol. Now the supervisor ordered a blood test for alcohol but I want to stop right here. We were talking about Fiorinal. Suddenly we're talking about alcohol. What's going on?

(William Moyers) 
A drug is a drug is a drug to an addict or an alcoholic.

(Lisa) 
I mean if you ask her about other substances that she was using, when they admit to one, you know it takes thirty seconds to ask about the others.

(Anna) 
And it's very common, very common to have multiple substances. In fact it's probably much more common than to have a single substance that's a problem.

(Kathy) 
I think one of the other challenges for Primary Care Physician's is you might hear no, no, no, the first six times that you're with that patient, but you need to ask that question over and over again.
 
(Peter) 
Her blood test is positive at work for alcohol. She's sent to an addiction expert in the hospital and Diane says that she did drink some in high school and college and some post partum depression after the birth of each child. By the way is that significant very quickly?

(Lisa) 
Yes.

(Peter) 
It is? Why?

(Anna) 
Depression is a risk factor for...

(Peter) 
Even post partum depression?

(William) 
That's for sure.

(Anna) 
Yeah, absolutely.

(Peter) 
She says she averages about ten drinks a week. Does that amount qualify her as an alcoholic and do you believe it?

(Anna) 
She's probably doing twenty to thirty.

(Peter) 
Are you using the two to one rule?

(Anna Rose Childress) 
People often minimize because they're really embarrassed.

(Gloria) 
There is sort of a public health recommendation about how much a person should drink. Seven drinks for women per week and more than fourteen drinks for men per week is indicative of a possible problem so at ten drinks per week we might think well she might have some sort of a problem.

(Peter) 
Diane reports that she had had a difficult argument with her son the night before and quote, accidentally, unquote, took a drink before coming to work to quote, get going, unquote.

(Anna) 
Yikes.

(Peter) 
She knew immediately she says she had made a quote, terrible mistake, waited for the alcohol to metabolize, quote, unquote, before coming to work. What do you think?

(Gloria) 
This could be an eye opener. She needs a drink to get going.

(Lisa) 
I've heard every story under the sun. You know my bathroom caught on fire and the only thing that burned was my Tylenol #4, can I please just have another prescription doctor?

(Peter) 
But what's accidentally I drank?

(Lisa) 
You don't accidentally drink.

(Peter) 
How do you accidentally drink?

(Dr. Lisa Harris) 
It just tipped over and spilled into her mouth.

(William) 
Well you don't but the point of this is that now we're seeing some dialog between the patient and the community around her.

(Peter) 
You want to hear what Diane said? I've got more. The addiction expert at her hospital concluded that she had an alcohol problem and that Diane was depressed. Diane disagreed but she was told that she had to enter a residential rehab program as a condition of continued employment.

(Lisa) 
She got residential? Wow, wow.

(Peter) 
She doesn't seem to think she's got a problem. She doesn't want to go away. If she denies that she's got a problem, can this residential program possibly work?

(Anna) 
I think what's behind your question in part is, if someone's not completely excited about going to treatment, can it be helpful? Can it take?

(Peter) 
If you lack self awareness is it going to work?

(Anna) 
The answer to that is yes. In fact lots of people have profound ambivalence right? That's part of the nature of the disorder too.

(Peter) 
If you relapse and I caught a whiff of relapse here. Does that mean it hasn't worked?

(Gloria) 
No not at all.

(Peter) 
Tell me about it.

(Anna) 
In fact I mean one way of thinking about this disorder is that the propensity to relapse is ever present; it's the thing that you have to deal with clinically. The nature of this disorder is it tends to be chronic and relapsing so you have to keep the guard up about relapse for a long time.

(Peter) 
Now did you relapse during the time that you were?

(William) 
I'm a product of four treatments over five years.

(Peter) 
That means four?

(William) 
I went to treatment four times before I learned to take personal responsibility for managing my chronic disease.

(Gloria) 
In treatment what we do is process why they relapsed and talk to people about a relapse prevention plan so that they can avoid relapse in the future.

(Glenn McGhee)  
Here's my worry though and I see it in an amazing Primary Care Physician. We don't teach residents, we don't teach physicians as much as we should about how to avoid the anger that you feel when that person comes back in relapse, maybe in the first case and that person comes back and it failed. You see this a lot with residents. Why are you bothering me when there are real sick people here and you don't care enough to try? We've got to teach better.

(Peter) 
Which brings the question to the floor; how do we treat addiction?

(Anna Rose Childress) 
Usually there's a combination right of individual treatment that's behavioral, that's supportive, including you know peer support groups. There are medications that do show effectiveness in some of these disorders. We don't have medications for all of them, but they're FDA approved medications.

(Peter) 
There are people who say that if you're going to use a pharmacologic, i.e. a drug to wean somebody off of another drug, aren't you just substituting another addiction for the first one?

(Lisa) 
No.

(Anna Rose Childress) 
I think that shows sort of old thinking about all drugs are the same. Most of these medications that we are talking about for addiction like drugs that would actually block the action of an abused drug, you can't give them away on the street because in fact they don't have any abuse potential of their own.
 
(Peter) 
I'll tell you about Diane. She completed a ninety day residential rehab program. She's back at work, continues to be involved in the Twelve Step Program, seeing a therapist, being treated for depression. Given all of this, what are her chances of; I'll use the word cure; or at least dealing with this addiction in a way that she's able to get through her life without using substances she shouldn't?

(William) 
I think she's very fortunate because most people who struggle with addiction don't get those same sorts of opportunities across a continuum of support.

(Peter) 
Let's take a moment her and sum up what we've been discussing. While addiction is a disease of the brain, it can be successfully treated. Relapses are unfortunately sometimes part of the recovery process and the treatment as we just heard, does take time. So what's on the horizon, that's what I really want to know? Is there a day in your view coming when we'll have a pill?

(William Moyers) 
I have a disease of the mind, the body and the spirit and while certainly a pill or pharmacological approach can help to address that craving or that disorder as it relates to my brain, there are other components of my illness that need to be treated and parts of my recovery that need to be maintained. They go far beyond just taking a pill.

(Peter) 
What I hear is GABAA, GABAA, GABAA. Gamma-amino butyric acid. There's a pill out there that's going to be a GABAA booster which is going to turn off something in your brain.

(Anna)  
Well we've been able to see that you know things that modulate this go system and GABAA agents are one, but they're not the only ones that, it's encouraging that we might be able to have some, some ability to be somewhat helpful right? But I don't think anyone is holding out a medication as this sort of panacea at this point.

(Lisa) 
You have to put all the factors; what lead to the behavior in the first place? How do you change people, places and things so that people don't end up in the same situations with the same triggers again?

(Peter) 
Public policy; are we anywhere with it in terms of getting at the root cause of addiction and being able to deal with this on a rational medical basis?

(Glenn McGee)  
I'll throw it right at you. Absolutely not. I don't see any evidence that our public policy system is even thinking about the next wave of drugs, let alone inpatient treatment.

(Gloria) 
And we're spending too much on incarceration and too little on treatment.

(Lisa) 
That's right, exactly. Treatment programs are closing.

(Peter) 
I don't want to leave without asking you personally; how are you doing?

(William) 
Well I'm doing well a day at a time which I think is what my managing my recovery is all about. To do that without using alcohol and other drugs requires me to never forget how painful the bottom was in 1994 and always to remember how fortunate people like Diane, the patient and I am to be able to get access to recovery in a way that most people in this country don't get.

(Peter) 
Well you know I want to thank you personally for being here. This is not an easy topic to discuss and to open yourself up to a television audience to discuss and again thanks. I'm sure the panel would join me in thanking you.

(William) 
Well thanks for including me.

(Peter) 
Well it's been an incredible discussion, but as is the case with television, it's time to wrap things up. We've covered a lot of ground today so let me just sum up the key things we want you to remember. Addiction affects millions of Americans. It's not just simply a failure of will or character. It is a disease of the brain. Addiction is a serious problem but not everywhere who takes drugs or drinks alcohol is going to become addicted. Not everyone with the addiction gene becomes an addict. Genetics and environment work together. They both play a role. Now while addiction is a disease of the brain, it can be successfully treated. Relapses are unfortunately sometimes part of the recovery process. The treatment does take time. There is hope. And our final message is always this; taking charge of your health means being informed, having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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