To understand drug abuse and drug treatment we need to talk about the physical changes that occur in addiction. The cell is the basic building block of the body. It has a plasma membrane that protects the cell from harm, a nucleus, which is the brain of the cell, and it has a variety of other specialized parts with specialized functions, called organelles. The nucleus is made up of deoxyribonucleic acid, or DNA, and it decides how the cell is made, and how the cell works. It is the manager of the cell in the same way that the brain manages your body. The plasma membrane is an actively selective membrane that chooses what comes into and out of the cell. People who need drug treatment have had their brain hijacked by a chemical. They lose the choice to use because using is the only way that they feel normal. Drug treatment teaches people how to feel normal without using drugs.
HOW DRUGS AFFECT THE CELL
Drugs pass through the plasma membrane in a variety of ways and influence how the cell operates. This is a very involved process, and we do not know exactly what each drug does. What we do know, however, is important, and you must understand some of this to understand addiction. Alcohol is a drug. One of its effects is it dehydrates protoplasm. It sucks water out of the cell. This prevents the plasma membrane from operating properly. This happens in every cell in the body, but it has its most noticeable effect on the central nervous system. It suppresses higher cortical centers in the brain. This reduces people's normal ability to perceive the environment. It tells the brain to go to sleep. This inability to perceive accurately makes us feel less inhibited. We lose the normal constraints the world puts on us. We miss the subtle cues. It makes us feel free.
The brain of the cell picks this up as a problem and changes the cell to correct the problem. Alcohol tells the brain to go to sleep. The cells tell the brain to wake up. At first these changes are transient chemical changes, subtle changes in metabolism, which will quickly return to normal after alcohol leaves the body. But if the alcohol keeps coming, the cell produces permanent changes in the plasma membrane. One way that it does this, is to make tunnels, or chloride channels, through the plasma membrane. This provides for easier transport of atoms across the plasma membrane. The more that alcohol stays around, the more of these chloride tunnels are needed.
HOW DRUGS AFFECT BEHAVIOR
Now lets see what's happening to an addict behaviorally. You start drinking, and one beer gets you that feeling you are after. One beer is all you need, but sooner or later, the cell produces those changes and you need two beers to get that same feeling. In a few weeks, or months, or years, you are going to need three beers, and then four, and five, and six, and so on. The more beer you drink, the more the cell corrects. This is called tolerance. You need more and more of the drug to get the same effect. All chemically addicting drugs create this physiological pattern.
TOLERANCE
It is important for you to know that these changes in the cell may take years to develop, but once tolerance is there, it is there permanently. The cell never changes back completely the way it was before. It never forgets. That is why you can never use drugs normally again. You have developed permanent changes in the cells in your body. If you were drinking a fifth a day, and you stay sober for twenty years, and you start drinking again, you will be drinking a fifth a day within thirty days. It took you years to develop tolerance the first time, but this time, it is there already. This will never change. You can recover completely from some of the psychological and social effects of this disease, but you can never recover from the physical changes that have taken place in your cells.
CROSS TOLERANCE
This is why cross-tolerance is such a problem. Alcohol, pot, sedatives, sleeping pills, all tell the brain to go to sleep and the cells counteract that drug in some of the same ways. If you develop tolerance for one of these drugs, you will develop tolerance for them all. You can't leave treatment and say, "Well, I'm sure glad I got that alcohol problem licked, but I never had any problem with pot. I can have a little pot now and then." This would be disaster for you. Taking a little pot is like taking a little alcohol because of the cross-tolerance.
What we find in chemical dependency treatment, is once you are addicted to one mood-altering chemical, you are addicted to them all. You have learned things physically, psychologically, and socially that will cross over to any other mood-altering chemical. If your drug of choice is whiskey, and you go out of here and smoke a little dope, you will be back to the whiskey very soon.
WITHDRAWAL
The cells produce all of these short-term and long-term changes to counteract what the drug is doing, so guess what happens when the drug is removed. All of these cellular changes are still there, and the drug is gone. The cells are producing wake up signals to the brain, to counteract the go to sleep signals the alcohol is producing, and all of a sudden, no alcohol. What happens is called withdrawal. The cells are screaming wake up and no alcohol is saying go to sleep. Acute withdrawal has been driving alcoholics to the liquor store every day. They go to sleep under the effects of alcohol and in a few hours they wake up feeling nervous and restless. They can't sleep. Their stomach feels upset. They have a headache. Their hands shake. All these symptoms are withdrawal symptoms.
Some of you learned that what you needed was a drink or a Valium to get you back to sleep, but, if you have that drink or that pill, the cycle starts all over again. Acute withdrawal is not fun. It produces the opposite effect of the drug you are using. If you were using a sedative drug, withdrawal will say, wake up. If you were using a stimulant drug, the withdrawal symptoms will say, go to sleep.
The length of acute withdrawal differs depending upon the drug you were taking. With alcohol, withdrawal is usually over within a few days. With cannabis or certain benzodiazepines it can be weeks or even months. Once acute withdrawal is over, protracted withdrawal extends the problems for about two years. Protracted withdrawal is characterized by random mood swings, sleep problems, and generalized feelings of stress. These symptoms wax and wane over the next few months. Don't think you are crazy or think that anything is wrong, just recognize the symptoms for what they are (Geller 1994).
The first three months out of treatment is the hardest because of the extended withdrawal syndrome. This is where people tend to relapse, so do everything in your power to work a daily program of recovery in early sobriety. The daily program will put hurdles in the way of the first use.
HOW WE LEARN
Drug use is a habit. We get into the habit of drinking or using in certain situations or when having certain feelings. A habit is some movement or thought that is so practiced that it has developed a nice smooth pathway in the brain. Whenever we even randomly approach that area in the brain we are very likely to take that pathway because it is so well traveled and easy to follow.
You have developed certain habits in your drinking or drug use. You may use when you celebrate, or when you feel angry, or when frightened or sad. You may always drink after work or always drink a certain kind of beer. These pathways in your brain are well developed. What treatment is all about, is teaching you to get what you want by doing something else other than using your old behavior. It is a process of learning new behaviors. If you want to feel less angry, for example, you will need to talk to someone about how you feel, and try and work the problem through. The second you realize that you are on one of your old pathways, you need to stop and change direction. Drinking and drug use are no longer an option for you. You need to find other methods for dealing with your problems.
TWELVE-STEP PROGRAMS
The idea behind twelve-step programs began with Alcoholics Anonymous that got started in 1935. Bill Wilson, one of the founders of A.A., had gotten drunk again. He was at the end of his rope. He was afraid to go home, he was afraid he was going to kill himself. He hated himself. His spouse was still sticking by him, but he couldn't trust himself anymore. He had tried to quit drinking countless times, in countless ways, and he had always ended up drunk. Here he was, in the hospital again. He didn't know if he wanted to live or die, but he knew that he didn't want to live this way anymore. Medical science had given up on him as hopeless. He had no where to go, he was trapped.
A SPIRITUAL AWAKENING
In his room alone, feeling totally powerless, he looked up toward heaven, and he cried out, "If there is a God, show me, give me some sign." At that moment Bill's room filled with a great white light. He felt incredibly filled with new hope and joy. "It was like standing on a mountain top with a strong clear wind blowing through me--but it was not a wind of the air," he said, "it was a wind of the Spirit." Bill felt like he had stepped into another world full of goodness and grace. There was a wonderful feeling of Presence that he had been seeking all of his life. He never felt so complete, so satisfied, so loved. Bill Wilson had finally surrendered, and when he surrendered, God came into his life. Notice that God came into his life with such power and force that Bill never denied God again.
Bill never took another drink, but his spiritual awakening didn't fully resolve his problem. He still had a craving for alcohol. One day he passed a bar and he felt himself being pulled into it. He thought that if he could just talk to another drunk, he might be able to pull himself back together. He got on the phone, and after making a few calls, finally found one, Dr. Bob Smith. Dr. Bob was a hopeless alcoholic. He had destroyed his medical practice and he was waiting to die. He reluctantly agreed to see Bill, but he had no hope that Bill could help him. Dr. Bob would have no nonsense, he had talked about his alcohol problem with the best, and now here was some other guy, a drunk, who was coming over to try and help him. He was in no mood for help.
TWO ALCOHOLICS TALKING TO EACH OTHER
When Bill got there, Dr. Bob was surprised to learn that Bill wasn't there to keep him sober. "No," Bill said, "I'm not here to keep you sober, I'm here to keep me sober." Well, this was the new concept, one alcoholic talking to another to keep himself sober. Dr. Bob was only going to give Bill a few minutes, but they talked easily, and Bill stayed for hours. Dr. Bob began to open up and speak as frankly as Bill was doing. Having common experiences, they could speak to each other without shame. They talked about the helplessness and hopelessness they had been feeling, the total feeling of powerlessness. They talked about all of the problems that alcohol had caused them. Bill told him about the spiritual experience that he felt had saved him.
These two persons became great friends and Alcoholics Anonymous was born. They began to meet with other alcoholics. They began to carry the program to others. Dr. Bob got drunk one more time, when he was away at a convention, but when he returned, he was more determined than ever to stay sober.
A bunch of drunks begins getting together to help each other stay sober. To everyone's amazement, it worked. Hopeless cases begin to recover. Of course, the groups had their set backs, but the way to recovery had been found. They wouldn't have the name Alcoholics Anonymous for four more years.
THE BIG BOOK
Bill dictated most of the first chapters to his secretary. He had considerable resistance when he came up with the Twelve-Steps. Some of the members of the group were adamantly opposed to including so much God talk in the program. They didn't want to scare drunks away with all the spiritual talk. Bill listened quietly, but he knew he was right. The only concession he made was to add the phrase God, as we understood him. That made some members of the group feel more comfortable.
As the program developed, and people began to stay sober, Bill was offered a job as the first alcohol counselor. A hospital wanted to incorporate the program and use it to help alcoholics. The group was opposed. They were afraid that it would make the program commercial and this would destroy an essential element of the group. This time Bill agreed, and Alcoholics Anonymous remained a free self-supporting program.
Another problem was money. The group needed money to pay for expenses and to reach out to the alcoholic still suffering. They went to John D. Rockefeller and he gave them five thousand dollars. They had asked for fifty thousand, but Rockefeller felt that financial backing would weaken the program.
With the individual stories written by the new groups, Bill completed the Big Book in 1939. They ordered five thousand copies to be printed. They didn't sell many until an article appeared in the Saturday Evening Post written by Jack Anderson. This gave Alcoholics Anonymous national exposure and the mail began pouring in. Alcoholic's Anonymous now has over one million members and it has meetings all over the world.
THE TWELVE STEPS
The program is made up of Twelve Steps. You will hear them read at every meeting. "(1) We admitted we were powerless over alcohol that our lives had become unmanageable. (2) Came to believe that a Power greater than ourselves could restore us to sanity. (3) Made a decision to turn our will and our lives over to the care of God as we understood Him. (4) Made a searching and fearless moral inventory of ourselves. (5) Admitted to God, to ourselves, and another human being the exact nature of our wrongs. (6) Were entirely ready to have God remove all these defects of character. (7) Humbly asked him to remove our shortcomings. (8) Made a list of all persons we had harmed, and became willing to make amends to them all. (9) Made direct amends to such people whenever possible, except when to do so would injure them or others. (10) Continued to take personal inventory and when we were wrong promptly admitted it. (11) Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for His will for us and the power to carry that out. (12) Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs (Alcoholics Anonymous 1976 p. 59-60).
There are many slogans in AA that will help you to reorganize your life and your thinking. Slogans such as, one day at a time, easy does it, keep it simple, live and let live, and let go and let God. These slogans have great meaning and they will help keep your program on track.
MEETINGS
After treatment, addicts attend a lot of AA or NA meetings. The more meetings you attend the greater your chances of achieving a stable recovery. You need to ask someone further along in the program to be your sponsor. They will guide you though the Steps and they will be there for you in times of need.
You will find this program to be a healthy family. The regular meeting you attend will be called your home group. There is a stable set of rules. People will care about you. They will respond to how you feel. They will care for what you want. They will be there for you when you need them.
The choice is yours. We strongly recommend that you throw yourself into this program with all the enthusiasm and courage you can muster. Tell your group the truth. Don't hold back. Alcoholic's Anonymous says, "Rarely have we seen a person fail who has thoroughly followed our path."
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1. Have you ever tried to cut down on your drinking?
2. Have you ever felt annoyed when someone talked to you about your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink in the morning to settle yourself down?
5. Have alcohol or drugs ever caused you family problems?
6. Has a physician ever told you to cut down on or quit use of alcohol or drugs?
7. When drinking/using drugs have you ever had a memory loss (blackout)?
If the patient answers any one of these questions yes that’s a red flag for alcoholism. If they answer two questions yes, that’s probable alcoholism. Make sure you don’t just ask the patient. Remember alcoholics live in a series of carefully constructed lies designed to keep them from feeling the fear of the truth.
Red flags for Adult Alcohol/Drug Abuse:
1. Tremor/perspiring/tachycardia.
2. Evidence of current intoxication.
3. Prescription drug seeking behavior.
4. Frequent falls; unexplained bruises.
5. Diabetes, elevated BP, ulcers; non-responsive to treatment.
6. Frequent hospitalizations.
7. Inflamed, eroded nasal septum.
8. Dilated pupils.
9. Track marks/injection sites.
10. Gunshot/knife wound.
11. Suicide talk/attempt; depression.
12. Pregnancy (screen all)
Laboratory Red Flags for Alcohol/Drug Abuse
1. MCV-over 95
2. MCH-High
3. GGT-High
4. SGOT-High
5. Bilirubin-High
6. Triglycerides-High
7. Anemia
8. Positive UA for alcohol or illegal drugs.
Red Flags for Adolescent Alcohol/Drug Abuse
1. Physical injuries; MVA, gunshot/knife wound, unexplained or repeated injuries.
2. Evidence of current use, e.g. dilated/pinpoint pupils, tremors, perspiring, tachacardia, slurred/rapid speech.
3. Persistent cough (cigarette smoking is a risk factor)
4. Engages in risky behavior, e.g. unprotected sex.
5. Marked fall in academic/extracurricular performance.
6. Suicide talk/attempt; depression.
7. Inflamed, eroded nasal septum.
8. Track marks, injection sites.
9. Sexually transmitted diseases.
10. Staph infection on face, arms, legs.
11. Unexplained weight loss.
12. Pregnancy (screen all)
Laboratory Red Flags for Adolescent Alcohol/Drug Abuse
1. Positive UA for alcohol illicit drugs.
2. Hepatitis A-B-C.
3. GGT-High
4. SGOT-High
5. Bilirubin-High.
Questions to ask the Adolescent Patient:
1. When did you first use alcohol/drugs on your own, away from family/caregivers?
2. How often to you use alcohol/drugs? Last use?
3. How often have you been drunk or high?
4. Has your alcohol/drug use caused you problems with: your friendships,
family, school, community? Have your grades slipped?
5. Have you had problems with the law?
6. Have you ever tried to quit/cut down? What happened?
7. Are you concerned about your alcohol or drug use?
Questions to ask the Parent/Caregiver:
1. Do you know/suspect your child is using alcohol/other drugs?
2. Has your child’s behavior changed significantly in the past six months: sneaky, secretive, isolated, assaultive, aggressive, hostile?
3. Has school, community or legal system talked to you about your child?
4. Has there been a marked fall in academic/extracurricular performance?
5. Do you believe an alcohol/other drug assessment might be helpful?