In this case, it seems, the monster below the surface was unresolved pathological depression. Of course, that mixed with an alcohol use disorder is a recipe for disaster. But the alcohol is an adjunct - it is both the (temporary) solution, and the (long-term) catalyst. It is not the primary disease.
I often see how by focusing on the SUD the real pathology is missed. Each relapse brings around renewed focus on the SUD rather than sparking the question: "Well, we know that SUDs die a natural death in most cases, unless there is a contributing factor, this person is not getting better, so what is the contributing factor, and how do we resolve that?"
It is sad that complex problems get reduced to the simple statement "Oh, he was an alcoholic".
In this newsletter I bring together some information from different types of addiction and drug use. When put together much of the research seems to be stating the obvious and, in my opinion, addiction looks more like a learning disorder or adaptive process and not a primary disease of the brain. It seems that Maia Szalavitz agrees with me.
We look at Marijuana and brain changes and schizophrenia, methamphetamine and brain changes, porn and brain changes, internet addiction (and brain changes), Tom Hovarth and SMART Recovery, the results of the Global Drug Survey. I hope you enjoy, and please feel free to comment! Please click HERE to find out more about the Cape Town Recovery Film Festival 2014.
"Gray matter density analyses revealed greater gray matter density in marijuana users than in control participants in the left nucleus accumbens extending to subcallosal cortex, hypothalamus, sublenticular extended amygdala, and left amygdala, even after controlling for age, sex, alcohol use, and cigarette smoking. Trend-level effects were observed for a volume increase in the left nucleus accumbens only. Significant shape differences were detected in the left nucleus accumbens and right amygdala. The left nucleus accumbens showed salient exposure-dependent alterations across all three measures and an altered multimodal relationship across measures in the marijuana group."
"These data suggest that marijuana exposure, even in young recreational users, is associated with exposure-dependent alterations of the neural matrix of core reward structures and is consistent with animal studies of changes in dendritic arborization"
Schizophrenia and Pot
Taking things a step further, a recent study in Molecular Psychiatry looked at a sample of 2 082 unrelated healthy males in Australia. The genotype for each individual was obtained. This data was compared with Swedish data which had previously identified a number of Single Nucleotide Polymorphisms that seem to indicate an increased risk of developing schizophrenia.
In a really clever second part of the study the researchers looked at the genetic risk of 990 twins (approximately 1/3 mono-zygotic) and then predicted whether one or both twins would use cannabis!
A significant association between level of genetic predisposition for schizophrenia and cannabis use was found. Having said this, the genetic risk is a small factor in developing a cannabis habit. What the authors did conclude was: "that to some extent the association between cannabis and schizophrenia is due to a shared genetic aetiology [cause] across common variants. They suggest that individuals with an increased genetic predisposition to schizophrenia are both more likely to use cannabis and to use it in greater quantities."
Of course, being a cross-sectional study there are limitations, and the authors also point out a number of other possible confounders and limiters. Interesting though that there were no huge headlines proclaiming "Schizophrenia Causes Cannabis Use!".
And as for that nature versus nurture debate, it is increasingly becoming clear that it is a false dichotomy.
The "controversial" but always thought provoking Dr Carl Hart recently published a critical review on cognitive impairment in methamphetamine users. Once again the ability to assign causation in cross-sectional studies comes into question. While Dr Hart certainly has an agenda, as the recuring themes of his work suggest, he makes some excellent points in his review of a variety of studies that examine cognitive function in methamphetamine users. He examines studies in a number of areas: Acute effects on drug naive and drug accustomed subjects, long-term effects on current and abstinent drug users, the brain structures and sizes of currently abstinent methamphetamine users and comprehensive neuropsychological testing of abstinent abusers.
While Hart acknowledges that there are some "brain changes", particularly in the area of dopamine transporter density in animal studies and that striatal binding potentials were lower in human subjects, this did not translate into clinically significant behavioural changes. The same was found regarding the gray and white matter structural changes observed in some studies.
Hart effectively highlights many of the weaknesses in these studies and makes a valid conclusion:
"Many researchers in this area begin with the assumption that methamphetamine abusers exhibit cognitive dysfunction, and that their research bears this out. Findings from this review suggest that this assumption should be reevaluated to document the actual pattern of cognitive effects caused by the drug."Certainly my experience with treating high dose meth users is that they do not seem to suffer any long-term cognitive defects, and certainly there is no problem using cognitive based therapies. There is some evidence emerging though that shows that cognitive training can improve outcomes for treatment, although I think we will find this to be true across all addictive behaviours.
Porn and the brain
Tom Horvath and SMART Recovery
Not only is Dr Hovarth the founder and president of Practical Recovery, but he is also president of SMART Recovery, the international nonprofit that offers free, self-empowering, science based mutual help groups for addiction recovery. SMART has over 20 to 30 000 members world-wide.
In both treatment modalities that Tom oversees the power is vested in the individual - there's no talk of being powerless in the face of addiction. Recently SMART Recovery has started meetings in Cape Town, and I am hoping that these find traction in my local setting where this type of intervention is much needed.
Global Drug Survey Data
The global drug survey aims to collect data from drug users around the world. It all started 15 years ago as a simple questionaire in a clubbing magazine and has now grown to an international web-based survey.
Filled with some fascinating pieces of information, such as cocaine was voted the worst value for money drug and MDMA the best, the results of the 2014 Global Drug Survey are out. The data was collected from nearly 80 000 self-selected participants around the world. Worth a look even if the sample is not truly representative.
One of the key messages from the survey was that current drug laws are a barrier to people seeking help for problematic drug use. The Huffington post talks more about this issue here.