A Disease of Free Will

HEFFNER: I’m Alexander Heffner, your host on The Open Mind. When I was the Fitzwater Fellow in Public Communications at Franklin Pierce University last fall in the deeply rural New Hampshire wilderness of Rindge, the epidemic of heroine abuse across the state was not an abstract case study, but rather an intimate, mass death sentence afflicting the young people I met.

In response to the plight of rural addiction and a long neglected urban crisis, we invited Center for Disease Control and Prevention Director Tom Frieden and more recently Rob Reiner, director of Being Charlie, whose son suffered from what our guest today calls a disease of free will.

We continue this critically important conversation with distinguished Mexican-born psychiatrist and scientist Dr. Nora Volkow, who leads the National Institute on Drug Abuse within the NIH- the world’s largest research depository on addiction.

This General in the drug war- as the New York Times chronicled- has pioneered the use of brain imagery to investigate the toxic effects of abusable drugs. As her research on the addictive properties of these chemicals has accelerated, so too has the rate of dependence. So I want to ask Nora first for a progress report. And welcome. Thank you. It’s such a pleasure to have you here.

VOLKOW: Well thanks for having me and uh- in terms of a progress report and the progress report is what you were saying in New Hampshire is not unique to New Hampshire. Um. In fact, we’ve seen a significant increase in people, um, injecting heroine and now um- addicted to prescription opioid medication and this is translated in to really a very devastating epi- epidemic of people becoming addicted to these medications but dying from them from overdoses.

And it’s basically- right now, uh, every twenty minutes, there is an American that dies uh from an overdose on a prescription. And that gives you an idea of the state of the- it’s very tragic. And it’s very unfortunate. And that’s one of the- I think- our obligation to come up with strategies to reverse this epidemic.

Which is very different from other types of um addictions because these are medications that are given by physicians and um they physicians give them, in principle, to treat pain- to help patients- and unbeknownst to them- uh- these patients may be taking higher doses or they’re diverting their medication. And we are, as a result of that, I mean, this uh, one of the most devastating epidemics that we have in, in our country.

HEFFNER: The basic vicious cycle, as I understand it- and do correct me if I’m wrong- is the over prescription of painkillers to some extent leading to the heroin use. The unprecedented heroin use.

VOLKOW: Effectively, uh, we recognize that this uh- this epidemic on opioid, um, abuse- emerge as the number of prescriptions increased dramatically around 2000. And there was a change that again was very well intended by the Joint Accreditation Committee for Hospitals that required if you wanted to be accredited as a hospital, you have to not only screen for pain, but treat the pain in your patients.

Then physicians, following these guidelines, start to actually prescribe opioids. Why? Because opioids are the most effective medications that we have for the treatment of severe acute pain. But it followed in their brains that if someone had pain, um, they started to prescribe them beyond severe- to start to prescribe them for moderate and then they started to prescribe, if it works for acute, then it should work for chronic, without no evidence whatsoever that the medications would be beneficial for any type of chronic pain and without an understanding that while these opioid medications can be very effective for severe acute pain, they’re also highly rewarding and they have effects in the brain that are no different from those of heroin, that actually result, yes, in very powerful anesthesia- uh- analgesia. But also very potent reward in triggering in those that are vulnerable, the changes that result in addiction.

So as the person becomes addicted to their opioid medications, um, and amidst this increase in, in, the number of prescriptions, there has been an attempt to make- to decrease those prescriptions and make it harder to get. So a person is already addicted to prescription opioids, then they transfer to heroin because heroin is much more widely available in many places and it’s cheaper. And so that’s how the transition appears to have happened. And it’s estimated that out of- three out of four new heroin abusers, um, went in to heroin first by abusing opioid prescriptions.

And in parallel to this there has been an entry of very pure heroin coming from Mexico that has decreased not just its price, increased its availability, but also the more potent the heroin- the purer it is- the higher the likelihood that you can overdose.

In parallel another um circumstance that has made this issue even more severe is that um- heroin started- started to be mixed with Fentanyl. Fentanyl is an opioid medication- probably one of the most potent that we have- ten or twenty times more potent than heroin, so, they mix the heroin with Fentanyl, you have a very potent drug. And that in turn, though, while it gives a very strong, um, experience to that drug user, also increases significantly the rate of um death and fatalities from overdoses.

HEFFNER: You related the science in a way that was quite understandable to me as a chocolate lover, a fellow chocolate lover at this table. It is a question of self-control and a question of a kind of medicine- a would-be medicine- turned in to an addictive drug that rewires you. Is it as simple as self-control, and once it’s beyond one’s control, how can the science remedy the problem?

VOLKOW: Yeah and- and-

HEFFNER: Because you are a chocolate lover, are you not?

VOLKOW: I love chocolates. I love black chocolates. I, uh- but and actually I can lose control over eating cho- uh-

HEFFNER: So can I.

VOLKOW: Black chocolates. But most of the time, I’m- I’m on control. And I think that we all have to be honest with ourselves and when we are faced with something that’s rewarding that we like- most of the time we may be able to actually consume as much as we wanted to, um, or abstain from consuming, but there are certain circumstances, if we are frustrated, if we are very tired, if we are very bored- that we give in. And we over consume. But most of the time, we’re OK.

When you transition from that stage where most of the time you are able to self-regulate the desires and control and manage your behavior even though you want to do it, you say it’s not a good idea- when you lose that capacity consistently, that’s when you start to get in to the transition of addiction. And and what do we know about it?

We know about it that- and very much emerging as uh investigating the brains of people that are addicted and comparing them with people that are not addicted. And one of the main differences is dysfunction of areas of the brain in the frontal cortex in people that are addicted.

Now this is- uh- important because the frontal cortex is necessary for you to make a decision to analyze a situation, make a decision, and carry it through. But if these areas of the brain are not functioning properly, which is what repeated drug use does to your brain, it erodes the capacity of frontal cortical areas- then your ability to self-regulate, your ability to make optimal decision gets dysfunctional.

In a very simple metaphor- and I use this because we always um judge and interpret the way, of course, in the basis of our experience. So if you’ve never been addicted to drugs, you say, well, why doesn’t the person just stop taking it and get their act together?

Because we are seeing it from our perspective and we know that we can exert control and free will. And most of the time we’re able to do it. But we need these areas of the frontal cortex in order to be able to do it. If those areas are not functioning, it’s literally like driving a car without breaks.

So you can cognitively say, I- and there’s a person crossing- say, I’m going to break so I cannot- I don’t want to hurt this person. And you don’t want to hurt that person. But if you don’t have breaks, how do you do it?

HEFFNER: We spoke with Tom Frieden in depth about new guidelines that have recently been unveiled to address this problem of over prescribing within the medical realm. But I really want to talk to you, Nora, about the addicted and how to put those brakes back in place. And it’s not a one step process.

We were speaking in the green room about efforts in Vancouver, Canada and now Ithaca, New York, where there are facilities being designed to allow- in a regulated environment- those addicted to shoot up- that seems like a first course in what is um- a longer journey back to, you know, reversing the damage that you describe.

VOLKOW: Yeah. No. And that- And so the issue is what can you do to improve the function of the brain in such a way that that individual um will be better able not just to resist the temptation of the drugs- which are very very strong drives and motivators of behavior in them- but actually allow them to recover and um- and lead- um- normal, normal lives without having to be worried about having to take drugs and the rituals.

So what can we do? Well, we know certain things that we should remove from the experience of the individuals. And one of them is stressors. Social stressors are probably one of the most harmful effects to your brain in terms of uh- they can disrupt your ability of exerting control. So I say- it’s drugs- drugs damage these systems. But so does um, chronic social stress. And particularly sensitive are children and adolescents but we are all are.

So, if you take an individual and that person is withdrawn and society is rejecting them, and they are thrown in to jail, those are massive stressors that are not going to help the brain recover. So what is it that we can do to recover? We have to provide them an environment where you minimize the social stressors.

Item number one. So. Which explains why throwing someone that’s addicted into prison or jail is not just ineffective- actually, it can further hamper the ability of that individual to successfully be able to recover from their addiction. It actually can do damage. That’s number one.

Number two, how do you provide the stability? And for those addictions, and so- as the case of opioids, they are medications that can actually can facilitate very much, creating a stable physiological state for your body that will facilitate your capacity to actually lead a normal life. And what do I mean by uh… By that? Medica…

When you’re addicted to opioids, you actually have uh, physical changes in your brain. Not just they are disrupting the actual capacity to exert self-control but the areas of the brain that are associated with mood are um basically driven towards- normally we have this stage of positive and negative moods- when you’re addicted, you actually become much more sensitive to having a reaction that results in a negative emotion like anxiety, depression.

And when you are taking drugs and the drugs are leaving your system, one of the reasons that leads you to want to take more is this very negative emotion- dysphoria, irritability. Medications allow you to stabilize that. Which in turn, allows you to lead a normal, productive life. And consistently, by many independent studies, uh, it has been shown, in fact, that medication treatments, whether it is agonist or antagonists [- and that’s methadone, buprenorphine, naltrexone- or naltrexone extended release, vivitrol- helps the person um stay in treatment, uh, incorporating um in to their lives and recover. And it also prevents them from overdoses. And it also prevents them- those that are addicted to prescription opioids to transitioning in to heroin.

So medication treatments are one of the interventions that can help stabilize and as you stabilize, the brain is very neuroplastic. So it has tremendous ability for recovery. So like now for example someone suffering from a stroke, we do rehabilitation treatment so that that they can be able to move the affected area of the body by compensating. So we can do interventions that will allow that person to be able to compensate or recover those uh areas that have been affected by the repeated use of drugs. And that’s the aim of treatment.

But it’s a- it’s an aim- that it doesn’t happen overnight. Which is another issue that people have a misconception. They have the sense- and it would be incredible- that, OK, I give you an antibiotic and you’re cured two weeks later. It would be extraordinary that we have such a thing for addiction. We don’t. And the changes are very long lasting, so it’s more like hypertension or diabetes. You need to be in treatment for a long period of time.

HEFFNER: Also, what about the social conditions- maybe the economic malaise or disempowerment that led folks to shoot up in the first place- how do you insure that after the intervention those conditions in society are not recreated?

VOLKOW: And you’re actually touching on something that we’ve all recognized in treatment. That we have someone that is um addicted to a drug and we treat them in a specialized treatment facility and say after three months the person goes back to the same environment that is surrounded by all of these social cues- some of them stressors but also one of the things that our brain does is that when you have anything that’s very rewarding, you create a new memory that will drive your behavior when you are in that space or place or with that person to want to experience that same um- situation as you did.

So that generates a desire to take drugs. So this is an incredible challenge. Because it’s not like you say, OK, you’ve been to treatment, let’s bring you in to another city. But one of the things that we can do- and again, there are certain changes that can be done at the structure- currently if you have been in prison, then you may be a drug abuser and addicted to drugs and then you are released, it’s going to be much harder for you to get an education, to get educational grants, it’s going to be much harder for you to get a job.

And being jobless is highly stressful so when- there are these opportunities to change those laws so that the person that has um been in the criminal justice system that is interested in stopping taking drugs, can be given an environment that is going to be more likely for him to succeed in um achieving the recovery.

So we can do structural changes to compensate for the stressors in the environment that the person is going to return to. But it’s not going to happen automatically. Because in many of the current systems, unfortunately there are still many road blocks that are making it much harder for the person that’s addicted to drugs to stop taking it.

HEFFNER: You say quite compellingly that the science and the politics here are intertwined insofar as the movement to ban the box so that people who are leaving the criminal justice system or leaving the facilities that we talk about are eligible to be employed and have an economic livelihood.

What do you think, in terms of the nature of this problem, is that most um- troublesome or fundamental kind of underlying cue? You talk about social cue. Is it an economic cue?

VOLKOW: I wish it would be very easy to my brain to say to you it’s this one and pinpoint and this is the one, and definitely you are touching on the notion of economic resources so you need to have an infrastructure that will be able to provide the treatment that the person needs, and that requires, of course, resources, but it’s more than that.

Because they also think that- a word that we use a lot to the point that we no longer register but it’s a key component, is stigma. And I have, again and again, people coming to me- their relatives or themselves- saying um- to- telling me, Nora, I am addicted to this or that drug or my son or my sister is addicted to this and they are so ashamed. And I am ashamed. They are incorporating the stigma into themselves.

Now what are the consequences? That stigma leads them to be afraid to seek treatment. That stigma leaves the physician or the healthcare system not to want to address it. And that stigma leads to actually not identifying the resources that are necessary because it’s not considered um, a condition or a disease as other diseases like Alzheimer’s or cancer where everybody feels immediate empathy.

Addiction is not per se a disease where you generate empathy and yet the person that’s addicted uh is probably suffering from one of the most devastating diseases- if you can just think about what it means that you cannot control yourself. No matter how hard you try, and that you’re ashamed of that and you blame yourself. What other disease does that?

HEFFNER: Mental illnesses. Mental- and they’ve been stigmatized for decades but you said to me off camera that it’s important to view the framework of policy today in a historical lens.

VOLKOW: Correct. I think that we are living at unprecedented times and- and in an unfortunate way the tragic situation that happens on the prescription opioid epidemic and heroin, um, is a result of our negligence, uh, in the health care system about addiction. And we- we- in the healthcare system have never though it’s part of our responsibility. We don’t’ get trained as medical students- even in specialty- I am a psychiatrist. In the residence of psychiatry, the average number of hours that you get trained on, in addiction- even though it’s one of the mental illness- highly comorbid with psychiatric diseases- patients with psychiatric diseases are at greater risk of mortality because of addiction.

We don’t’ get trained properly, so- that is one of the main issues that needs to be addressed. We need- we need to actually change it. The lack of recognition of it’s important has resulted in the situations that we currently are. And that’s one.

On the other hand, that has made because of the overdoses, everybody aware that we need to educate on the uh- health care system about addiction and the other side is we also need to educate on pain. Because there is also the need of patients suffering from pain- how are they going to be treated? Uh- I actually- we need to recognize that this is an area that we have to put resources to come with alternatives that will help those patients suffering from pain.

But apart from this, there’s been two developments that are actually very fundamental right now and enable us to change the culture of addiction from criminal to healthcare. One of them is the parity law. So the parity law allows us now to uh- insurances- it requires insurances to cover for the treatment of substance abuse disorders and other mental illnesses.

Like any other medical disease. You cannot discriminate. Which has been consistently allowed all along. And the other one is healthcare reform. Because healthcare reform is providing for the first time insurance to many individuals suffering from a substance abuse disorder or addiction. So for the first time these individuals have an insurance and now the insurance based on the law- it’s the law- has to pay for their treatment.

Now you could say that- that those two very important advances would have um transformed the treatment of um people that are addicted to drugs. And unfortunately it hasn’t. Even though now there is this structure that should have allow, there are still many roadblocks that result in patients not getting the treatment that they- they would benefit from.

HEFFNER: I want to ask you why, in the context of delivering testimony before the U.S. Congress, and what the disconnect might have been there in your testimony based on the questions that you got. So why hasn’t it transformed, and is it because of anything that you discerned when you were delivering the testimony and saw the feedback from our elected officials?

VOLKOW: Well I think that one of the issues why it hasn’t happened is that when you have a culture and a tradition of um- treating patients in a certain way- even if there’s a new law- it- you don’t see the transformation right away.

Why to start with the physicians, the nurses, the the- nurse practitioners are not trained to properly, actually screen or treat people with substance abuse disorders. So they tell you they should be screening and then physicians are afraid. And if I ask them the question and they say yes, what do I do?

So it’s better not to ask. So this is probably one of the most important issues that we need to address. The proper training and education of individuals in the health care system so that they can properly deal with it.

HEFFNER: You think there’s a lot of that not asking and not telling still going on?

VOLKOW: There is still a lot going on. Of not asking. And I think that I- I- it occurred to me enormously when I think about it and I don’t per se actually but I use it nonetheless because I illustrate um- Seymour Hoffman. He was given an opioid medication for pain and no one asked him had he been addicted in the past. Had they asked that question, they perhaps would have not prescribed an opioid medication.

So- and we see that, for example, in terms of patients that are given an opioid prescription that are given these medications without consideration that those persons might be at particular risk for becoming addicted to their medications because they had had a past history of addiction.

And so that’s so elemental and yet, it’s not being asked by some physicians. So this is an example. And we have become much better at asking about cigarette smoking and asking about alcohol. But it’s much less so about elicit substances.

And then when it’s asked, then it really- there’s no plan on the type of intervention that the doctor is going to be doing if the patient does respond yes, I do have a problem with drugs. Or even for testing it.

You know, many- and I’ve asked the physicians and they say no, I feel very uncomfortable asking this person this question- it’s an old lady, how am I going- I’m going to offend her. I’m going to offend her. So this is the question. And if you don’t ask, the patient themselves, which feel embarrassed a little bit are not necessarily going to bring it up themselves.

HEFFNER: Lastly, Nora, science is going to back you up and back these doctors up how?

VOLKOW: Well science provides solutions. I always think about it in terms of if you look from the perspective of how we’ve advanced, and how the um, minimal survival has increased increased increased increased.

It’s science that it’s providing that knowledge that then is applied to change our behaviors and come up with treatment and interventions that can not just expand our lives but improve the quality of our lives.

So I believe that uh- certainly science- I mean, we are funding research to try to get much, I mean, alternative, and more medications for the treatment of drug addiction. Doing research to try to determine how to actually accelerate the degree of recovery of the brain- wouldn’t that be incredible? And the brain is neuro plastic.

So then why don’t we take advantage of that opportunity? Also, how do we communicate messages such that you can maximize your prevention for kids not um- experimenting with drugs in ways that will actually be disrupting their life later on.

How do you do that? How do you maximally have an impact? So these are many of the things that we are currently doing now. Some of these are very- in a way- transformative. We’ve been funding research, now, for example, to come up with vaccines against drugs.

So if you are vaccinated you generate antibodies that would bind to the drug and the drug can never get in to the brain. So you can never get high on that drug. So there are multiple alternatives that we are using.

HEFFNER: We could do a whole other episode on that, that’s fascinating. I think you point out- incredibly importantly- that the clinical use of brain mapping should be used and geared toward and around the patient just as much as the researcher when you’re analyzing what’s going on in here.

VOLKOW: Well, you know, I love that whole concept that we could use brain images, right? And we could map and I could see what are the areas, just like you do right now in your heart where you can identify where exactly the myocardial infarction or the ischemia is happening.

Imagine if we could do that in the clinics at an accessible price that could tell you that this is an area that’s not functioning properly and we have learned the rehabilitation process in such a way that I can accelerate the ability of that area of the brain to work uh- back to normal.

We’ll be- I mean, we- we can do that now, but it’s not cost a- I mean, it’s very very expensive, it’s in the research arena. It’s not very fast and it cannot at this point- we have not developed tools that are specifically tailored to one individual. We are basically at this point trying to understand how to stimulate an area so that it can increase its function and it’s communication with other areas. But it’s not tailored to the person yet.

HEFFNER: Doctor. Thank you for joining me today.

VOLKOW: You are very welcome.

HEFFNER: And thanks to you in the audience. I hope you enjoy us again next time for a thoughtful excursion in to the world of ideas. Until then, keep an open mind. Please visit The Open Mind website at thirteen.org/openmind to view this program online or to access over 1,500 other interviews. And do check us out on Twitter and Facebook @Openmindtv for updates on future programming.