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Addiction, or “Substance Use Disorder,” as it is termed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is a chronic, progressive and potentially fatal brain disease. The brain is composed of 100 million cells and is in charge of virtually all human functioning – what we do, say, think, remember, decide, all our actions, emotions, sensations and so much more. The brain is divided into several parts – the two areas of focus for this discussion are the frontal lobe (thoughts and executive function) and the midbrain (reptile brain), which contains the limbic system (survival functions and emotions.)

In defining addiction, certain symptoms and characteristics are the hallmark of the disease process. Craving is one symptom of addiction and is defined as having the desire for the drug or behavior when it is absent. Tolerance occurs when the body accommodates to the substance with chronic use, and the substance has less effect on the body over time, despite an increase in the dosage (this is the condition when a person can “hold his/her liquor” without appearing intoxicated). Physical dependence occurs when the body has changed so much after regular use of the substance, that it is not normal without the substance, and the person will experience withdrawal (the opposite effect of the drug).

The most common reasons people use substances are to feel good (reward) or to escape from feeling bad (relief). Everyone wants to feel good and avoid bad feelings – that’s human nature. What happens in the brain with addiction is the person feels so good and gets so much relief that he/she pursues this “improved state,” despite the fact that over time, bad things happen and well-being is lost. The drug works so well it develops survival salience, which means that the person’s brain thinks and feels like

it needs the drug to survive – even more than food, water, sleep or sex. This state results in the pathological pursuit of reward and/or relief.

Loss of control is another key symptom that occurs for an addicted person, essentially because of a brain short-circuit, so that one drink inevitably leads to 10 and a binge, a DUI, broken promise or squandered paycheck. Cutting back does not work very well to treat addiction, because of this loss of control phenomenon. Optimal treatment is abstinence from all mood-altering drugs with the aid of outside resources such as treatment.

The other defining characteristic of addiction is continued use despite consequences. In other words, addicts continue to use even though their job is on the line, relationships are jeopardized, finances are wrecked and self-esteem is down at the bottom of a deep dark well.

The Brain Disease of AddictionBY DR. MEL POHL, M.D.

ARTICLE FORCLE CREDIT

• Stimulants include cocaine, methamphetamine, nicotine and prescription drugs like amphetamine (Adderall) and methylphenidate (Ritalin) used for attention-deficit disorder.

• Cannabis or marijuana is the plant that contains more than 150 chemicals – the intoxicating one is THC. Here some important facts about THC: Today’s marijuana is harmful, often 30 times stronger than marijuana of the past. Legalization in the U.S. has had significant costs such as hospital visits,

workplace productivity, car crashes, secondhand smoke issues and environmental concerns.

“Medical marijuana” and recreational marijuana are different—one was legislated to be a medicine and the other is used for intoxication.

Drugged drivers killed more people than alcohol last year.Adolescent brains are damaged by marijuana.Cannabinoid abuse is a growing problem in the U.S.First-time use in college is highest in three decades.Usage increased in Colorado and Nevada after legalization.Cannabis is associated with psychosis and suicidal ideation.1-8

• Opioids are also known as narcotics or painkillers and include codeine (Tylenol with codeine), hydrocodone (Lortab, Norco), oxycodone (Percocet, Oxycontin), morphine (MS Contin, Duramorph), fentanyl (Duragesic, Actiq), hydromorphone (Dilaudid), heroin, methadone and buprenorphine (Suboxone, Subzolv) to name just a few.

• Behavioral or process addictions including gambling, spending, video games, sex/pornography and others will not be discussed in this article.

There is no one-size-fits-all for treatment, and not all forms of treatment are appropriate for everybody. Treatment ought to be tailored to the person and his/her situation and needs. For more information about addiction and treatment facilities, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357.

These are the levels of formal treatment available through the treatment industry:• Inpatient levels of care: detoxification, rehabilitation and residential. • Outpatient levels of care: partial hospitalization, intensive outpatient, outpatient

and individual counseling. • Supportive living: halfway house or recovery residence.

Most folks prefer not to enter an inpatient center. If one cannot stop using, however, then inpatient stabilization in a center will be most beneficial and may be necessary, especially if the person is physically dependent on a drug.

Medications to treat addiction are available through consultation with a knowledgeable physician. These medications include: disulfiram (Antabuse), when taken daily, causes nausea and vomiting if the person drinks alcohol; Naltrexone (oral Revia, injectable Vivitrol) is a medication that blocks craving for alcohol and blocks the opioid receptor; buprenorphine (Suboxone, Subzolv) is an alternative and safer opioid medication that partially blocks the opioid receptor and diminishes cravings; methadone is a long-acting opioid that can only be dispensed for addiction treatment in a clinic with a special license; and naloxone (Narcan) is an overdose reversal drug.

Medications are, at best, an adjunct to the overall treatment of addiction. Recovery is a lifestyle and requires a critical evaluation of one’s perceptions, assumptions about life, attitudes and behaviors. Recovery involves assessment and changes to enable the addicted person to live his/her best life without substances.

For an addict, drug usage is only approximately 5 percent of the problem. Once the drug(s) or behavior is eliminated, the other 95 percent involves healing brain functions that have become disturbed by addiction – behavior, thoughts and feelings. Unless behavior, thoughts and feelings are addressed, only 5 percent of the problem is likely to change.

Recovery does not include relapse and occurs only one day at a time, however, without substances, the addict finds him or herself miserable with no relief from the physical and emotional pain. Giving up the drug and/or behavior that served as an anesthetic for problematic thoughts and feelings leaves the addict vulnerable. Eventually, relapse will most likely occur if that 95 percent isn’t addressed. Addressing the 95 percent is the difference between abstinence and recovery.

The most-used substances leading to addiction include:

• Alcohol is the most-used depressant and causes the largest number of deaths and illnesses. Alcohol is legal for those of age, causes a decrease in function with increased doses until it puts one to sleep and eventually coma if there is a high enough dose. It’s particularly risky to mix alcohol with other depressant drugs.

• Other Depressants (downers) include sedatives and anti-anxiety drugs available with a prescription, including benzodiazepines like diazepam (Valium), alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), and sleeping medications like zolpidem (Ambien), eszopiclone (Lunesta), triazolam (Halcion) and temazepam (Restoril).

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The Substance Abuse and Mental Health Services Administration (SAMSHA) defines recovery as: “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Recovery is solution-based. Some of the underlying principles of recovery include surrender, honesty, open-mindedness and willingness. Essential elements in 12-step recovery include being honest, internally examining one’s thoughts, feelings and behaviors, learning how to handle negative feelings without drugs/alcohol/behavior, and being able to enjoy life without drinking/using drugs.

Over time, enriched recovery includes engaging in a process of growth and development, reacting to life’s ups/downs in a more balanced way, and taking responsibility for the things that can be changed.

A word about spirituality and the 12-step programs. The word “God” appears in the steps and literature, and if one attends meetings he/she will hear people talk about God, but it is important to keep in mind that there is typically a broad welcoming approach to one’s individual spiritual beliefs. Some members of the 12-step programs are religious, but Alcoholics Anonymous (AA) and other 12-step programs are not religious. It appears that because of the limbic system short-circuit, which is the basic problem with the addicted brain, recovery works best with a connection to a “power greater than oneself,” which some call “God.” Belief in God is not necessary to successfully participate in a 12-step program, so please don’t throw out the baby with the bathwater here. Atheists and agnostics are welcome. Data supports 12-step programs as effective tools in recovery from addiction.

If you have been reading this article intending to help your clients, terrific. But at least 10 percent or more of you are likely to have an issue with substances of your own. If so, reread the parts about brain disease and treatment with an eye towards how you can take better care of yourself and your family. According to one study, 21-35 percent of U.S. lawyers meet criteria for substance use disorder with alcohol being the most prevalent.

Potential problems for lawyers that put you at risk for addiction include:• Competition;• Loss of good, healthy values-turn to external rewards, status, comparative worth;• Reliance on reputation-loss of

self-esteem;• Isolation, especially in solo practice;• Anxiety and stress;• Binge drinking at alcohol-laden events; and• Concealment is the norm due to multiple barriers. Addiction in attorneys is a chronic health condition, a brain disease, that is

entirely manageable using validated processes and standards of care in occupational addiction medicine (such as physicians and airline pilot programs). Successful sustained recovery with medically monitored return to professional work should be the expectation for lawyers with an addiction problem.

The Brain Disease of Addiction

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CONTINUED FROM PAGE 25

The National Academy of Distinguished Neutrals is an invitation-only professional association of over 900 litigator-rated Mediators & Arbitrators throughout the US and a proud sponsor of both the DRI & AAJ. For info, visit www.NADN.org/about

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CONTINUED FROM PAGE 27

The Brain Disease of AddictionRecovery-Focused Mutual-Help Groups:

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*0= None 1=Descriptive studies only 2 = Observational (correlational, longitudinal) 3= Experimental (random assignment, controlled). Source: Kelly & Yeterian, 201

ENDNOTES1. Hartman RL, Huestis MA. Cannabis effects on driving

skills. Clin Chem. 2013;59(3):478-492. doi:10.1373/clinchem.2012.194381

2. Wang GS, Hall K, Vigil D, Banerji S, Monte A, VanDyke M. Marijuana and acute health care contacts in Colorado. Prev Med. 2017 Nov;104:24-30.

3. Whitehill JM, Harrington C, Lang CJ, Chary M, Bhutta WA, Burns MM. Incidence of Pediatric Cannabis Exposure Among Children and Teenagers Aged 0 to 19 Years Before and After Medical Marijuana Legalization in Massachusetts. JAMA Netw Open. 2019 Aug 2;2(8):e199456.

4. Lozier MJ, Wallace B, Anderson K, et al. Update: Demographic, Product, and Substance-Use Characteristics of Hospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019;68:1142–1148.

5. Elsohly, M. A., Mehmedic, Z., Foster, S. (2016). Changes in Cannabis Potency Over the Last 2 Decades (1995-2014): Analysis of Current Data in the United States. Biological Psychiatry, 79(7), 613-619. doi:10.1016/j.biopsych.2016.01.004.

6. Volkow, N.;, Baler, R., et.al. (2014) Adverse Health Effects of Marijuana Use. N Engl J Med 2014; 370:2219-2227.

7. Petrangelo A, Czuzoj-Shulman N, Balayla J, Abenhaim HA. Cannabis Abuse or Dependence During Pregnancy: A Population-Based Cohort Study on 12 Million Births. J Obstet Gynaecol Can. 2019 May;41(5):623-630.

8. NIDA. 2020, May 27. Letter From the Director. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/letter-director on October 19, 2020.

MEL POHL, MD, DFASAM is a family practitioner and is the chief medical officer of Las Vegas Recovery Center (LVRC). Dr. Pohl was a major force in developing LVRC's Chronic Pain Recovery Program. He is certified by the American Board of Addiction Medicine (ABAM), and he is a clinical assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Nevada School of Medicine. He is the author of A Day without Pain, revised edition (Central Recovery Press, 2011) and The Pain Antidote - Stop Suffering from Chronic Pain, Avoid Addiction to Painkillers, and Reclaim Your Life (DaCapo, 2015). Dr. Pohl filmed a show for PBS on chronic pain that aired around the country in 2016.