In the previous article, I tried to shed some light on this current “Opioid Epidemic”, the social and political complexities and it’s intersection with the HIV/ Hepatitis epidemics.
Most recent estimates are that about 9% of new HIV infections in the US are due to injection drug use, primarily opioids. In Eastern Europe, the situation is very different. In Ukraine, it is estimated that about a quarter of all new infections result from sharing needles during heroin use with an infected person, whereas in Russia, that percentage goes up to a staggering 50%! These countries along with other Eastern European countries have very serious opioid epidemics fueling their high HIV infection rates and unlike African and Asian countries, they have failed to implement policies and interventions that have been proven to slow the HIV epidemic.
If there is a silver lining, at least here in the US, we can treat opioid addiction effectively and we have ways to prevent transmission of HIV to uninfected drug users. So let me start by presenting some very basic principles about addiction. Everyone who uses a particularly addictive drug doesn’t become addicted, in fact, most don’t. Recreational drugs have different addiction potentials.
For example, with alcohol, only about 1 in 20 persons who use it will develop an addiction, whereas, for cocaine, it could be as high as 1 in 3 users becoming addicted. There are many factors that determine whether you will be that unfortunate person who becomes addicted. Psychosocial factors are very important determinants but there can be genetic factors as well.
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How can we tell if someone is addicted to a drug? There are certain common features for all addictions.
1. Inability to control use. A person finds themselves unable to stop using the drug even when there are problems related to their drug use (e.g. driving while intoxicated, financial chaos, damaged relationships, loss of employment). There are people who can pretty remarkably hold it together in spite of drug use that is out-of-control, so called “Functional addicts”. But eventually, they will succumb to the consequences of drug use.
2. Tolerance: increasingly more drug required to get the same effect. The body tries in many ways to minimize the effects of the continuous exposure to the drug. This is a defense by the body but for the addict, they are still trying to reach the desired effect. So more drug is needed to overcome the body’s defenses and achieve the “high” the addict craves.
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3. Withdrawal. As mentioned above, your body attempts to counteract the effects that a drug produces by activating opposite effects. For example, continuous exposure to a depressant like alcohol will drive the nervous system to activate stimulatory systems to counteract the depression on the brain. This tug-of-war between the drug and the body’s defense result’s in a sort of “truce”. The body has adapted to the continuous effect of the drug and counteracted it. Now, if the drug is abruptly removed, the brain is thrown off balance because the stimulatory actions that were protective no longer have any alcohol to work against. Now the body is in a hyper-agitated state that can actually be very dangerous. This very uncomfortable state forces the person to seek more drug and reestablish the balance.
So how does one get addicted in the first place? Most drugs activate pleasure centers in our brain. Our brain has a reward system that encourages behaviors that increase individual survival and perpetuation of the species. When you eat your favorite food, usually high in fat and sugar, the pleasure centers are activated. This is because, in nature, the consumption of high caloric foods provides a survival benefit because access to food is often unpredictable. Sex also activates pleasure centers (did I need to say that?) and without sex, a species becomes extinct (very little chance of that with 7 billion+ humans on the planet).
The euphoria and intense feeling many recreational drugs produce are linked to these pleasure pathways. The nerves involved in these pathways release the chemical dopamine. This neural chemical dopamine drives the desire for the drug and establishes the foundation for the addiction. Again, who becomes addicted to a particular drug and who doesn’t is often complicated and hard to predict.
As we can see, there is a whole lot going on in the brain during the process of becoming addicted. All of the changes the brain goes through in adapting to an addictive compound change the structure and chemistry of the brain. The brain of an addicted person is not a normal brain. Even if the person ends the addiction, it will take years for the brain to normalize, if it ever does. But it’s not just about nerves and chemicals and the body, it is just as much about behavior.
The process of addition leads to drug-seeking behaviors and patterns that drive the addiction. What are the situations where the person is using the drug? What are the emotional triggers that make a person use? Who are the people the person interacts with to acquire and use drugs? What measures does the person use to conceal their drug use? How do they get the money to support it? These behavioral aspects of the addiction may contribute to the changes in the brain networks and reinforce the addiction.
We can use medicines to treat drug addiction (there are medicines that suppress craving for the drug of abuse and halt withdrawal). We can use behavioral models to treat drug addiction (e.g.12 step programs, cognitive behavioral therapy). While either approach, medicinal or behavioral can be effective, It is my belief that both areas should be targeted to get a more effective, durable response to treatment. In the next article, I will present some treatment options for persons addicted to opioids, whether they are prescription or street drugs. I will focus on approved medicines.
Dr. Crawford has over 25 years of experience in the treatment of HIV. While at Howard University School of Medicine, he worked in two HIV-specialty clinics at Howard University Hospital. He then did clinical research as a visiting scientist with the AIDS Clinical Trials Group (ACTG) at Johns Hopkins University School of Medicine. He served as the Assistant Chief of Public Health Research with the Military HIV Research Program where he managed research studies under the President’s Emergency Plan for AID Relief (PEPFAR) in four African countries.
He is currently working in the Division of AIDS in the National Institutes of Health. He has published research in the leading infectious diseases journals and serves on the Editorial Board of the journal AIDS. Any views and perspectives in his articles on blackdoctor.org are not representative of any agency or organization but a reflection of his personal views.
