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Pressing Questions About Addiction and Mental Health: Part 1
July 14, 2020
Weill Cornell Medicine, in conjunction with the 92Y, presented a full-day summit about mental health for the public. Throughout the day, experts from Weill Cornell Medicine shared their insights about mental health, mental illness, and other important topics, answering attendants’ questions along the way.
During one session, Dr. Richard Friedman joined Dr. Mitchell Rosenthall to answer questions from attendants about mental illness and addiction.
Dr. Richard Friedman is a Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medicine. His clinical and research specialties include anxiety and mood disorders, as well as psycho-pharmacology and refractory depression. In addition to treating patients and conducting research, Dr. Friedman also frequently contributes to The New York Times as an op-ed columnist.
Dr. Mitchell Rosenthal founded the Phoenix House in 1967 in New York City. Under his leadership, the organization grew to become the nation’s leading provider of alcohol and drug treatment. Currently, there are 52 locations across nine states that offer 97 programs for 3,530 patients. Dr. Rosenthal also founded the Rosenthal Center for Addiction Studies, an organization that provides information to individuals and families grappling with addiction, healthcare professionals, and policy makers.
Understanding that there is strong interest in the correlation between mental health and addiction—as well as pervasive misinformation and misperceptions—Dr. Friedman and Dr. Richard invited attendants to ask their pressing questions. Here is a summary of this important discussion.
There are new drugs being used to treat addiction. Are these really “miracle drugs”? Can they “cure” addiction?
“For almost all addictions, it’s never simply a drug that’s enough to solve the problem,” asserted Dr. Friedman. “It’s never simply a drug that’s enough to solve the problem because although the drugs target the brain, they involve a whole host of behaviours that are linked up with everyday life. You can definitely cut craving and make it easier for people to stop drugs by using, let’s say opiate blockers.”
“Let’s say,” he continued, “that someone is addicted to an opiate like heroin or Oxycontin. Drugs like naltrexone can be lifesaving. They cut the craving for the drug by blocking the receptors in the brain. But they don’t change patterns in your life. They don’t change all the associations that you have with this drug, your past experiences with this drug. And you still have to learn to live your life without the drug. That requires a lot more than just the pill.”
“Drug use used to be considered a character problem—and is too often still thought of this way—drug use is a character problem, it's a weakness,” detailed Dr. Friedman. “But we really know that addiction is a brain-based problem. There are differences between people who get addicted versus those who don’t. And it’s not weakness, it’s not character weakness. It’s actually genetic biological differences.”
“So you can’t just say to somebody who is addicted, ‘You know what? Cut it out. Just pull yourself up and stop using that drug.’ Drugs like naltrexone are effective because they deal with the biological process.”
Dr. Rosenthal continued, “This is such an important point, because there are many people who believe that these new miracle drugs are all that you need. But it really is a beginning. It allows you to get the biological cravings out of the picture and get yourself engaged in self examination and social interaction and jobs—and all the things that will go on to make you successful.”
“One of the worries that I have had in the last couple of years—as we have these wonderful adjunctive drugs—is that people say, ‘Oh, this is all that I have to do.’ And that would be a terrible mistake,” concluded Dr. Rosenthal.
Does the brain heal after drug use stops?
“This is a wonderful question,” said Dr. Friedman. “You’ve been exposed and, let’s say, begin abusing the drug and become dependent, and then stop. Does the brain somehow restore itself and go back to how it was before using the drug?”
“We know from studies in humans and animals that the brain is very plastic and changes and does reset,” he explained. In studies on animals, evidence suggests that the changes are not permanent, unless the drug contains a contaminant.
What is dopamine? How do drugs affect dopamine levels?
Dopamine is a type of neurotransmitter that the body produces. It affects many aspects of our mental and physical function, including how we feel pleasure.
Drug use causes a surge in dopamine. “One of the things that predisposes people to use drugs in the first place is having too few dopamine receptors,” detailed Dr. Friedman. “Drugs release dopamine in the brain, and this release is what makes people feel euphoric and tells the brain a message. This is an important experience, and it helps set the person up for addiction.”
Interestingly, many mental health disorders are associated with having either too many or too few dopamine receptors.
“When they get chronically exposed to a drug, the brain actually changes,” continued Dr. Friedman. “The receptors actually get smaller in number and they become less sensitive. And what does that do? It makes the person more wanting to use the drug because if you have fewer of these receptors, you’re basically walking around in an under-stimulated state. But if you stop using the drug, the receptors do go back up.”
Nature versus nurture: what is more important when it comes to being predisposed to addiction?
“Let’s say,” described Dr. Friedman, “your parents had an addiction to cocaine, there are specific genetic variants that might increase the risk of addiction. And there are different variants with different frequencies, and they only contribute a very small amount to the outcome. So, the answer is that you’re probably at a slightly higher risk, but it’s not that high.”
Learned behavior and exposure are more influential, but much more difficult to understand or study. “Behavior is a very complicated thing with lots of inputs,” said Dr. Friedman.
“If you have parents who have not recovered, who are using drugs or alcohol, and whose behavior is out of control in different ways—including different types of abuse—then you’re talking about a very different equation,” explained Dr. Rosenthal. “And certainly, a lot of the people who have seen—maybe most of the people we have seen at Phoenix Houses over the years—have had real troublesome backgrounds.”
“If you take somebody who’s at low risk, genetically, for addiction and put them in a situation where they have easy access and exposure to drugs,” detailed Dr. Friedman, “you will actually convert them from low risk to high risk.”
The good news is that this is reversible. “You can take away the drugs, be in a program, and remove the influence. By doing this you will actually lower the risk and change the brain,” said Dr. Friedman.
“Let’s say you got high in your friend’s house, stopped using the drug, and then later visited that friend again” he continued. “Well, guess what happens? You go into that room and, without you being consciously aware, you start to crave the drug because your brain has linked to all these situations. People experience craving to all the cues that are linked to the experience of using a drug. You can't just get rid of the craving. You have to rewire experience to change the link between these cues and the craving.”
Is there hope for recovery?
Dr. Rosenthal has worked extensively with people struggling with addiction to rewire these experiences and change their lives through treatment.
“You really want to change the social fabric, you want to create new relationships, that’s what long-term treatment is about,” he explained. “Whether it’s seeing a counselor or alcoholics anonymous, narcotics anonymous, or these other wonderful institutions. Because forming relationships with people who have been able to change their lives, who have become reflective about their lives, who understand themselves, having the support of these people while you make that journey is critically important.”
“And it’s inspiring! It really is inspiring to see somebody who comes into a program homeless, addicted, very unhappy, with maybe little education, and then a year or so later starters to go to school, finds out he or she is actually quite bright. One person I saw go through treatment graduated from Harvard Divinity School.”
“In the midst of the raging problems that we have now, it can seem very hopeless. I like to remind people that we have more than 20 million people in America who are in recovery. This is a very treatable illness, but it has to be treated.”
Learn more about the therapy and behavioral health services offered by our skilled and compassionate psychiatrists, the Midtown Center for Treatment and Research, and the Phoenix Houses of New York.