Episode 18 – The Opioid Epidemic
Dr. Ashish Bhatt ❘
What caused the Opioid Epidemic? And more importantly, what can be done to stop it? Dr. Bhatt, MD breaks it down.
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Hayley: Hello, my name is Hayley, and you’re listening to “Straight Talk With The Doc.” with Dr. Bhatt, a podcast that answers your questions on addiction and mental health. I’m here today with our content director, Jeff and of course, Dr. Bhatt. And today, we’re going to really examine addiction.
Now, we’ve all heard of addiction, and most of us have probably known someone who has struggled with it, and maybe we have struggled with it ourselves. Today, we are going to break down what addiction really is, and what’s going on in the brain. Dr. Bhatt, could you give us the definition of addiction and then talk to us about why that definition is what it is?
Dr. Bhatt: Sure, thanks Hayley. I think addiction, it probably can be interpreted differently by different people. To define it, probably could come up with multiple renditions, depending on where you are in the world. But here, mainly in the United States and in the addiction community, we see it as a disease. We have the disease concept of addiction and we really look at it analogous to other chronic diseases.
If you look at some of the major authorities here that dictate how we practice the standards of care, look at the American Society of Addiction, they do have a definition that talks about addiction being a chronic medical disease that involves interactive, interaction of brain circuitry, genetics and environment and an individual’s life experiences and how one engages and responds to substances of abuse in a compulsive-obsessive manner despite negative consequences.
So they’ve kind of summarize it to be a little bit looser, this definition has evolved over the last many years but I think the take-home message is that it’s a chronic medical illness that is manifested with a lot of maladaptive relationships with substance use despite negative consequences.
Hayley: You mentioned how it’s changed over the years. Can you talk about why it’s changed?
Dr. Bhatt: Yeah, I mean I think many of us know, at least those of us who practice in this field that a long time ago, or not so long time ago, addiction was looked at as a behavioral problem. It’s something that you could just talk it out of them, that people had some sort of weakness or lack of willpower, and we’re doing this with the ability to just change, turning the light switch on or off, really force the medical community to re-evaluate is that really the case? And that’s evolved over time.
So going from a place that would just be a weakness of a lack of willpower to more of a medical disease concept has helped us really even the levels of playing field and allowed those who suffer from addiction and mental illness to actually receive the care for medical services. So going from a real non-scientific definition a few years ago back I think it was back in 2011 where the American Society of Addiction went and really defined it as a chronic brain disease of motivation, memory and reward of related brain circuitry. And that evolved then a little bit more to a little bit looser interpretation of what we just spoke about, a minute or so ago.
Hayley: And not only have people’s opinions changed, but I also feel that society’s views have really started to evolve on addiction.
Dr. Bhatt: Yeah for sure. I mean I think culture plays a big part, and I’m hoping society’s views haven’t changed because of the impact it’s only taken on us financially and the cost economically, but also the fact that they are open to really looking and seeing it as the disease concept and getting the help for these individuals. Because something it’s unfortunate that when it hits people, it is hitting them in their pocketbook?
That’s usually attributed to doing something about it? But looking at it from cross-cultural perspective, yeah, I think there’s some ethnic groups, me, myself, I mean, I’m of Indian descent. I know people from India historically, they thought people with mental illness or substance abuse problems just really had, you know they really had to snap it out of them. It wasn’t about some underlying neurobiological changes that are occurring in the brain. I do believe, where you are, how you grew up, the family that you’re within, either the impact it’s had on your life, it influences how it define or accept the definition of addiction.
Hayley: Like you said, it is a brain disease. Can you tell us what’s going on in the brain when someone’s having an addiction?
Dr. Bhatt: It is complicated. There’s so much going on in the brain, I mean brain is the most awesome organ that we have and the brain is made of so many different things going on inside. But to simplify, nobody knows what relationship a substance has with you and our body. I mean genetics plays a huge part. But what we do know is that there are some chemical changes that occur, so when somebody starts using a substance for example that provides them sort of reward, that happens because it’s affecting a major neurochemical; that’s dopamine, so we start to see this kind of relationship develop when the drug creates a reward that makes somebody want to pursue it more.
If they start to feel good because dopamine’s increase because a certain substance is introduced to them, that motivates them to use it again. It’s when that imbalance starts to occur when somebody tends to use where they continue to use despite the negative consequence that is happening in their lives. What hierarchy gets altered so they continue to use despite all these things that are going wrong.
Jeff: I know Dr. Bhatt that you, you’re just talking about how addiction is a biological, medical condition. Do you feel like, obviously genetics plays some role on the development, but also cultural and social factors and individual personal choice impacts the development of addiction too. Can you maybe discuss some of the factors that influence addiction a little bit?
Dr. Bhatt: From what we know, at least the science has been evolving to said, let’s say the majority 50% of someone’s predisposition to develop addiction is genetically based. We say genetics, that’s half of it right there. The other half is everything else that occurs in your life. So if you have the genetic–and genetics doesn’t simply mean inheritance. I think sometimes people get that confused. Genetics meaning the underlying construction of us on a microscopic level at a very small level. That’s our building blocks.
Everybody might be genetically similar in some way, but that doesn’t mean they’re all going to have the same resiliency when exposed to a substance of abuse or any substance at all. That compounded with the presence or absence of other risk factors, if you have an underlying mental health condition or medical condition, a pain disorder, if you’ve been exposed to trauma or abuses in your life, if you’ve used earlier. The right insult, the right time, combined with the right risk factors, on top of your underlying foundation that really set against the backdrop of the environment you live in that kind of all together plays the roles in formulating someone’s path to addiction.
Hayley: You mentioned trauma and abuse. Can you tell us what are the other risk factors?
Dr. Bhatt: Some of the other risk factors is really early onset. From some of the studies that are done through NIDA and other governing bodies–let me say that–we do see that early onset of usage, early frequency of usage, if there is certain genes that are present the ones that we do know, can’t help be protective, especially in the development of alcoholism or an alcohol use disorder. If concurrently, you are having, I would love to say mental health really plays a huge factor I believe in further using substances. Because somebody’s depressed, and at the start they start using cocaine, it alleviates their depression.
It’s gonna be a negative reinforcement. It’s taking away their depression, so they’re gonna continue to use. Similarly if somebody suffered from anxiety, they can benefit from drinking a beer, in their mind, that’s it’s helping them calm them down, getting rid of their anxiety. There’s been a further solidify them using. So trauma, abuses, earlier onset, presence of absence of mental health issues, and also physical conditions. I mean pain, trying to get rid of pain right now, physical, psychological that’s contributing now to a lot of people using and using in excess.
Hayley: So what does that use become in addiction? Because somebody having a beer doesn’t necessarily mean they’re becoming an alcoholic. When that does transition?
Dr. Bhatt: It transitions from a chronological perspective individually. Neurobiologically, it’ when there’s enough of these changes when it occurs in the brain, where the ability to sustain from the substance, there’s a certain amount of control, there’s a certain amount of craving, a dysfunctional recognition of negative consequences and than there’s emotional liability and fluctuation and when those five characteristics keep going on and become a persistent pattern throughout a certain period of time while engaging with a substance of abuse, use and misuse, which creates this dependency all together. I mean I don’t want to rattle off the DSM criteria for a substance use disorder in essence I’m trying to paint a picture that somebody is using and using in an obsessive compulsive way, and they’re functioning.
It starts affecting parts of their lives that weren’t affected prior to drinking. Now there’s cut off levels that qualify us for heavy drinking, or binge drinking but in essence, when you’re drinking or using drugs to the point when your life becomes a negative. You’re having a disorder that’s starting to come about.
Hayley: What about the case of say…someone’s a high functioning alcoholic, they’re able to hold a full time job, they might still have good relationships. Can you talk about that a little bit?
Dr. Bhatt: There’s a lot of dynamics involved with that, because some people who would cheat higher end jobs are employed. They often come from certain types of backgrounds, temperament, resiliencies that have allowed them to get to that level. They tend to have certain other characteristics that can help them compensate. A lot of times, you’ll see the breakdown occur first in their personal life because there’s less external accountability.
They’ll start drinking when they come home, and they’ll start, their wife or husband or spouse getting, recognizing first, they might end up getting in fights, but then when they go to work, they kind of step it up a little bit and they find themselves vulnerable to externali(?) of their employment that helps them earn a living. You’ll see this person maybe start to decompensate in their private life, but they tend to work and stay employed but that starts to take effect later on. Usually, I’m talking about this for everybody, but we tend to see preservation in employment but we see functionality happening. People tend to have their personal life affected first. We often will see these benign functional people because they can fulfill external obligations, but it does not mean they are not suffering from a substance use disorder.
Jeff: We talked about alcohol, and I know that is the most commonly abused substance in the United States, most of the world and also what is the most common addiction. But is addiction to different substances fundamentally similar? I know there are specific differences between how different substances affect the brain, but in terms of the addiction process and the development of an addiction, are there significant differences or are there fundamentally the same from substance to substance?
Dr. Bhatt: I would say fundamentally it’s the same, the way that we understand it is like I mentioned before. Once the drug is introduced or substances introduced, the relationships in how it affects the brain, the reward mechanisms, the motivational mechanisms, the changes in the hierarchy, they usually end up following a similar path, in terms of the reward mechanism, and the development of an addiction from the neurological, neuroanatomical perspective. They follow a similar course.
Hayley: Besides alcohol, what are the other most commonly abused substances? Cause obviously some are more addictive than others? What have you seen in your work?
Dr. Bhatt: I mean I think one of the things we don’t probably talk about is nicotine, it being the most addictive substance that’s there, and that’s really a high toll that it has on morbidity and mortality around the world that’s a very addictive sustenance. But beyond that we’ve seen such a huge risk I think in everybody it’s so publicized, not just effective people on a personal level who may not be listening to this, I think when you see it on television and the government talking about it the Opioid Epidemic, that’s really been something that has been something that has hit hard, really hard. I think we’ve seen things change over the chronology of time, from the 60s and the 70s through this decade.
Currently we’ve seen a rise in multiple different levels of drugs and overdose, especially during the COVID pandemic. Not only have we seen the Opioid Epidemic hit so hard, but we’ve seen rises in other things and other classes of drugs and alcohol, cocaine, cocaine actually overdose and deaths have spiked over the more recent years than I would have thought. I think they go through their stages, but definitely I think opioids, and both prescription pills and heroin, and then these kinds of other offshoots of opioids I think those are really the biggest deals right now only because of the mortality that’s associated, the rapid death that can occur with those drugs.
Hayley: Also, you brought up the pandemic. I wanted to talk a little bit about the mental health issues that have arisen through this time and how those connect to substance abuse.
Dr. Bhatt: I mean I don’t know one person that’s one affected by this right? None of us do. It’s a pandemic that affected the world. I think that the amount of stress, the anxiety, the unknown, obviously it would take people that who are susceptible who, if I had to divide those who suffer from addiction or mental health issues and those who didn’t, I think when you put someone with external stress like this within this magnitude, you’re really challenging their sobriety. So the increase of I think the way that the world was unprepared for this, we’re living our lives daily. I don’t think everybody’s thinking, “Am I gonna catch the next superflu?,” and at least not here, maybe in the U.S. as much because we are considered scientifically and medically advanced, we haven’t been running around with masks and stuff like so. When this happens, there probably is different stages of acceptance with how this will affect this person.
Depending on your background if you are somebody who is catastrophic in your thinking and you suffer from an addictive process, you could use that from early on to say “Oh my God, what’s the point? To get a case of the ‘I don’t give a damn; let me just go head and relapse,” but then that’s different that somebody that really starts to have a true exacerbation of their mental health symptoms that ultimately suffer from stress and anxiety then starts to drink more and more excessively and use substances that they weren’t using previously. I think there’s a combination of both. You’ve seen people relapsing. then you’ve seen higher usage on substances of people who probably didn’t meet a substance use disorder during this time.
Jeff: So Dr. Bhatt, we talked a lot about what is addiction generally, but for individual listeners who are wondering maybe if they are suffering from addiction on a specific individual basis, what would be the best way for someone to get answers to those questions for their individual circumstance about themself of someone that they love?
Dr. Bhatt: That really depends on their resources. It’s hard to get information for yourself not just because we’re here speaking, and we’re online and on air, that we service and information data bank at AddictionCenter.com, we’re always available to provide information to those seeking help. People go online nowadays, and it’s the first step people try and do to seek help for things regardless of whether it’s a medical illness or a health issue, and I think that’s the first place people look.
We’re taught in medicine we should be providing primary, secondary, tertiary interventions. So hopefully, if somebody has you in a primary care provider, not feeling the stigma, the taboo that can’t bring it up because a lot of times, people who are suffering from underlying conditions, they don’t bring it up to their internist or their family doctor. It’s unfortunate, because these doctors are there to help. They can help earlier on than they are maybe perceived. And maybe due to the shame and to the guilt, they won’t bring that up.
This is that compounding relationship that society’s understanding that they can seek help from those individuals earlier on. Or they are suspecting substance use issues or mental health issues, but also the primary care provider’s responsibility to increase and enhance screening for these issues. It’s a combined, I believe, proposal that I would say that everybody needs to do for yourself or an individual. Most people are looking online there’s obviously other nuanced places that they can go to, but how do you first come out to discuss it? I think you try and seeking a healthcare professional, even your doctor or going online is a place where people look first and foremost.
Hayley: What could somebody expect from treatment? If they think that they and are struggling with an addiction, but they really have no idea what to expect? What would that start with?
Dr. Bhatt: I think treatment varies for each individual; it should be determined based on the needs of a person, uniquely. I don’t think a treatment center private, public, can treat everybody. They need to recognize their limitations. There are uniquenesses, unique characteristics to be matched with a patient’s needs. Depending on what is determined, there are multiple levels of care that are established by the American Society of Addiction Medicine. It starts anywhere from when directly talking about substance abuse… is there’s inpatient high acute levels of care, all the way to early intervention, which is a lower level of care for lower intensity, lower impairment, higher functioning individuals.
Depending on where you are in your addiction, and how are you functioning from a withdrawal, an intoxication perspective, how are you functioning from a psychological and emotional and cognitive perspective? How are you suffering from how’s your recovery environment? Do you have a place to stay? What’s your relapse group? You match those multiple dimensions up amongst the person and use it kind of like a crosswalk that ASMI has established for people and see such level of care would best suit them.
I know I’m not going into specifics, but a person willing to withdrawal should end up in a detox facility so that you can get adequate and somebody, who, might be smoking cannabis here and there but is contemplating stopping, but is still functioning not have a major negative impact happening in their life maybe wants to go to a lower level of care, so it really depends on the individual and where they’re at.
Hayley: I feel like a lot of people are struggling, but they’re like “I can do this on my own. I don’t need to get help.” Do you think professional treatment is always better?
Dr. Bhatt: There’s the statistical answer and that evidence has shown if you seek treatment and you engage in treatment, you’re gonna have a better outcome than those that don’t see it. But that’s based on the clinical population that is being looked at at that time. It’s very hard to assess how many people who are out there who would meet a substance use disorder diagnosis, and who are getting better without treatment. It’s hard to give you that number or that percentage and especially because we’re talking about a global issue.
From our experience though, from people who are engaging in treatment, who are relapsing, going back to treatment, if they attempt treatment, go through the support systems, have their underlying co-occurring illnesses identified, and get on appropriate medications they may need–yes their outcome would be much better than if they don’t receive that type of support through those therapeutics, environmental changes and appropriate meds if needed.
Hayley: Are there things people can do to decrease their chances of relapsing?
Dr. Bhatt: I think people use this phrasing, “Work the program” it’s really looking tat those multiple dimensions of their lives that have affected them in not replicating those things that they used in the first place so whatever environment was conducive to them using, they have to change that whole construct that might include avoiding people, places, things and situations that triggered certain thoughts, that created certain emotions that led to certain behaviors. It means changing a lot of your life to help you live a positive life. If there were negative friends that you were using around, avoiding those people.
Obviously I’m saying this in a very constructive way, it’s not necessarily an easy thing to do when you’re suffering from something that has hijacked the way you think. In essence, it is really about creating that proper support system, that environment, getting on the right support system if you need it, and staying engaged. I think social isolation and not being/having a good network of people around you that are sober and healthy supports really deconstructs your chances of staying substance free. Definitely, changing the construct of which your substance use existed psychologically, socially, environmentally, spiritually, and putting those, replace those, with positive variables and positive people and that’s really, the way that you could stay, at least increase your chances of staying substance-free.
Hayley: Right. Yeah I’m sure that takes time too though to kind of build up that support system. Not everybody has that right away if they get out of treatment.
Dr. Bhatt: And how are people thinking about that when they’re obscured with substances on their mind right away? I think that’s what happens. When you’re talking to somebody who’s still in the acute phases of addiction, I don’t think they’re thinking correctly, they’re not feeling correctly. They’re motivation to change is often so distorted. And their motivation to do anything; the reality becomes so obscured because you’re living a life that is artificially created. It’s being created by the substances that are powerfully affecting how you think, feel, move, breathe, so, trying to be rational at that point becomes very hard, and trying to look out for your self preservation becomes even harder.
Hayley: Yeah, absolutely. Jeff, do you have any questions for Dr. Bhatt?
Jeff: No. I don’t think that I do. I think this has been a great discussion we’ve had.
Dr. Bhatt: I appreciate you guys speaking with me today and I think it’s such a complex theme and it affects us all differently. And sometimes unless it affects you personally, sometimes people don’t think it’s something to deal with. Just on a major chronic medical condition, addiction’s taken a toll on our world. I think everybody has a role to play in helping; and especially if you know somebody that is suffering with addiction, pointing them in the right direction, and the right tools; and I know at AddictionCenter.com, I know there’s a lot of information there, so hopefully people reach out.
Hayley: Well thank you for talking with today, Dr. Bhatt, and thank you to everyone who tuned in to another episode of “Straight Talk with Dr. Bhatt.”
Jeff: Thanks guys.We’ll talk to you guys next time.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.