“[We] came to believe that a Power greater than ourselves could restore us to sanity.” –(The Twelve Steps of Alcoholics Anonymous, step 2)
This week I received a letter from Dr. Vivek Murthy, MD, MBA, who is currently the United States Surgeon General. In fact, every doctor in America was sent the same letter, and this is the first time in history that a Surgeon General has reached out individually to every physician in the United States. What public health crisis was so important as to warrant this historic action? Was it the Zika virus? Was it heart disease or cancer, the top two causes of death in the US? It was none of these. His subject was the opioid epidemic, a problem caused largely by our profession’s chronic mismanagement of pain. His letter states:
“It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught – incorrectly – that opioids are not addictive when prescribed for legitimate pain.
“The results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed.”
(The full text of the letter can be found here: TurnTheTideRx.org.)
Early in medical school I was taught in a memorable lecture that it is shameful for a doctor to let a patient suffer pain. We were instructed to open the flood gates and bathe our patients in the sweet balm of narcotic goodness they needed. (The lecture was a bit more nuanced, but that was the very clear take-home message.) A year or so later during my clinical rotations I began to see firsthand a much darker side of the picture: drug-seeking addicts with insatiable appetites for controlled substances, manipulating every relationship with the goal of getting more drugs. I have seen how addiction can poison doctor-patient relationships in every specialty I rotated through in medical school and residency, in hospitals, clinics, and emergency rooms, and countless times during my career in neurology.
The human brain contains a very important circuit which produces a feeling of reward or pleasure when certain tasks are complete. This circuit is essential for survival, as it reinforces and encourages behaviors like eating, reproduction, and exercise. But this reward circuit can also be stimulated by behaviors which are not productive, like using mind-altering drugs. Everyone has this circuit in their brain, and anyone could misuse it to develop a bad habit, but some people are especially vulnerable to this risk. Some people, when exposed to a drug which stimulates the pleasure centers in the brain, will have very little power to resist the urge to use that drug again and again. They will continue using the drug despite negative consequences in their lives and will justify lying, cheating, stealing, and other harmful behaviors. Eventually an addict may sacrifice their home, family, friends, occupations, and anything else in their lives which stands in the way of their continuing to use the drug.
Over the years there has been some argument about the nature of addiction and how to treat it. The traditional view, which is still held by many, is that addiction represents some spiritual or moral deficiency. According to this model, addiction starts with sin and continues until the sinner repents. While it is obviously true that addiction is associated with all sorts of bad behaviors, there is more to it than that. A more modern view describes addiction as a biological disease based on altered brain function. The reward circuit seems to be wired differently in some people, making them vulnerable to addictive drugs and behaviors. There is strong evidence for a genetic basis for this difference, because a tendency for addiction runs very strongly in some families. About 12% of the North American population is prone to addiction, meaning that if 100 random people are all exposed to mind-altering drugs then on average about 12 of them will become addicts, who will rearrange everything in their lives in order to keep using that drug.
I knew a medical doctor who was very successful in his early career, but who nearly lost everything after he was in a bike accident and became addicted to Percocet. His disease of addiction had been lying dormant for all of his life, and he never knew that he was an addict until he was first exposed to the drug. He used more pills than he was prescribed, shopped around to find doctors willing to give him more, and kept using the drug when negative consequences started to happen in his personal life and in his professional work. Eventually the state medical board revoked his medical license, which ended his career as an academic cardiologist.
Addiction is a disease which has no cure. Once it is activated, people never return to the way they were before. Even after years or decades without using their drug of choice they can relapse back to heavy use in the course of a just a few days if they are re-exposed to it. Although there is no permanent cure for the disease, there is an effective way to manage it. The only long-lasting “treatment” for addiction is for patients to individually choose to make and maintain a radical spiritual life change.
In the 1930’s two alcoholics in Ohio worked together to produce this spiritual life change in themselves, and then spent the rest of their lives helping other addicts to do the same through the organization they founded, called Alcoholics Anonymous. They described 12 sequential steps to catalyze the change, and which are meant to become a way of life for recovering addicts. Since their publication these 12 steps have helped millions of people around the world to experience a “spiritual awakening” and to move along the road to recovery. Although it often speaks of “God” or of a “higher power” which is indispensable to the process, the Alcoholics Anonymous program is intentionally vague about the concept. Each member is encouraged to use their own concept of God to draw strength from, and is not required to accept someone else’s definition. Alcoholics Anonymous refers to itself as a spiritual program, not a religious one.
I first read the “Big Book” (the basic text of Alcoholics Anonymous) when I was a medical student working in an acute detox hospital, and I was fascinated by its spiritual philosophy which I recognized as being essentially identical to my own. The spiritual life change described in the 12 steps was already occurring in my own life through following the teachings of Jesus Christ. His teachings had become my way of life as I had iteratively revisited the process of repentance over and over again, just the way addicts are taught to do with the 12 steps. “No wonder this works,” I thought. “It is based on true principles.”
The 12 step programs are not the only way to achieve the necessary spiritual life change. I have met many successful recovering addicts who simply didn’t like the style of Alcoholics Anonymous or just didn’t get anything out of attending meetings. Some people get the spiritual life change through attending a church. Others seem to work through the steps intuitively without really knowing what they are doing.
Latter-day Saints have a unique perspective on addiction, mostly because of the Word of Wisdom. This is the Lord’s law of health revealed to the prophet Joseph Smith in 1833, recorded in Doctrine and Covenants section 89. (I discussed this revelation in a previous post in 2014.) It has been observed that all of the things which the Lord counsels against using are habit-forming: alcohol, tobacco, coffee, and tea. Modern church leaders also include mind-altering drugs in this category, so the recreational use of marijuana, pain pills, sleeping pills, hallucinogens, inhalants, etc. is also considered a violation of the Word of Wisdom.
Learning about the disease of addiction from a medical perspective has helped me to understand Joseph Smith’s description of the Word of Wisdom as being “adapted to the capacity of the weak and the weakest of all saints, who are or can be called saints” (Doctrine and Covenants 89:3). There are many people in the world who can tolerate drinking moderate amounts of alcohol without becoming alcoholics. But there are some people among us who cannot tolerate any amount. These are the approximately 12% who have a genetic predisposition for the disease of addiction, who are “wired” to become addicts if exposed to their drug. The only way to prevent them from activating their disease is for them to totally abstain from using the drug, and the best way to encourage abstinence is to place them in a society of abstainers. Whether or not I am prone to addiction myself (I hope I never find out), I am willing to go my entire life without using drugs or alcohol if it will help my neighbor avoid their addiction.
The Church is interested not only in preventing addiction but also in treating it. We have adapted the original Alcoholics Anonymous 12 steps as the core of our own Addiction Recovery Program: 1. Honesty 2. Hope 3. Trust in God 4. Truth 5. Confession 6. Change of Heart 7. Humility 8. Seeking Forgiveness 9. Restitution and Reconciliation 10. Daily Accountability 11. Personal Revelation 12. Service. The steps are exactly the same concepts in the same order, but they are taught using a religious vocabulary. Comparing the two programs side by side is enlightening.
If the effective treatment for this condition relies completely on patients choosing to radically change their own lives, then what can doctors do to help? The Surgeon General suggested a few ideas in his letter. For starters, we can be a lot more careful about how we prescribe controlled substances and about how we monitor patients for the development of addiction. We should not be adding fuel to this fire.
I remember a conversation I had with a nurse a little after midnight on a very busy call night when I was an intern. This nurse was taking care of a patient who had been persistently and forcefully requesting intravenous narcotics for pain throughout the evening, but did not outwardly appear to be in severe pain. She said that the patient was reclining in bed, eating potato chips, talking on the phone, and watching television, but every hour or so would call for the nurse and report that he had “10 out of 10 pain,” and would ask for a stronger medication to treat it. All that I knew about the patient was from a short paragraph written by the intern who had taken care of him during the previous day. And my to-do list included evaluating several other patients who seemed far more deserving of my attention than this patient did.
“No matter what I do, we don’t win this game,” I complained to the nurse. “If I give an order for some IV narcotic, it can make our night quieter, but it just feeds the beast of this guy’s addiction and he ends up worse off. If I resist his demands, then it doesn’t really cure this guy of his problem, and he can make our night miserable.”
The nurse looked at me in silence, apparently having heard this soliloquy before. “So what do you want to do?” she finally asked.
I looked down and breathed a deep sigh. I was very tempted to give the patient his fix so that he would leave me alone for the rest of the night. No one would fault me very much for adding just one more drop to the bucket. But this felt like the wrong thing to do. It felt like being part of the problem, and I always prefer to be part of the solution. Finally I said to the nurse, “If I can’t win the game, then I should at least do what I think is right. I’m not giving any pain medications beyond what was ordered by the day team.”
She shrugged her shoulders and said, “Alright. You’re the doctor.” And so began a night that I expected to be very long. But it wasn’t as bad as I expected. I think I only heard back about that patient once or maybe twice, and it was easier to hold firm after I had staked out my position at the start. In fact, my decision that night changed my approach to these situations forever.
Doctors can also help educate patients and the general public about addiction. Many patients over the years have heard my pep talk/lecture about addiction recovery. One memorable occasion happened several years ago in the hospital. A young woman had taken some additional medications from home without telling any of the medical team, and this led to an overdose when the nurse administered her hospital medications. We found out what was happening and averted the disaster using naloxone and flumazenil, medications which act as antidotes to narcotics and benzodiazepines. Later I came back to this woman’s room to talk with her, and she freely admitted what she had done. For the next half hour or so we talked about her addiction and her various struggles against it. She had been to a few 12 step meetings, but had never really tried to follow the steps.
“Do you have a higher power?” I asked.
“Yes, I’m a Christian,” she replied.
“Then I know your Higher Power,” I testified, “and I know that he has the power to heal you if you will turn to him and ask for his help.”
From a medical point of view I was simply offering this woman the only effective treatment for her disease. I don’t know what happened to her, and I never saw her again after that night, but I like to think that I helped her in some way.
The treatment of addiction is an example of the general truth that God is the ultimate source of strength and healing. This is true for any medical condition or any other challenge in our lives. The pattern of repentance outlined in the 12 steps is the same pattern that prophets of God have taught for millenia. It worked in ancient times, and it works now. The gospel of Jesus Christ will always work, and it will always be the right answer for the greatest challenges faced by God’s children on Earth.