David Sheff is the New York Times bestselling author of the powerful and inspirational book “Beautiful Boy”. David will be doing a book-signing event at Loft 107 to celebrate the release of his new book “Clean” which comes out on April 2, 2013.
Teenagers And Addiction: They Are Not Simply Younger Adults
“Youth are heated by nature as drunken men by wine” Aristotle (350 B.C.)
“I would that there were no age between 10-23, for there’s nothing in between but getting wenches with child, wronging the ancientry, stealing, fighting…” Shakespeare “The Winter’s Tale”, Act III (..1594)
As the medical field continues to make strides towards gaining a clearer understanding about the disease of addiction, one of the greatest challenges remains the understanding of how drugs of abuse and addiction affect teenagers.
Far from being simply “younger versions of adults”, teenagers are at a stage of brain development that is, as it turns out, developmentally unique. That is, as the human brain develops from childhood into adolescence, certain brain regions seem to flourish, and other areas don’t fully develop until adulthood.
Over the past decade, advances in brain imaging have allowed scientists to more fully understand the process of normal adolescent brain development, and this in turn has had a great impact upon our current understanding of how teenage addiction and the impact of substances of abuse affect the developing teenage brain.
During this normal time of developmental “limbo,” teenagers are prone to risk-taking, pleasure-seeking and experiencing intense emotional reactions to seemingly minimal problems; likewise, they often lack the ability to effectively weigh risks vs. rewards, make reasoned judgments about the consequences of their actions or make sound decisions during times of emotional upheaval. In fact, neuro-imaging studies have shown that when making emotional decisions, teenagers and adults utilize different parts of their brains; teenagers rely on a more primitive brain area called the Amygdala and adults utilize the Prefrontal Cortex, a more mature brain area that is last to fully develop. (See Figure 1)
To further complicate matters, these developing regions of the teenage brain that are growing rapidly towards the “balanced” adult brain, are the very same regions that are biologically prone to damage from drugs of abuse! (See Figure 2)
The reason this is so important is not only because developing a clear understanding of the adolescent brain’s vulnerability to drugs and alcohol will likely provide key insights that allow for more effective treatments, but also because parents who bring their teenagers in for evaluation and treatment need to understand that their kids are not yet adults, and therefore require specialized care and treatment that is known to be effective for adolescents.
It is important to realize that while many teenagers manifest signs and exhibit symptoms that indicate a likely problem with substance abuse such as declining grades, behavioral problems, social isolation and irritable or aggressive behaviors, this is not always the case. That is, a good number of young people with teenage drug addiction issues look absolutely normal in terms of their ability to function, maintain good self-care and even perform well academically!
Another important issue is the fact that many teenagers who experience problems with drugs and alcohol also suffer from co-occurring psychiatric problems such as attention deficit hyperactivity disorder (ADHD), anxiety disorders, mood disorders, and other behavioral health issues, which not only make them more vulnerable to developing serious problems with drugs in the future, but may affect their course of treatment significantly. Therefore, it is of paramount importance that a qualified addiction specialist be involved early on.
As a parent, or a friend of a teenager who you suspect may have a problem, it is never too late to get help. The best place to start is with an evaluation by an addiction specialist with expertise in the treatment of teenagers, or a treatment facility that specializes in teenage drug addiction treatment.
I. An Exciting and Challenging Time in Recovery
The period of time immediately following one’s stay at a residential treatment facility for addiction is one of the most misunderstood periods of recovery. Family members, partners, friends, employers and even clients often have the misconception that a person who has just completed a course of treatment is not only healthy, clean and sober, but is also ready to re-enter the community “firing on all cylinders”, ready to return to the way life was before addiction took hold.
Unfortunately, not enough attention is paid to making sure that everyone understands that this is a difficult and challenging time when a large number of clients relapse.
Even among those who do recognize the challenges of re-entry, many do not take the steps necessary to ensure the best chance at sustained recovery. While many people can tell you that the first 90 days post-treatment is a vulnerable time, few seem to offer sound advice about how to maximize the chance for success.
There are essentially four major reasons why those who successfully complete a course of residential treatment relapse:
- Upon return, they do not participate in a continuing program of recovery;
- i.e., AA or other 12-step program, continuing relapse prevention treatment, sober living, therapy with an addiction specialist, etc…
- They try to return to a high level of functioning too quickly;
- i.e., work, parenting, dating, or other high-pressured responsibilities.
- They continue to associate with substance using peers in environments where drugs and other temptations or “triggers” are readily available.
- i.e., socializing with substance using peers, hanging around bars, parties, etc…
- Support systems expect too much of them upon return, and expectations for sustained sobriety in the context of high functioning are unrealistic.
Make no mistake, this is a huge problem. The fact is that in many cases, identifying an addictive disorder and making a recommendation for residential treatment is the (relatively) easy part. The challenge is to convince not only the client, but also their entire support system (family, friends, teachers, bosses, etc…) that their problem will be a continual one to be managed and supported, not cured.
As clinicians, I believe that we have a duty not only to our clients, but also to their support systems (relatives, partners, teachers, coaches, bosses, etc…), to educate them about the importance of sustained recovery and the challenges of re-entry, as well as ways in which they can maximize the chance of achieving long-term sobriety.
II. I Just Returned Home From Treatment – Why Is Everything So Difficult?
When a car breaks down, the expectation is that the mechanic will diagnose and (hopefully) fix the problem, we receive an invoice, pay the bill, take back the car and life goes on. Unfortunately, when a person goes away to rehab for treatment of an addictive disorder, many people – including the client – often have a similar expectation. Nothing could be farther from the truth. As I discussed in the last section, completion of a stint at a residential treatment facility should really be thought of as more like a starting point rather than the end of a difficult process. In this section, I will address one of the common challenges that families face when a loved one returns home.
As an example, consider the experience of buying, and moving into a new home. Anyone who has ever purchased a home is familiar with the issue: During the first several months after moving in, things begin to break. The doorknobs fall off, toilets run, door hinges squeak and floorboards come loose. Many a new owner has experienced a feeling of “buyer’s remorse” left to wonder, “what is the problem? I just spent all of this money, had the house inspected…why isn’t it perfect? Is the house possessed by evil spirits?” Not exactly. A logical explanation is that the family who previously occupied the home spent years acting and behaving in certain ways (e.g. opening cabinets, turning faucets, walking, flushing toilets, etc…) which the house “got used to”. When a new family interacts with the home in a different way, the result is that certain “weak” points of the home may malfunction or break.
I particularly like this example because it addresses many of the same challenges that occur when a loved one — who has been away in treatment for 30, 60, or 90+ days — returns home. Everyone is excited about the prospect of a new and healthy beginning, but few are prepared to handle the challenges that arise. Much in the same way that a new home is “used to the old ways” and “breaks” when new behaviors are introduced, family systems often “bend and break” under the stress of the new and healthy behaviors that a returning loved one introduces. It is pretty much standard issue in my practice that within weeks to months of a person returning home from treatment, family members report increased levels of stress, and concern about the difficulties they are having. Marriages may suffer, parental relationships can deteriorate and friendships definitely change. The good news is that while challenges should be expected, they do not have to mean an interminable period of difficulty. Clients, their families, friends and other support systems need to be aware that re-entry will likely mean a need to re-adjust to the new behaviors and expectations that come with sobriety and managing the chronic relapsing-remitting disease of addiction. With time and the right work on the part of the loved one and the family, (e.g. therapy, al-anon, etc…) these re-adjustments can be useful and hopefully lead not only to more fulfilling relationships, but also to a period of sustained recovery.
Scott Bienenfeld, M.D.
The article “Listening To Xanax” by Lisa Miller (New York Magazine March 26, 2012) http://nymag.com/news/features/xanax-2012-3/ , stirred up more than a bit of controversy among not only the medical community in general, but also among the recovery community, as well as those who specialize in the treatment of addictive disorders. Informative for sure, the article in some ways glamorizes the use not only of Xanax, but the entire class of medications known as Benzodiazepines, or “Benzos”. These drugs are portrayed throughout much of the article as trendy counter-measures to the ubiquitous stress of the last decade, analogous to Prozac, the “game changer” of psychopharmacology which arrived on the scene in the 1980’s. While Benzodiazepines are well-established as a (for the most part) safe, and effective treatment for a number of psychiatric disorders, their problematic use in patients who present for treatment of substance use disorders cannot be overestimated, and often create complex treatment scenarios. We see large numbers of adolescents and young adults who are either addicted to, or are severely abusing these drugs. Withdrawal from a drug like Xanax can be dangerous and even life threatening. The fact that so many adults use these medications, whether for legitimate reasons or not, means that millions of teenagers and young adults nationwide have access to them via the medicine cabinet at home. Kids rarely perceive a parent’s medication as being potentially dangerous or life-threatening, let alone addictive, and the issue of legality seems like a non-issue because they are prescribed. Kids often start by raiding the medicine cabinet at home, and then seek the drug on the street. Finally, it is important to remember that medications like Xanax and other Benzos regularly turn up in addition to other drugs in post-mortem toxicology reports that are labeled “multiple drug deaths”. While Benzos alone are probably not a common cause of death per se, the combination of these medications with other powerful drugs like pain killers, cocaine, heroin and even alcohol can be deadly.
Scott Bienenfeld, M.D.
Parents and Doctors Beware and Be Prepared!
Over the past several years, there has been increased concern about kids using “synthetic” drugs – substances that are developed in a laboratory and intended to mimic more “familiar” drugs such as marijuana and amphetamines. Two factors make these compounds particularly frightening: 1) They are packaged as “legal” substances in order to avoid DEA scrutiny, and 2) They are quite difficult to test for using routine drug screens.
A synthetic form of marijuana known as “K2” or “Spice” which is usually marketed legally as plant food or incense and is obtainable at head shops, gas stations and via the internet, has been a matter of serious concern in recent years. Emergency rooms nationwide have reported an increase in the number of kids presenting with an array of bizarre symptoms and negative drug screens. Symptoms usually consist of agitation, hallucinations, panic-like reactions, suicidal ideation, seizures and strange behavior. Now technically illegal in The United States (http://www.deadiversion.usdoj.gov/fed_regs/rules/2011/fr0301.htm), these compounds are still relatively easy to get a hold of, especially via the internet. Certain labs can test for the presence of these synthetic cannabinoids, but routine testing will not detect them. Brand names of these compounds include: Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury, and Zen.
“Bath Salts” are another example of synthetic substances that mimic more familiar drugs of abuse. The compounds, which are marketed as bath products, mimic amphetamines, which are powerful stimulants. As with synthetic marijuana, “Bath Salts” are very hard to detect with routine drug testing, and increasing numbers of cases of kids in emergency rooms are popping up. Kids high on these drugs often have increased blood pressure, rapid heart-beat and even hallucinations and other psychotic symptoms. Street names for these compounds include: drone, bubbles, meow-meow, MCAT, Ivory Wave, Vanilla Sky, Cloud 9, Red Dove, and White Rush.
It is important for clinicians and parents to be both aware of and educated about these new types of substances that are becoming widely abused by kids. The DEA is beginning to crack down on these dangerous products, but as one substance becomes illegal, another one is likely to take it’s place.
Scott Bienenfeld, M.D.
Marijuana: A Complex Clinical and Political Picture
As the legalization of marijuana expands throughout The United States, debates about the pros and cons of this policy will continue. The discussion exists not only among members of the medical community, but also among those who suffer from addictive disorders and the legions of clinicians who treat them. Regardless of where one stands on this issue, its evaluation requires knowledge about the latest data and information regarding marijuana, particularly as it applies to the risks, benefits and alternatives involved. It is also important to remember that new information is constantly emerging regarding both the medical benefits of this drug, as well as the potential for clinical risk factors, including both medical and psychiatric complications.
By far the most widely abused illicit drug worldwide, marijuana has a reputation for being perceived as “safer” than other drugs among adults, adolescents and their parents. (A qualitative comparison of parent and adolescent views regarding substance use. Journal of School Nursing. 26(1):53-64, 2010 Feb.) Many in favor of legalizing marijuana cite the fact that there are no known deaths that can be explained purely by marijuana overdose – a fact that is most definitely not true for many other drugs including: alcohol, cocaine, heroin, painkillers (opiates), crystal-meth, sedatives, sleeping pills and many over-the-counter and prescription medications.
Fatalities aside, studies indicate that marijuana is hardly a benign drug. In fact, the marijuana produced today is significantly more potent than what was grown during the 1960’s and 1970’s — which may account for recent findings that marijuana can be dangerous for some people. Most importantly, it has been clearly demonstrated that adolescents who abuse substances early on (including marijuana), are at an increased risk of developing a severe addictive disorder later. Marijuana is considered to be a “gateway drug” for many adolescents who then go on to use “harder” drugs such as cocaine and heroin. Neuropsychiatric studies clearly indicate that chronic marijuana smokers suffer from cognitive impairments in the areas of short-term and working memory, visual-spatial processing and abstract thinking. Recent data link chronic marijuana use starting at an early age with the later onset of psychosis in young adults who may already be at risk. (Cannabis use in patients with a first psychotic episode and subjects at ultra high risk of psychosis: impact on psychotic- and pre-psychotic symptoms. Australian & New Zealand Journal of Psychiatry. 44(8):721-8, 2010 Aug.) Finally, while many adolescents and adults seem to “self-medicate” with marijuana, it has been clearly demonstrated that chronic marijuana use is associated with, or “co-occurs” with a number of psychiatric disorders such as bipolar disorder, attention deficit disorder, anxiety disorders, and ultimately has a detrimental effect on treatment outcomes for those suffering with these problems.
The point of this discussion is to remind parents and clinicians that marijuana abuse and dependence often presents a complex clinical picture that should be taken seriously, especially in adolescents and young adults who suffer with psychiatric illness and/or have a family history of addiction. While marijuana use may have potential medical benefits for some, it poses the risk for short and long-term side effects, as well as the potential for abuse and dependence.
Scott Bienenfeld, M.D.
A Final Common Pathway of Addiction:
Recently, at a clinical conference on addiction, I overheard an intern ask a straightforward question about why a person recovering from a severe cocaine addiction should not consume alcohol, a drug they never really had a problem with. As it turns out, this is a common question asked by both clients as well as their spouses, families and friends (who often want to be able to drink socially with them). Seasoned clinicians, long-standing AA members and others who have successfully managed their addictions all seem to understand that a person battling a substance use disorder will be at a serious risk of relapse or “cross-addiction” if they start drinking or using another drug. The question as to why this is the case is of great interest medically and, as it turns out, has major implications not only for promoting abstinence among those with addictive disorders, but also for one day developing medical treatments that can directly target brain areas that are directly involved in both addiction and recovery.
Over the past twenty years, advances in brain imaging and neuroscience have greatly enhanced our understanding of several aspects of addiction. For a really good and technical overview read the article: (Nestler EJ. Is There a Common Molecular Pathway For Addiction? Nature Neuroscience. 8(11):1445-9, Nov 2005). One of the most interesting findings has been that when drugs of abuse are absorbed by the brain, certain important areas become activated in a predictable manner. This is only true for drugs that can be abused and/or cause addiction, and not true for drugs or other substances that cannot. The areas that “light up” on fMRI scans during ingestion of drugs of abuse are located deep in the brain in an area called the ‘mid-brain’ (see fig. 1) which is considered to be responsible for feelings of reward, pleasure, euphoria, compulsion, salience, and perseveration. Although different drugs of abuse cause a variety of feelings when ingested (e.g., cocaine, alcohol, marijuana and heroin have very different effects emotionally and physiologically), they all have a very similar effect on these sensitive yet powerful mid-brain areas. These areas activate very quickly and, frequently unbeknownst to the person. In fact, it has been clearly demonstrated that these important brain areas become activated even before the addicted individual actually ingests an addictive substance! So, when an alcoholic walks into a bar, or sees a beer commercial on television, it is quite likely that her mid-brain is firing and activating – a situation that probably accounts for what is known as “cue-induced relapse”.
There are three major reasons why this is important. First, if highly sensitive mid-brain areas can be activated by thoughts, sights, smells, etc…it is a very good reason why those with addiction need to avoid people, places and things associated with drug use. Second, as it turns out, the mid-brain communicates directly with the frontal part of the brain, the area responsible for decision making, weighing risk vs. reward, and managing impulsivity. In those suffering from addiction, the frontal brain areas (which by comparison activate slowly), seem to be overwhelmed by the impaired mid-brain areas which continuously fire and dominate the person’s actions and behaviors. Finally, since all drugs of abuse have a common effect upon sensitive mid-brain areas that are associated with feelings of reward, pleasure, euphoria, compulsion, salience, and perseveration, then it stands to reason that a person who suffers from an addiction to one substance should avoid ALL substances that could cause addiction!
Scott Bienenfeld, M.D.
Thursday, March 7
We pounded chicken breasts to about ½-inch thickness, which will insure a juicier final dish. Coat the chicken breasts in flour (keep one hand dry, one hand wet), shaking off excess. Brown chicken breasts in olive oil (with a little butter if you wish). Remove breasts from pan. Wipe pan mostly clean and add chicken stock (better) or water (adequate), plus lemon juice to pan. Cook, stirring occasionally, until flavors have combined and mixture has reduced by about 1/3 to 1/2. Add butter and capers, and stir to combine. Turn off heat, taste and reseason with salt, pepper, butter, capers, lemon juice. Put chicken back in to pan to warm and/or coat with sauce. Finish with chopped parsley, if desired.
We used approximate measurements for sauce. (Obviously tailor to your tastes and you may need to double, depending on how many people you are serving and how much sauce you want): Chicken stock or water = 1/2 cup; lemon juice = 1/3 cup; butter = 3 tablespoons, capers = 1 tablespoon.
Cut low-moisture mozzarella (important: not fresh mozzarella!) into desired size. (We used Organic Valley low-moisture mozzarella cheese). Dip into flour, then egg, then panko (or regular breadcrumbs). Put pieces onto plate or baking sheet and freeze for 30 minutes. Remove sticks from freezer and pan-fry in olive oil. Amount of oil = a little less than half the height of the mozzarella sticks. Cooking two sides is all that is necessary. Drain on paper towels, try to eat immediately. If possible, serve with marinara sauce (see below).
Chop onion and cook in olive oil, stirring occasionally so onion doesn’t brown. If desired, chop one or two cloves of garlic and add about five minutes into onion cooking time. Cook for another three or four minutes. Add tomatoes (we used a 24-ounce jar of Bionaturae organic strained tomatoes, but diced or stewed tomatoes work as well) and simmer until sauce thickens about 15 to 20 minutes. If using herbs, add dried when you add sauce; add fresh at end of cooking process. Let sauce cool for about 10 minutes, stirring occasionally. Taste and reseason with salt, pepper and herbs, if using.
Thursday, March 14:
THAI GREEN OR RED CURRY WITH SHRIMP AND VEGETABLES
Which vegetables to use is completely personal preference.
Yield: 4 servings
1 to 1.5 lbs. Shrimp (wild and domestic, if possible; shells on is preferable)
1 can Coconut milk (we used Native Forest brand)
1 to 2 tspn. Green or red curry paste (we used Maesri brand)
1 Carrot, ¼-inch rounds (optional)
1 Red, yellow or orange pepper, ¼-inch strips (optional)
1 Zucchini or yellow squash, ¼-inch half-moons (optional)
1 Baby bok choy, stems chopped in ½-inch pieces (optional)
1 Onion, cut into strips (optional)
2 Tbs. Brown sugar or honey
1 Tbs. Fish sauce (we used Ka-Me brand)
1. Pour about 1 Tablespoon neutral-flavored oil (i.e. canola, vegetable) in a sauté pan, swirl in pan and heat. Add curry paste to pan and cook, stirring occasionally, for 30 seconds, or until you smell strong aroma. Add coconut milk and the vegetables you are using and cook over medium heat until vegetables begin to soften.
2. While the vegetables are cooking, peel shrimp. When the vegetables start to soften, add the peeled shrimp and simmer uncovered until the shrimp are about 70 percent cooked. Turn off heat and let shrimp finish cooking in the hot sauce.
3. Add fish sauce and brown sugar or honey; stir to combine. Taste and correct seasoning.
Shrimp are a great go-to when cooking quickly is the goal. For example, one of my favorite—and easiest—shrimp dishes entails browning some sliced garlic in butter or olive oil, adding shrimp to the pan, turning off the heat when the shrimp are 70 percent cooked, and then adding chopped parsley, fresh lemon juice, unrefined sea salt and fresh ground pepper. This takes less than 10 minutes.
Another straightforward shrimp dish is coconut shrimp.
First, combine some shredded coconut and bread crumbs (panko, Japanese bread crumbs, work well) in a shallow bowl. (The ratio depends on how much you like coconut!) Mix an egg in another bowl. Peel the shrimp. Dip the shrimp in the egg and then coat with the coconut-bread crumb mixture. Set on a plate big enough for all of your shrimp.
After coating is complete, heat olive oil and/or butter and/or coconut oil in a pan (enough to coat the pan). Add shrimp, be patient and let first side brown. Turn and let second side brown. Remove to paper towel-lined plate, sprinkle with unrefined sea salt and fresh lime juice. That’s it.
For complementary flavor I make an orange dipping sauce using orange fruit spread that I thin out with some water and lemon juice. (It’s too thick for dipping without the added liquid.) Another possibility is honey; it’s sweetness works nicely with the coconut and shrimp flavors.
If possible, buy wild shrimp, which far exceed farmed shrimp in flavor and nutrition. In addition, the growing conditions on most fish farms are less than ideal
Still Feeling This Ride!
1) Mona Lisas and Mad Hatters – Elton John
2) Viva La Vida – Cold Play
3) Airline to Heaven – Billy Bragg and Wilco
4) Jungle Love – Steve Miller
5) Train in Vain – The Clash
6) A Message To You Rudy – The Specials
7) The Spicy McHaggis Jig – Dropkick Murphys
8) Misty Mountain Hop – Led Zepplin
9) Breed – Nirvana
10) Blue Monday – New Order
11) Givin’ Up – The Darkness
12) Walls Come Tumbling Down – The Style Council
13) Confetti – The Lemonheads
14) She’s a Rainbow – The Rolling Stones