Sunday June 1, 2008
Recovering from addiction
By LIM WEY WEN
Photos by RAJA FAISAL HISHAN and AZHAR MAHFOF/The Star
The memory of the high when they use is the greatest hurdle for recovering addicts. This understanding may be the key to long-term recovery.
AT 30, Hafizi Harun can still remember in detail how he took heroin when he was in his teens.
“It is difficult to forget the art of taking drugs – the way you roll the foil, the way you light up, or the way you search for a vein to inject,” says Hafizi.
Listening to this without judgment, it occurred to me that he is just describing something that is most pleasurable to him at a point in his life. Just as my mother would describe, in detail, the way her dough rises in the oven when she bakes.
“You miss the ritualistic behaviour that comes with drugs,” says Hafizi. But spending a year in Pengasih rehabilitation centre had changed Hafizi’s life. Even though memories of his life as an addict come back, he has learnt the art of talking himself out of it.
“Overcoming the wanting or craving is the most difficult hurdle for drug addicts who want to stop their habits,” says Mohd Yunus Pathi, President of Persatuan Pengasih Malaysia – a non-profit organisation initiated by reformed drug users in 1987.
Even after stopping drugs for 10 years, it takes only one time of drug use to cause a relapse, says consultant in addiction medicine, Dr Mahmud Mazlan.
“No addict in the whole world wants to be addicted, but all addicts want to use drugs once in a while. That’s why they often experience relapses,” he continues.
But understanding and admitting the possibility of going into a relapse might be the key to Hafizi’s success in keeping clean for about 10 years now.
“I applied what I learnt in Pengasih and used the techniques to overcome my craving,” says the Persatuan Pengasih Malaysia training manager.
The reward circuit and you
“The one thing you have to understand about drug addiction is that it is pleasurable,” says Dr Mahmud.
And brain scans have shown that our tendency to like pleasurable things and avoid less attractive ones may have a lot to do with the way our brain is wired.
“Two areas in the brain, called the ventral tegmental area (VTA) and the nucleus accumbens (both located in the centre of the brain), are the primitive parts of the brain. They are the ones that control our drive to eat and to have sex because they are vital for our own survival and the survival of our species,” Dr Mahmud explains.
When we are experiencing something pleasurable (anything from good food to sex), the neurons (brain cells) in the VTA release neurotransmitters (chemicals) called dopamine to other parts of the brain to makes us feel good.
So, if you have a soft spot for chocolates or nasi kandar, your brain will secrete these chemicals every time you take them.
“You will take it again and again because you feel good,” Dr Mahmud elaborates.
And if sexual orgasm is the highest attainable pleasure any mortal can have, drugs can give a person more, he says.
But, what feels good may not be good for you. Too many chocolates without adequate exercise can lead to obesity, and too many nasi kandars may land you with hypertension and high cholesterol levels.
Even so, that knowledge does not stop us from indulging every time we have cravings for them.
Pleasure brought by drugs has a similar effect. When you have something that gives more pleasure than could be attainable from a normal life, the brain “short-circuits”, and other pleasures in life pale in comparison, says Dr Mahmud.
“Withdrawal symptoms are not the main reason why drug addicts can’t stop, but it is because they can’t find pleasure in life anymore without drugs. They have a reduced ability to experience normal pleasure.”
Making things worse is our brain’s tendency to suppress painful memories and retrieve pleasurable ones. “After stopping drugs for one or two months, the memory of the pleasure comes back to haunt them (drug addicts),” says Dr Mahmud. “Craving is not just thinking about the drug. It is the hunger of the drug.”
In what Dr Mahmud describes as “drug insanity”, the whole body of a drug addict reacts when the hunger strikes and all rational thoughts are thrown out of the window.
“At that moment, what matters to them is only how to get their drugs,” he explains.
While drug addiction used to be a regarded as a moral failing rather than a medical condition. But in recent years, doctors are increasingly viewing it as a disease.
In a US National Institute on Drug Abuse (NIDA) press release in 2004, Director Dr Nora Volkow said, “Drug addiction is a brain disease. Although initial drug use might be voluntary, once addiction develops, this control is markedly disrupted.
“Imaging studies have shown specific abnormalities in the brains of some, but not all, addicted individuals. While scientific advancements in the understanding of addiction have occurred at unprecedented speed in recent years, unanswered questions remain that highlight the need for further research to better define the neurobiological processes involved in addiction.”
The progression of drug addiction
“People do not go straight into addiction once they take drugs,” says Yunus, who came out of heroin addiction 25 years ago.
Judging from the intake of residents at the Pengasih rehabilitation centre and drop-in centres, Yunus estimates almost 65-70% of youths in Malaysia have experienced taking drugs at least once.
“These people are drug users. They are not addicted,” he adds.
In 2007, the Malaysian Crime Prevention Foundation found that 71% of new drug addicts are between the ages of 19 and 39. Most teenagers try out drugs for the first time between 13 and 15.
While most of us try drugs because of curiosity, stress or peer pressure, the continued use of drugs has a lot to do with the physiological response of our brains to drugs.
“People become addicted because they are experiencing emotional, psychological or spiritual disturbance,” Yunus says.
At first, when people take drugs, they can control their intake, Dr Mahmud says. At this stage, people can take drugs occasionally without experiencing dependency on the drug. But after a longer period of time (depending on the type of drug), they start to take drugs every day and it takes another year or two for the disease to set in.
When the disease sets in, drug abusers lose control of their drug intake. Physiological changes in the brain and mental dependence on the pleasure brought by drugs make them unable to do so, says Dr Mahmud.
“At that time, the need to have money (to buy drugs) increases but the ability to produce income decreases. That’s why people go for crime to get money to support their habit,” says Dr Mahmud.
You know you are addicted to drugs when you can’t stop although you want to, says Dr Mahmud. Your drug stores seem to deplete faster than usual and life seems boring to you.
“Drug users know when they are addicted, but it is also difficult for them to accept the fact,” Dr Mahmud notes.
Realising this, Dr Mahmud feels that one of the ways to treat addiction is to point out to addicts that there are other things in life that is worth looking forward to.
What Yunus does now is to remind young people around him that they can find happiness in other things in life, but not drugs.
“If you think you have a problem now, drugs will only make it worse,” he says.
Is willpower enough?
Ask anyone who was hooked on drugs and they will tell you that addiction was not their intention.
Jeffri Ahmad, a recovering addict, told me as much. “When I started using drugs, I was also under the impression that I would be able to control it,” said the 38-year-old.
However, recreational use turned into addiction when Jeffri found it very difficult to stop. “It is so easy to get back on drugs because the sometimes you just want a little bit of relief from the pressures in life once in a while.”
At one point, Jeffri decided to stop because he could no longer sustain a lifestyle with drugs anymore.
“I wanted to stop drugs on reasons of self-preservation,” says Jeffri. To be on drugs, he had to make more money, but at the same time he was less able to work efficiently.
After a couple of years being on treatment, Jeffri is still in the process of recovery. “My business partner asked me to go for treatment and he has been very supportive.
“Willpower is not enough, because no one has managed to come out of drug addiction alone,” says Jeffri. “You need somebody to tell you that you need to stop,” he added.
Reviewing treatment approaches
Despite tough measures we have taken to curb drug abuse and addiction, including the death sentence for drug peddlers and prison for those in possession of drugs, the population of drug addicts is still large.
While public education should be ongoing, treatment (drug substitution therapy, rehabilitation and counselling) should also be made easily accessible to drug addicts.
“Nowadays, drug addicts who come for treatment can be arrested in front of the clinic itself.
“Certain laws should be amended to protect these people who came for treatment,” says the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) president Dr Steven Chow .
A recent public education programme called ‘Jiwa Baru’ offers a hotline (1300-80-7777) where people can call up and seek advice on drug addiction. Personnel manning the hotline would be able to help people locate the nearest treatment facility available in their area.
“Based on today’s statistics, there are about 250,000 to 270,000 registered addicts on heroin alone. And the actual number of addicts that you are able to detect is only one quarter of the actual number,” says Dr Chow.
In a community based treatment (CBT) programme provided by FPMPAM, with the guidance of the Ministry of Health, addicts now can have confidential medical treatment in settings such as private clinics, specialist centres or at home, says Dr Chow.
”It all boils down to logistics. If 500,000 drug addicts needed treatment, it is impossible to treat them all in an institution.
“You have to try to let them go back to the society, remove the stigma against them, give them their lives back as fast as possible and they must be spiritually connected to a religion of their choice,” he adds.
“All these can only be done in a community,” says Dr Chow. Medications is just a bridge for someone that is totally out of control to come back to his senses.”
However, the best mode of treatment in addiction depends on many factors, including the type of drug used, the motivation of the addict, the duration and the severity of addiction.
“We have one of the best policies for drug abuse in Malaysia, but there is a need to review our approach to treatments for drug addicts, particularly the needle exchange programme and methadone replacement therapy,” Yunus said, adding that rehabilitation centres can also make themselves self-sufficient in order to reduce government expenditure.
He says that although both the programmes are meant for reducing the spread of diseases such as HIV, there is a need to evaluate whether these programmes are also effective in curbing the drug problem.
Methadone therapy, for instance, is effective only when properly administered. Otherwise, addicts will abuse it if administered without proper supervision, Yunus said.
A National Drug Substitution Therapy Register has been established since year 2006 to monitor patients and doctors involved in drug substitution therapy (methadone and buprenorphine/naloxone) to prevent abuse.
“We should make a clear stand. Are we moving towards a drug-free nation, or are we saying that its ok to take drugs, as long as we use clean needles?” Yunus says.
“The government, NGOs and medical professionals should come together and discuss the way forward for us to curb our drug problem,” he adds.
On what the society can do to help curb drug addiction, Yunus said that helping drug addicts seek treatment and embracing recovered drug addicts back into the society helps.
Helping drug addicts is only in the society’s best interest, he concludes.
“You will never know if your loved one will become a drug addict one day because drugs are available everywhere. If you help your son’s friend who is a drug addict recover, you help your son by preventing him from becoming one too.
“When I first started to take drugs, I didn’t learn to do it from a manual. I learnt it from my friends,” Yunus says.
Hafizi, however, thinks that recovered former drug addicts should also do their part to earn the society’s trust.
“We should not sit back and ask the society to trust us. We must work hard to prove ourselves so that we will earn their respect,” he says.