Nature of addiction

I read this morning that The Saskatchewan College of Pharmacy Professionals (SCPP) has approved in principle a ban on exempted codeine products (ECPs).

Narcotics (including ECP) are addicting substitute solutions to real unmet needs.  I believe policies, regardless of intention, that bans “substitutes” such as ECP or legalizes cannabis are in themselves “substitute” solutions for the growing issue of addiction in society.  Individuals or governance that are unaware of the nature of addiction will simply switch from one substitute to the next easiest accessible substitute.

My perspective on Cycle of Addiction ( reminiscent of some computer programming language)
Sample program 1: Diabetes type 2 (sugar addiction)

1. Real need: Whole Foods & appropriate physical activity
2. Craving from needs unmet: hunger
3. Easy substitute: simple carbohydrates
4. Brief relieve from hunger
5. Craving recurs from needs unmet: hunger
6. Go to 3.

Sample program 2: Opioid crisis (opioid addiction)

1. Real need: wholefood, appropriate physical activity, ability to pay attention to what is important & self-compassion
2. Craving from needs unmet: pain & suffering
3. Easy substitute: opioids
4. Brief relieve from pain & suffering
5. Craving recurs from needs unmet: pain & suffering
6. Go to 3.

Sample program 3: Workaholism (intentionally left blank. It may be familiar to some readers)

Three challenges of addictions are: 1. Suffering caused by a real need unmet. 2. Side effects of the substitutes.  3. Vulnerability to other harmful substitutes.
I believe much more conversations at an individual and system level about the true nature of addiction are needed.

My conversation with patients about addiction.

I am sometimes asked by patient to prescribe benzodiazepines, cannabis or opioids.

My approach is similar for all medications and substances with potential addiction properties.
1. I explain to them that no one (for emphasis of course, I point out the obvious) including myself is “immune” to addiction; that given the situation, anyone can become addicted. (They usually don’t believe me at this point)
2. I then explain to them the mechanism or cycle of addiction (fear of some suffering/ craving for end of it; seeking a quick relieve / a substitute solution; relieve from suffering; effect of quick solution begin to wear out; triggers the fear of suffer... then the cycle’s intensity compounds); I talk about some real life examples; and there is no lack of stories.  By now, they begin to see how addiction applies to them personally.
3. I then help them understand the lengthy list of other unintended and serious side effects of the substitute solution ( Eg.  Increased risk of falls in seniors; respiratory arrest, quality of life, etc.; I try to use examples most relevant to the individual.
4. I ask them and help them identify what it is their suffering the are hoping to alleviate.
5. I then offer them a real solution to their sufferings.  (Eg. my Basic Wellness Messages)
6. In my experience, above approach has resulted in various satisfactory outcomes; many embrace the knowledge and come to attend my wellness groups and learn more about the Basic Wellness Messages;

some are disappointed but still respect the time spent and reasoning; none leaves with a quick fix or substitute solution without a clear understanding and an agreement on a solid plan to eliminate the substitute with the real solution.

In my opinion, the key ingredient of addiction management are:
1. That I take the time.
2. That I understand addiction is a common humanity. ( remove stigma and judgement of which self-judgement or shame is most intense)
3. That I explain the mechanism of addiction in a way that can be understood by the individual
4. That I help find a real solution to replace a substitute.
5. That a reasonable plan is agreed upon to safely wean off the substitutes and apply the real solution.
6. That I use “physician-led self-management education and support groups” to help patients begin personal transformations.

I believe we need a system solution that supports more conversations at an individual level.

I see each patient encounter as a valuable opportunity to engage patient in a conversation on the nature of addiction; whether it is to sugar or opioids or anything else for that matter.

I then enrol them in our weekly “physician-led self-management education groups” to continue our journey of awareness and wellness.

I have ran this group for over a year now.  It has proven to be an effective way to help my patients.  

There has been many stories.  John’s story stands out (fiction name).  He has eliminated the substitutes in his life (street drugs, alcohol, cannabis and tobacco) and replaced it with what he truly need (wholefood, appropriate physical activity, improve ability to pay attention to what is important & self-compassion through practice of BAM)

For type 2 diabetes, John’s HbA1C was 11.5 on SGLT, DDP4 and metformin. His last HbA1C was 5.6.  This type results is not uncommon in my patient population. According to a study published in Lancet, “at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care”

John meditates daily with his wife and eats 400 grams of non-starchy vegetables per day.  
He enjoys great relationships with his wife, daughter and his grandchildren.  We hope to collaborate and share our perspectives on the importance of vegetables in our diet.

The case of Type 2 diabetes.

According to Shaun Loney, author of “The beautiful bailout - how a social innovations scale-up will solve government’s priciest problems”:

Annual health care cost per Canadian = $6604
Annual health care cost per Canadian with diabetes = $26416
Difference per year = $19812
Even though I don’t have the numbers for opioid crisis, I believe they are also staggering.

It appears to me there is plenty of money to do wonder if we can simply target the real needs rather than direct most of our attention to the substitutes or substitute it with a yet more costly substitute without a clear vision.

Above are my personal opinions based on my clinical experience.

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