Dr Ved Mahla
The problem of substance use is a public health issue world over. We keep hearing about “Opioid Epidemic” in USA and other countries. In India, the problem has been highlighted in states like Punjab where use of substances like opioids and alcohol has been in epidemic proportions. My own experience while dealing with opioid and alcohol use disorders in Haryana suggest that small towns like Rohtak and other parts of Delhi-NCR have overtaken Punjab as far as opioid use, especially heroin is concerned. The increasing use of substances like heroin, which is one of the most addictive substances known, has rung alarm bells for the state and health professionals dealing with these disorders
The reasons for increasing use of substances are many folds; ranging from hereditary to ubiquitous environmental factors which include; unrealistic parental expectations, cut throat competition, peer pressure, seeking immediate relief from stress and pain (physical and psychic), curiosity for experimentation and so on. The fact remains that people have been using substances since time immemorial, either to relieve pain or to enhance pleasure. And the fact remains that drugs work but then they no longer work. That’s where the problem lies. An addiction has set in.
To understand the treatment of addictive disorders, we have to understand the four specific areas of the brain which play pivotal role both in addiction and its treatment
- The Reward Pathway which is governed by Ventral Tegmental Area and Nucleus Accumbens . These areas are responsible for the “kick” or “Highs” of a substance of addiction. They are like accelerator of a car driving for more pleasure. We now have substances like Bupronorphine and Naloxone. The former is a partial agonist of opioid receptors, not allowing the high associated with opioid use. The latter is lifesaving in opioid overdose. Naltrexone is used for “maintaining abstinent” after the person has been clean of opioids for 7-10 days. These are the standard treatment for opioid use disorders targeting the reward pathway.
- Hippocampus and amygdala are the brain areas associated with memory and emotions. Conditioning of drug use and the associated cues happen in these areas of the brain. These areas are associated with “wow, what an experience that was! “These areas are associated with relapses caused by a stimulus even remotely resembling a drug taking behaviour like a telephone call by a former friend who is high on a substance. We can use Cognitive Behaviour Therapy models to prevent relapses by keeping these brain areas in mind.
- The orbital cortex which is a brain region responsible for motivation, both, to take drug or not to take it. We can influence this area of the brain by Motivational Interview and Motivation Enhancement Techniques to keep a recovering patient sober.
- The prefrontal cortex which is responsible for putting brakes for behaviours including drug taking behaviour can be influenced by continuing family support, 12 steps Rehab Programs and self-help groups like Alcoholics Anonymous (AA) and NarcoNon.
There are two additional things to be kept in mind while dealing with the problem of substance abuse.
Firstly, do not be judgmental about the patients. Telling somebody that he has ruined his family or health will simply drive him away. Addiction is a chronic relapsing brain disorder, a real disease and not something wilfully brought on oneself. Secondly, do not lose hope. Patients do get well, will give up their addictions forever someday but don’t know when but it will happen.
(The author is Professor and Head of Psychiatry Department in the Faculty of Medicine and Health Sciences, SGT University, Gurugram)