Looking at Addiction and Suicide Through the Lens of Brain Science

From BBRF's Brain & Behavior Magazine - July 2019 Issue

The New York Times reported on March 7th that drugs, alcohol, and suicide together claimed more than 150,000 American lives in 2017. The grim statistic, attributed to two public health nonprofit groups, was based on mortality data compiled by the U.S. Centers for Disease Control. Suicides accounted for over 47,000 of these deaths. Five hundred deaths per week were attributed to overdoses of synthetic opioid drugs such as fentanyl. We called upon Nora Volkow, M.D., the Director of the National Institute on Drug Abuse (NIDA), to help us make sense of these numbers. Dr. Volkow, a pioneer in brain imaging with “PET” technology (Positron Emission Tomography), is one of the world’s leading experts on the biological basis of addiction and a longtime member of BBRF’s Scientific Council.

Dr. Volkow, the numbers seem to keep going up. This must be disturbing to you.

Yes, and it leads us to ask what is driving the unexpected mortality associated with opioid drugs. Opioid-associated fatalities are still going up even though opioid prescriptions have started to decline. Many of the deaths from overdoses are likely to be suicides, but there’s no easy way of distinguishing them from those caused by unintended overdoses. Overall, it’s estimated that between 20% and 30% of opioid fatalities are intentional. Thus, the contribution of suicide to overdose fatalities is not negligible and their prevention will require additional interventions.

The question is complex. Is someone committing suicide because they are depressed? And when they are depressed, have they taken drugs as a means to escape their depression? Or is it someone who is taking opioid drugs without being depressed— but becomes depressed because of chronic opioid use? There are many possibilities of why a person abusing opioids could be at greater suicide risk and it is notable that so many people with an opiate-use disorder (OUD) also have a co-morbid mood disorder.

Can you explain the connection between mood disorders and OUD? I mean, in terms of the biology of addiction.

The association of OUD and mood disorders is not surprising, because the mu-opioid receptors [in the brain], which are the target of drugs like morphine or heroin or Oxycontin, among their other functions modulate the serotonin system, which plays a major role in regulating mood. Many antidepressant medicines act on the serotonin system, too. So, recognizing that opioid drugs will affect the serotonin system in the brain leads you to predict that they are likely to affect mood.

But we must also ask: why is this problem with opioid addiction happening in the United States, and to whom, exactly, and why right now? A lot of people have written about it. We need to look at how it all started. Two sociologists at Princeton, Angus Deaton and Anne Case, have looked into the demographics of people who have borne the brunt of drug- and alcohol-associated mortality.

You’re referring to their important paper, which was published in the Proceedings of the National Academy of Sciences in 2015. It focuses on “rising morbidity and mortality in midlife among white, non-Hispanic Americans.” Exactly. They point out a midlife “reversal” in mortality statistics— numbers that were dramatically improving throughout most of the 20th century that are now showing a reversal. Who is affected? Many are lower-middle-class white Americans, people in their 40s, 50s and 60s. Deaton and Case ask: What are the factors that are driving it? They propose that it is the loss of jobs and the lack of new opportunities, driven in part by limited education, that explains the rising mortality in lower-middle-class white Americans. Addiction to drugs and alcohol (along with suicides) are illnesses of the body that can be thought of as “diseases of despair.”

The analysis of Deaton and Case is very enlightening, because it suggests what we might do to address the problem. They distinguish those people who have a very high risk of actually dying by overdose. Among white lowermiddle- class people, it’s those who do not go beyond high school. Which, of course, then limits their opportunities for work and constrains them in other important ways. This forces us to think about the socio-economic and cultural factors that underlie the rising mortality from the so called “diseases of despair.”

Whether you call it “addiction with overdoses,” or you call it “suicidality,” or you call it “alcoholism” (which is also a substance-use disorder), you have to consider those aspects of our social system that help people overcome stressors so that they can be strengthened, versus factors that weaken the social structure, and limit possibilities and alternatives for individuals.

In light of what you say, I suppose it would be unrealistic to expect a quick drop-off in the mortality—because this is a very deep problem with structural causes that far transcend even medicine.

Correct. It definitely transcends medicine. But interestingly, the data reminds us of something that prior research has told us: that one of the best predictors of your health is your level of education. We do not normally see education as part of public health. But they are closely interlinked. That’s why I like the analysis of Deaton and Case, because they highlight an element that you can target for prevention in the future. If you want to create resilience in your citizens, to protect them against these conditions, you have to ensure that they are properly educated. That will give them multiple alternatives for how they are going to develop talents, and earn a living, and build their life.

It has been said that doctors have been responding to their role in the opioid crisis. In the last couple of years, their prescription practices have become more conservative.

Addressing the wide availability of opioid prescription drugs is fundamental in addressing the opioid crisis. But it’s not sufficient. You also have to provide proper treatment for people suffering from pain. Because if you don’t address their needs for pain treatment, they are at great risk of seeking out opioid drugs in the black market, exposing them to very potent and dangerous products.

We also need to address the fact that as a nation, we still over-prescribe opioid drugs. Last year, 170 million opioid prescriptions were given in the United States. While that is less than the peak in 2011 of around 275 million, it is much higher than the rates in other countries. This number of prescriptions is hard to justify when one considers that opioid medications should be reserved for the most severe pain.

We have to recognize that opioid analgesics, when used properly, can be life-saving. In this sense they are not like other addictive substances with no medical utility. Getting rid of opioids would do a tremendous disservice to health, because they are extraordinarily useful for management of severe pain and for anesthesia. A person with severe pain who does not respond to other medications may require the use of opioids. And if you make it much harder or impossible for them to get opioid analgesics while not providing any viable therapeutics, some patients will go to the black market to seek relief for their pain condition.

In view of this, what is your recommendation?

We need to educate physicians on the proper utilization of opioids, and we need to structurally change reimbursement practices for the management of pain. Because right now, it’s much cheaper to prescribe an opioid than to provide multipronged approaches for treatment and management of chronic pain. And many insurance plans won’t pay for it.

Also, we need to focus on prevention, including aggressive campaigns to educate people about the dangers of opioids. In visiting some of the areas most affected by the opioid crisis, I’ve been surprised by the fact that many people do not know how dangerous the synthetic opioid fentanyl is. I ask myself, how can this be? We need to do an education campaign so that people recognize why these drugs can be so harmful. We also need to provide, as part of the prevention, activities and support systems that will give resilience to those who are vulnerable, so that they don’t end up taking a drug as a means of escaping their realities.

If you look at the demographics, those who are at greater risk of using synthetic opioids or heroin are young people in the transition from adolescence to young adulthood. That’s also a group with some of the highest rates of overdoses. It’s also the age group in which we’re seeing some of the largest increases in overdose mortality over prior years—very significant increases. So, we need to develop prevention efforts that target the transition into young adulthood.

I wonder if we can also talk about vaping. It seems that due to the rapid increase in teen vaping, nicotine addiction may actually begin earlier and become even more entrenched than it ever was in the past, when smoking cigarettes was the main “delivery device” for nicotine.

We’ve made major advances in prevention efforts for reducing smoking among young people. It’s actually quite dramatic, and a beautiful example that prevention works when you put your mind to it.

The concern now is that we’re starting to see very rapid and very significant increases in vaping among teenagers. NIDA has been recording it for the past three years. In the first year, many of these kids were claiming that they were using the vaping devices just for the flavors. But in the second year, we had more kids claiming that they were using it for nicotine than for flavors.

Nicotine is an addictive drug. They’re going to become addicted to nicotine by vaping, which is a reason for concern. We may lose ground on all of the advances that we have made in the prevention of cigarette smoking. It is worrisome, and we need to take it very seriously.

Vaping devices also make it possible to ingest very high concentrations of THC, the active ingredient in marijuana, right?

Correct. In our most recent survey, which we released this past December, 10% of those who were vaping said they were vaping THC, which is the ingredient that produces the “high” in marijuana. With vaping, you can concentrate it and get a very high content of THC. This highly potent version is linked with adverse effects, including the risk of acute psychosis. In those who are vulnerable, this can lead to chronic psychosis.

Can anything be done about this on the part of the device makers? Or is this another problem that must be tackled via better education?

We should create policies to regulate these products. These include regulating vaping devices and the cartridges that are used in them. We also need to create policies that interfere with the selling of these devices to minors, just like we have done for cigarettes and alcohol.

Dr. Volkow, for years you have been eloquent on the subject of addiction being a brain disease. Yet some people continue to resist that idea. What would you say to skeptics who claim that addiction, in the end, is a failure of personal self-control?

We all see reality through our own experiences. And when someone has not been addicted themselves, they see that they are able to control and regulate their actions. Even while sometimes they may not be successful, most of the time they are able to regulate their emotions and desires.

It may help to do a thought experiment to help illustrate the significance of losing the capacity to self-regulate. You normally don’t think twice about picking up a glass of water. But if you have a stroke in the motor area of your cortex, you will not be able to do it. And why not? Because the area of the brain that sends the signal to the muscles in your arms is not working. It cannot send the signal.

Similarly, in an addicted person, the area of the brain that regulates the desire to have the drug isn’t working properly. It’s not sending the signal. Nobody would question this when someone has a stroke. We would say: well, that person’s brain can no longer send the proper signal. But people have difficulty in bringing that logic into a situation like drug-seeking which concerns an inner, cognitive control process as opposed to one that concerns the movement of a limb.

For people who have never lost control, it becomes very difficult to conceptualize. And that’s why, to me, it’s very important to imagine what it might be like. Say you haven’t eaten anything for five days. You are starving. And someone places food in front of you that is likely to be contaminated with salmonella. You know you shouldn’t eat it. But the ability to stop that extreme hunger from taking over is very hard, and with further food deprivation it might be almost impossible. Your brain is processing it as a state of emergency. You feel that if you don’t eat now, you’ll die. The threat of your getting sick in the future becomes almost theoretical. This kind of situation of overvaluing the “now” at the expense of the “later” is at the heart of addiction.

This relates to the science you and others have done on this subject, concerning the way our brains are wired for motivation and reward. You have said that these mechanisms, so central to our survival as a species, get hijacked in addiction.

Yes. In the brain of a person who is addicted, an artificial sense of deprivation is generated, akin to the sense of hunger that leads the starving person to eat the contaminated food. The hunger for the drug is equivalent in its power to motivate the behavior of an addicted person. For in addiction, the survival circuits that motivate your actions have been hijacked.

In addiction, you’ve generated an artificial sense of being in a state of deprivation that is just like one feels in a desperate survival situation. You feel that unless you address it, it could cost you your life.

How ironic.

But this may help a skeptic understand that addiction is, indeed, an illness in which the brain is not functioning properly. This illness can be overcome, but it is not a trivial matter of simply wanting to assert self-control. Addiction is a chronic illness that must be treated in a continuous model of care that includes the social support systems necessary.

Nora Volkow, M.D.

Director, National Institute of Drug Abuse

National Institutes of Health

Scientific Council Member

— Written By Peter Tarr

Click here to read the Brain & Behavior Magazine's July 2019 issue