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Addiction Specialist: The Real Cause of the Opioid Crisis

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In an attempt to fix the stigma, my field started overpathologizing normality in an unconscious attempt to make everybody feel more empathy towards people who are mentally ill.

Recent announcements on how President Donald Trump plans to tackle the opioid epidemic leave some cheering and others dismayed. There is no question that something needs to be done, as more than 115 Americans are dying of opioid overdoses every day. Will capital punishment or public health initiatives solve the opioid crisis?

On March 19th, Merion West’s Erich Prince spoke with Louisiana-based addiction treatment specialist Dr. Howard Wetsman on what causes addiction, how to treat it, and how the public’s perception of addicts leaves them with limited options.

Erich Prince: Good morning Dr. Wetsman, thank you joining us. To start, can you can give us an overview of your professional background, your medical work, and how you see the intersection of your work with the national conversation on drug use and addiction?

Howard Wetsman, M.D.: I’m a board-certified psychiatrist, but I don’t practice psychiatry anymore. I went full-time in addiction medicine 12 to 15 years ago, though I had been primarily treating addiction before that. This was after Hurricane Katrina. I eventually developed a new way to treat addiction.

My goal is to end addiction as a problem in American life, so treating it is only part of how we need to do that. There needs to be a rapid, highly accessible, cheap and effective treatment for addiction because it affects 10 to 20 percent of the population. I’m not just talking about drug addiction. You can describe obesity and many other things as forms of addiction.

In developing this new way to treat addiction, I found that the old adage that “people have to want to get sober to get sober,” isn’t true at all. Addiction is an illness just like tuberculosis. If you treat it, it gets better. You don’t have to believe you have it; you don’t have to want it to work. Like any disease, it gets better because you treat it, but it’s a very different treatment than what we’ve been thinking about.

Erich: Do you think that perceptions about drug addiction being a result of choice prevents people from getting help? Are we getting closer to the ideal you’re describing of viewing addiction like we think of any other ailment?

Howard: That’s why I’m making a documentary entitled “Ending Addiction.” I have tried for so many years to get those in charge to take a look at the data and see that what we’re doing is wrong. They won’t, and I think the only way to get the message across is to go to the people who are suffering and give the information directly to them so that they can demand change from the people who are running the system.

Erich: I understand that you’ve done some advocacy with the Libertarian Party. I’m wondering about some of your thoughts about the recent government action with Chris Christie and then various people in the Trump administration trying a top-down approach to treating these opioid crises. What is your response coming from a libertarian perspective?

Howard: Well, I’m not so sure. Today, someone asked, “What kind of libertarian are you?” I said that I am the kind who doesn’t mix his politics with science. I have beliefs about personal liberty, but I might differ from a normal libertarian in that I don’t let those [beliefs] get in the way of science. I think where the Libertarian Party makes its biggest mistake is in not recognizing that there are people who can’t.

There are people who can’t use drugs, there are people who can’t have a gun, there are people who can’t be safely walking around without violating the rights of others. Until the Libertarian Party comes up with a solution to that, they’re not going to get trusted to govern because they are just trying to get votes from a public that can so clearly, on the face of it, see that there are people who can’t.

To my point about what I think the government is doing, I think first that the biggest mistake is focusing on opioids. This is actually the third opioid addiction or opioid overdose crisis we’ve had in the history of this country. The other two burned themselves out, and this one will too. Government does all kinds of things that have nothing to do with resolving the crisis. Then when the crisis resolves itself, the government will pat itself on the back saying, “See what a great job we did! We put life sentences for using heroin, or now we’re going to kill dealers, so we fixed the problem.”

Meanwhile, what happens is everybody with addiction just switches to the next best, least costly alternative. Then, down the road we have another crisis that isn’t really another crisis. It’s the same illness being expressed with a different reward, and we’ve been doing this for a hundred years.

Erich: Returning to the more medical perspective, what sort of traits or commonalities do you see among patients, who were using drugs when you were practicing medicine? Are there commonalities that are shared by a lot of the people who happen to have this addiction problem?

Howard: With addiction, you’re coming to us from two different places; there are two different primary biologies. One is low dopamine; one is normal dopamine. The brief version is that you can either have normal to high dopamine, or low dopamine. If you start with low dopamine, what people generally have are symptoms of low hedonic tone. They can’t remember things very well, can’t pay attention, and they have no motivation. They like exciting things, from the very earliest day, they like going out and getting dopamine. They jump out of an airplane with a parachute; they’ll do all sorts of interesting things to get excited. Other people who start with normal and high dopamine, especially those with high dopamine, they like sedatives.

They’ll start with benzodiazepines and alcohol. Through the action of those drugs on the dopamine center, they will lose dopamine in the reward center over time. So even though they still have their anxiety, they started compulsively seek stimulation later in life. So, we have a guy who’s been drinking for sedation for 20 or 30 years. When we offered him a cigarette at age 11, he thought it was way too much stimulation. He was so adversely affected he’d never talk to you again, but now he’s smoking crack because he needs the dopamine.

Erich: What sort of relationship do you see between high dopamine levels and anxiety?

Howard: Yes, absolutely. If you look at OCD or PTSD and the severe anxiety disorders, they all have overstimulation by dopamine. Which is why we give people antipsychotics which block dopamine, or SSRIs which actually lower dopamine release. That’s how we treat OCD.

Then you have the social issues. We know that the issue here for the people is dopamine tone, and dopamine tone is made up of how much dopamine you release, the number and function of the dopamine receptors that see the dopamine and the amount of time that dopamine is available to the receptors. If you genetically don’t make enough dopamine or have bad dopamine receptors, you’ll have low dopamine tone. There’s a whole bunch of ways to have that low dopamine form of addiction, but there’s also a social way. We know that if we take a social mammal and isolate it or make it subservient, we can actually lower the number of dopamine receptors.

So you could be born genetically normal, but because of social influences have lower dopamine tone just because of dopamine receptor abnormality that’s brought on by society. So when you think about what we do to people who use drugs, we put them in jail which is isolating and you feel less than. We’re really actually worsening the disease.

Erich: So you think that there are social remedies for people inclined towards addiction and drug use: can having a social healthy lifestyle be as powerful as certain medically based treatments?

Howard: If you’re genetically well, then I think there are social policies, because these things are so far beyond personal choice we’re talking about. For example, we can say, “Run and eat healthy.” But if you’re living in an urban housing project and you have to take three buses to get to work and there are no supermarkets around for you to go get healthy food, I don’t know how you can make those healthy choices. There are public policies that have created cases of addiction. And, of course, the government doesn’t see that.

They say, “Oh, look people are making choices!” But what’s really happening here is, this part of the brain has been keeping mammals alive for 100 million years. You are completely incapable of making choices that overpowered this. This would be like saying even though you don’t steal on a daily basis, but if you hadn’t eaten in seven days, you could refrain from stealing in order to eat. You can’t because this center is so powerful, and that’s how people with low dopamine feel all the time. It’s like the way you would feel if you hadn’t eaten in seven days.

Erich: Is our country doing enough in terms of spending on mental health?

Howard: I would rather focus on where government is spending money to worsen mental health and stop doing that. No matter how much money you spend to fix mental health, you will not fix mental health as long as you’re paying to worsen mental health.

Erich: What sort of changes have you seen since you began practicing about the stigma or public perception associated with mental illness?

Howard: In an attempt to fix the stigma, my field started overpathologizing normality in an unconscious attempt to make everybody feel more empathy towards people who are ill.

So now, we have the Diagnostic and Statistical Manual where you’re a rare person if you manage to get through that without being diagnosed with something. Basically, everyone is diagnosable now, and you hear this coming out of the federal agencies. You hear things like “everyone is at risk of mental illness!” and “a huge percentage of the population has mental illness!” All of this was an attempt to de-stigmatize things. I don’t think it’s worked.

Erich: Overly zealous, these activists and some physicians have been hoisted by their own petard you’re saying?

Howard: Yes. They should have really seen that coming. These are experts in human behavior, and they weren’t going to figure out that humans weren’t going to just get suddenly empathetic with people who creep them out? And that they weren’t going to respond defensively when you said, “You’re just like that guy that creeps you out.”

Of course we’re going to respond defensively and actually have more stigma.

Erich: Is this related to certain claims for example that we’re overprescribing ADD/ADHD medication?

Howard: Right, the whole thing is overpathologized. Now we’re talking about how people with mental illness can have guns, and there isn’t not a person in America I couldn’t go through the DSM with and find some criteria for a diagnosis. And then we’re going to call that a mental illness and then say you can’t vote or you can’t have your gun or you can’t drive. They’ve pathologized culture.

Erich: You believe this is an issue of misrecognition? We’re saying the problem is opioids, but really it’s this natural tendency towards low dopamine, wanting some sort change in chemistry and just being redirected, time and again, towards one different substance after another.

Howard: Right, and then there’s the reality that not everybody can get addiction. We can take people, strap them to a table and inject them with heroin. They’ll become dependent on heroin; they’ll have withdrawal and stop, but they won’t have addiction.

They never go back to the heroin. They don’t look back on and think, “Wow, what a great pleasure that was.” They actually would view it as a torturous two weeks and ask, “Why would anyone do that voluntarily?” You can’t make everybody an addict, but that’s what the government is saying because they want it to be about drugs. That’s the easy answer, but it isn’t the real answer.

It’s about the brain. There are some people who are born with addiction, some people who can easily get addiction. Those people probably shouldn’t use drugs. 75 to 80 percent of the population is at literally no risk at all. They would use drugs the way everybody else drinks. They would just do it socially and if they go too far they’d say, “I’m not doing that again.” And then they don’t.

Erich: Dr. Wetsman, thank you very much for your time this morning.

Howard: Sure, thank you.

This interview has been lightly edited for length and clarity. 

Erich J. Prince is a Co-founder and contributor at Merion West. Erich has written for a variety of publications including The Philadelphia Inquirer, the Hartford Courant, The News & Observer, and the Orlando Sentinel. His writing has been honored with two awards from the Columbia University School of Journalism. He studied political science at Yale University, completing his thesis on the history of polarization in the United States Congress. Contact Erich at erich@merionwest.com.