‘An unhappy chemical accident’
Kurt White, the director of ambulatory services at the Brattleboro Retreat, believed in 2008 that he was seeing the peak of the opiate epidemic. Eleven years later, the annual death toll has doubled.

‘An unhappy chemical accident’

Why does a substance become an addiction? Where’s the line between a bad habit and a psychiatric illness? A Brattleboro Retreat specialist offers a primer on the medical underpinnings of an epidemic gripping the region and country.

BRATTLEBORO — According to Kurt White, more people in the United States died from opioids last year than U.S. soldiers from the Vietnam War during the entire duration of that conflict.

From that perspective, the director of ambulatory services at the Brattleboro Retreat believes that opioids aren't getting enough attention.

“If it was a war, it would. But it is kind of a war - but with hidden victims,” he said.

This class of drugs, and their negative effects on the people in Windham County, has received - and will continue to receive - intense focus from community members, emergency responders, medical professionals, human service agencies, and selectboards alike.

One organization, Project CARE, is organizing a series of forums over the summer to help educate the public on substance-use disorders. The first takes place on Tuesday, June 18, at the Central Fire Station on Elliot Street.

CARE stands for “community approach to recovery and engagement.”

The Brattleboro Police Department first formed the Project CARE team, which includes personnel from the Brattleboro Retreat, Brattleboro Memorial Hospital, Brattleboro Union High School, the Groundworks Collaborative, Habit OPCO Treatment Center, HCRS (Health Care and Rehabilitation Services), and Turning Point of Windham County.

A question of distress or impairment

The forum will discuss the meanings of “addiction,” a word easily tossed around in daily parlance. People will say they're addicted to their favorite TV series or ice cream flavor or to social media.

But what makes something like a substance (like opioids) or an experience (like gambling) an addiction and not simply a bad habit?

According to White, a lot of the situation depends on how much a behavior or substance interferes with a person's life and functioning.

In a forum in May at Brattleboro Memorial Hospital organized by Project CARE and aimed at people working in the medical field or emergency services, White discussed some of the fundamentals of substance-use disorder and the Brattleboro Retreat's Uniformed Service Program, which works with military and emergency-service personnel dealing with post-traumatic stress disorder.

“An addiction is a compulsive [activity] that we engage in that causes some sort of distress or impairment, usually in multiple areas of a person's functioning,” he said.

Binge watching an entire season of a TV show while eating junk food is hardly the healthiest way to spend a weekend, but it's unlikely to become all-consuming, White said.

That's because the experience and the chemicals released in the body aren't enough to overwhelm the person's ability to prioritize experiences, he explained.

According to White, it's unlikely the behavior on its own will drive someone to stop going to work or stop spending time with loved ones.

For an activity to rise to the level of an addiction, a very predictable series of chemical responses happen in the brain.

The result, White said, is that “the brain's reward system gets hijacked.”

Reward vs. pleasure

“An unhappy chemical accident” is really at the root of many addictions to substances, White said.

Humans evolved with a reward system - a neurotransmitter, or brain chemical, called dopamine - to help their brains know how much and how often to engage in life-supporting activities that keep the species going, such as drinking water, eating, or mating, White continued.

When humans do these sorts of things, they get a shot of dopamine as a reward. That dopamine creates a feeling of well-being and encourages a repeat of the behavior.

White cautions that this chemical feedback is considered a reward and is not exactly they same thing as pleasure, which is a different system in the brain.

“The brain no longer knows how to prioritize activities and experiences; it sort of demands to be doing the addictive behavior even when perhaps the person doesn't want to, or even when there isn't much pleasure associated with it anymore,” he said.

“A rat knows how to live, even through a rat doesn't consciously think about menu planning,” he said. “It's just an unhappy accent that substances like heroin mimic the chemicals that help regulate how you interact with the environment.”

Compare this to caffeine, White said. People may resort to their morning cup of coffee as a compulsion, but with caffeine, there are very few harms, and it rarely interferes with functioning, he said.

Even if someone feels groggy without their morning coffee, they're unlikely to miss a day of work, for example.

And if drinking coffee does lead to health issues, people tend to just set it aside, White added.

When White says “hijacked,” he means that the brain's reward system becomes overstimulated by a substance. Eating a sandwich gives a little shot of dopamine, but substances such as heroin or cocaine “give a much greater reward than anything you can do without the influence of the drug,” he said.

Fundamentally, this overflow of reward chemicals in the brain sets someone up for a compulsive experience. Suddenly, one's brain believes the body needs a substance such as opioids more than it does a sandwich - or even water.

Part of the compulsion comes from the fact that, from an evolutionary standpoint, the part of the brain affected by the substance “is so old, it can actually motivate a person to move toward those substances” by messaging the motor cortex and thus bypassing a person's conscious-thought process, White explained.

White said it's not uncommon for someone who has relapsed to not know why. This is because the part of the brain under one's control - conscious thought - wasn't the part that triggered the person to find and use the substance, he said.

It's a tricky situation, according to White, because the reward center of the brain can drive a person into a compulsive cycle that keeps them using a substance - or, in the case of gambling or similar behaviors, seeking an experience - even when that person no longer enjoys it.

“In the beginning, it's often about getting the benefit of some pleasure out of [using the substance] or avoiding some feeling,” White said.

But once using the substance becomes compulsive, “the logic of it changes, and the person is just doing it because they have to do it,” he said.

“It's a complicated thing, because oftentimes the reasons a person starts to use drugs, for example, are not the reasons that people end up continuing to use drugs or [the reasons that people have] trouble setting them aside after they've developed a compulsive pattern of use,” he said.

White said brain chemistry is a complex subject, and he leaves most of it to the neuroscientists.

In broad strokes, however, the brain's reward and pleasure centers operate a little differently.

Pleasure is something people might enjoy, but it's not linked to survival.

That's the job of the brain's reward system, which doles out boosts of dopamine to reward eating - an evolutionary trait that normally makes food consumption a biological imperative for even the pickiest of eaters.

That's the system that gets disrupted by opioids, which convince the body to make their continued use the same sort of biological imperative.

In other words: addiction.

No two brains are alike

The way the brain responds to substances isn't the same for every person.

According to White, a variety of factors predispose people to becoming addicted. Genetics contributes about 50 percent of the tendency. Other contributors include early childhood trauma and one's current social situation.

Social and emotional deprivation can prime someone's brain to become addicted, he said.

White points to studies from the 1980s where researchers gave cocaine to rats along with bowls of food and water.

As expected, the rats started consuming the cocaine and ignored the food and water.

But when researchers created “a happy rat paradise” with places to run, other rats, food, and water, they found that the rats tried the cocaine but were less likely to become compulsive users. The conclusion: The rats had an environment and relationships that sustained them.

Also, substances aren't equally rewarding to individuals, he said. Some people will use opioids after surgery and feel sick; others, he said, will successfully taper off just fine because they “felt loopy.”

Yet, some people respond to a post-surgery prescription with an “Oh, man, this is great stuff!” and want more of it, White said.

“The need for more is a sign that the reward system is operating at a high level,” he said. “Alcohol is like this - some can take it or leave it. Meanwhile, some people, even those who aren't alcoholic, would hate the thought of never drinking again.”

Another huge factor is one's age when one first uses the substances, White said.

“The brain is not the same at every stage in its development,” he said. “Most addictions have their seeds in adolescence.”

“If you can reach full adulthood without developing an addiction then your risk of developing one - even with heavy genetic loading for addictions - normalizes to the baseline for someone without the genetic loading,” he said.

The message: “Prevention beats genetics,” he said.

In Vermont, White's greatest worry is twofold: the large percentage of young people who use alcohol and marijuana as teens, and the large number of adults who use cocaine.

“We're at the bottom of the statistics for this,” he said. “It really is a bad sign for those populations' risk of developing addictions.”

He's not sure why that is the case in Vermont.

He speculates that marijuana - now legal to possess under some circumstances under state law - has become part “an environment of permissiveness.”

“People just don't believe it's risky anymore,” he said - and that relaxed attitude might carry over to opioids and provide users with a false sense of invincibility.

Living through an epidemic

White feels that the extent to which the community is focusing on opioids and their negative impacts is appropriate.

In 2008, he said, the number of opioid-related deaths surpassed the number of traffic fatalities in a year. At the time, White thought, that would be as bad as the opioid epidemic would get.

Now, 11 years later, the number of yearly deaths from opioids has almost doubled.

Still, he cautions that just because this one class of substances is receiving attention, other addictive substances have not gone away.

The number of people struggling with opioid misuse didn't get worse because fewer people are struggling with alcohol misuse, he said.

The number-one myth White hears regarding addiction is that “people could just stop if they really wanted to.”

“It's often more difficult than that,” he said.

People often need to go through recovery many times and with a lot of support, he said. In most cases, people would choose to not be in the throes of addiction.

The disease itself “erodes a person's ability to make a rational, responsible choice,” he said.

White said that while people need to be held responsible for criminal behavior, most of the negative or criminal behavior is done by people who are not in treatment.

Substance-use disorder takes a giant toll on communities, and the disease is a puzzling thing, White said. “But we have to keep trying until we live through.”

“It is very easy to think about addicted individuals as an other,” he acknowledged.

But, he said, “I have a vantage point of really telling you it's not true, it really cuts across all areas of our lives.”

The problem of opioid addiction is “very close to everyone in this area, and that's what an epidemic is,” White said. “Largely, people live through epidemics rather than solve them.”

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