Opioid Crisis in U.S. Military Driven by Combat Exposure in the War on Terror, Research Finds

United States military service members who experience combat are more likely to misuse prescription painkillers than those who don’t engage in combat, according to a new working paper from the National Bureau of Economic Research.Prescription painkiller misuse is 7 percentage points higher among service members whose units were deployed to combat zones and engaged with enemy fighters, compared with those deployed to combat zones whose units didn’t engage the enemy, the authors find.“This study is the first to estimate the causal impact of combat deployments in the Global War on Terrorism on opioid abuse,” the authors write.They also find that younger, enlisted personnel are at greater risk for misusing prescription painkillers after combat exposure. Service members in the authors’ sample come from similar socioeconomic backgrounds. This suggests the association is driven by what happens on the battlefield, not other factors like race, ethnicity and income levels that have been broadly linked to opioid misuse.“Among military populations, combat is a very major reason for the opioid epidemic,” says Resul Cesur, an associate professor of healthcare economics at the University of Connecticut and one of the paper’s authors. “It’s not because of who these people are. It’s because of what they are being exposed to.”The authors conservatively estimate that government health care costs top $1 billion per year to treat active-duty service members and veterans who misuse prescription painkillers.While not all prescription painkillers are opioids, oxycodone, hydrocodone and other opioids are among those prescription painkillers generally most likely to be misused -- compared with painkillers like nonsteroidal anti-inflammatory drugs, which typically aren’t thought to be addictive.“For this reason, I think these [prescription painkiller data] are very good proxies for what we want to capture,” Cesur says.Combat exposure is also associated with higher rates of heroin use, according to this paper. Looking at a different dataset, the authors find deployed service members who saw combat used heroin at a 1.4 percentage point higher rate than deployed service members who didn’t engage with enemy fighters. The authors identified the largest effects among service members in the Army, Marines and Navy, relative to service members in the Air Force. The government cost of treating active-duty service members and veterans who misuse heroin is nearly $500 million per year, the authors conservatively estimate.Enlisted Personnel Bear the BruntThe U.S. military has two distinct career tracks: enlisted personnel and commissioned officers. One of those tracks bears the brunt of the opioid crisis in the military, this research finds.Enlisted personnel perform tasks. They usually receive specialized training, and their specialties can vary widely. Enlisted personnel may scout a battlefield, or service biomedical equipment, or care for government-owned animals or perform any number of other specialties. A four-year degree is not required to enlist.Commissioned officers serve primarily as management. They handle operations and strategy and give orders to lower-ranked officers and enlisted personnel. Each branch of the military has slightly different paths toward becoming an officer, but most include having or obtaining a four-year college degree.In addition to having more formal education, officers also typically earn more money than enlisted personnel.Enlisted personnel account for nearly all of the association between combat exposure and painkiller misuse, the authors find. Of the nearly 2.8 million service members who have served overseas since 9/11, 86% were enlisted, according to a 2018 analysis by the RAND Corporation.“We find the effects among officers are almost zero,” Cesur says. Younger enlisted service members, age 18 to 24, who saw combat are also more likely to have misused painkillers, the authors find.Data SourcesThe authors draw their findings from two surveys of military service members.The first is the National Longitudinal Study of Adolescent and Adult Health, also called Add Health. This nationally representative survey originally interviewed about 20,000 adolescents in grades 7-12 during the 1994-1995 school year. Researchers asked about kids’ social and economic backgrounds, their performance in school and their psychological and physical well-being. They followed up with the original respondents during 2007-2008.From Add Health, the authors analyzed a sample of 482 men aged 28 to 34 who reported actively serving in the military during the Iraq and Afghanistan wars in the early- and mid-2000s. Detailed socioeconomic information allowed the authors to study respondents who had similar upbringings. This sample led to the finding that prescription painkiller misuse was 7 percentage points higher among service members whose units were deployed to combat zones and engaged with enemy fighters.The other, much larger sample was the 2008 Department of Defense Health and Related Behaviors Survey. This survey included nearly 30,000 active-duty service members aged 18 to 50. The authors’ sample included responses from 11,542 soldiers deployed overseas who provided information on recent prescription painkiller misuse. Respondents were also asked about other illicit drug use.This sample led to the finding that heroin use is higher among service members who experience combat, and to the broader finding that enlisted personnel account for almost all of the link between combat exposure and painkiller misuse.Men made up more than three-fourths of enlisted personnel who saw combat and responded to the DOD survey. Before 2013, women were not allowed to take up many frontline positions.Injury, Easy Supply and PeersThe authors reason that soldiers might start using opioids for their original medical purpose: when warzone service members are injured, opioids can help manage their pain.Post-traumatic stress disorder also explains a big chunk of the relationship between combat exposure and painkiller abuse, Resul says. Traumatic events that military personnel experience, even among those who don't serve directly on the front lines, can increase opioid misuse, according to the paper. In the authors’ DOD survey sample, 10% of active-duty deployed service members had PTSD.Another reason for opioid misuse among military personnel who saw combat could be that cheap, high-quality opioids were available in the very places service members were deployed in the 2000s. Opium poppy cultivation in Afghanistan grew steadily in the years after 9/11, according to data from the United Nations Office on Drugs and Crime.“Opium production in Iraq was much rarer than in Afghanistan, but production in Iraq began to grow in the aftermath of Operation Iraqi Freedom,” the authors write. “Production appears to have accelerated during the period just before and during the so-called ‘surge’ of U.S. Armed Forces to Iraq in 2007-2008.”There may also be peer effects at play.“People go to combat zones and then see their colleague is using opioids because he is stressed,” Cesur says. “So that may be another pattern. Humans are social creatures and we copy from each other.”Veterans at RiskPrograms aimed at reducing painkiller prescriptions to soldiers and veterans appear, so far, to be working.Opioid prescriptions from Department of Veterans Affairs doctors fell more than 40% from 2012 to 2017, according to the authors. This coincides with the VA’s Opioid Safety Initiative, which began in 2013 and aims to educate healthcare providers on the benefits and risks of prescribing opioids.The authors note that, “the reduction in opioid prescriptions to curb abuse may have the unintended consequence of reduced pain abatement for opioid users who do not suffer from addiction,” and that “sudden negative shocks to prescription painkillers could induce veterans to more dangerous, and perhaps deadly, forms of opioid use such as heroin or fentanyl if these drugs are substitutes.”Despite fewer painkiller prescriptions, the opioid overdose death epidemic among veterans is still very real -- and appears to be getting worse. After troop surges in Afghanistan and Iraq in the late 2000s, opioid use disorders among veterans rose 55%, according to data the authors cite from the VA.Veterans broadly are twice as likely to die from accidental drug overdoses, according to one widelyandrecently cited study analyzing data from 2005 and published in 2011 in the journal Medical Care.More recent research in the American Journal of Preventive Medicine bolsters the premise that veterans remain particularly vulnerable to addiction. The rate of opioid overdose deaths among veterans in 2016 increased 65% from 2010, according to that paper -- even as the percentage of veterans who received prescriptions for opioids in the three months before their deaths fell from 54% in 2010 to 26% in 2016.The authors of the new NBER paper cite evidence suggesting that medical marijuana could be an effective substitute for opioids in treating chronic pain. Medical marijuana may not play a straightforward role in easing the broader opioid epidemic, however. Research in the Proceedings of the National Academy of Sciences from just a few months ago found -- contrary to prior research -- that opioid overdose death rates increased by nearly a quarter in states with legal medical marijuana.Can medical marijuana really play a role in easing the nation's opioid epidemic? Here’s what the most recent research says. Plus, see the parts of the country where opioids are prescribed the most. And, America’s other drug epidemic. Last but not least, don’t miss these 10 rules for reporting on war trauma survivors, created in collaboration with our friends at The War Horse.This article first appeared on Journalist's Resource and is republished here under a Creative Commons license.

Jeff Finds a SMART Solution

This month we spoke with Jeff, an alumni of the Sunshine Coast Health Centre. He checked in for treatment in January of 2019 and has remained sober since the day he walked in. After entering Sunshine Coast Health Centre he realized that it was the perfect package for him. In his words, “The Meaning-Centered Therapy, Somatic Therapy, the massages they offered and even meditation which helped open my mind, it was perfect!” Most addiction treatment centers offer an exclusively 12-step approach to recovery. For decades this has been considered the only way to go. While many suffering from addiction have positively benefited from this approach, others have found themselves in conflict with fundamental aspects of 12-step programs. Sunshine Coast Health Centre changed gears in 2008 by moving to a non 12-step approach to treatment.Meaning-Centered Therapy Sunshine Coast Health Centre now uses a Meaning-Centered Therapy model that is based off of Viktor Frankl's MeaningTheory. One of the benefits to the Meaning-Centered Therapy model is that it empowers clients, allowing them to decide what works best for them. No client is expected to conform to the same approach, and while a purely 12-step approach may work well for one person, Meaning Centered Therapy might work better for another.In our talk with Jeff he made a statement that seems to echo some of the philosophy of Sunshine Coast Health Centre. He said, “So regarding 12-step programs, I say whatever works for the individual. I don't shun anything. SMART Recovery was a good fit for me.” Under the umbrella of Meaning-Centered Therapy, Jeff was introduced to the SMART Recovery program an alternative to the 12-steps. SMART meetings can be found internationally.What led Jeff to seek treatment at Sunshine Coast Health Centre? Well, Jeff has had a 30 year career in the military, and comes from rural Manitoba. He had already been a heavy drinker, but after a few years crammed with significant personal tragedies, his drinking began to spiral out of control. Drinking had begun to affect his work life, and he had a moment of clarity in which he realized he was slowly destroying himself. Through the intervention of a few higher ranking officers at his base he was encouraged to seek help to get himself well. He explains, “I went and I talked to the addictions counselor at the base. When we started looking at places to go there was an option to do one here. It was a place just north of Winnipeg here in Manitoba. That was the 12-steps based program, and they were allowed visitation with family on Sundays and stuff which I was honesty not really keen on. For me if I was going to go away and get help I wanted to go for 45-60 days, and just be away from everybody. That includes somebody from the military, from the base up there. So I wanted to get away from Manitoba.”An Alternative to 12-Step ProgramsHe continues, “They started asking whether I wanted to go into the 12-step based program or non 12-step based. For me I was kind of indifferent. I honestly didn't give the 12-steps a shot, so I said okay, I'm not averse to it, but there were still other factors with the 12-steps which I had issues with. I didn't believe in giving yourself up, you know, surrendering yourself. The whole day by day or one day at a time thing I can do, because a lot of the time that's what recovery is, but there are just certain aspects of The 12-steps that I don’t like.”The good news for those who share Jeff’s feelings about the 12 steps is that there are other effective treatment options options available! After successfully finishing up at Sunshine Coast Health Centre, Jeff has transitioned back to living life in Manitoba. He continues to attend SMART groups at home and expounded on what has kept him enthusiastic about going to his weekly meeting, “They've got a great workbook and the discussions and crosstalk can be really enlightening. What I really like are the tools they employ. There are so many of these tools that apply to everyday basic living. When they're looking at addiction they're really looking at the patterns, the psychology and the physical chemistry behind it. It becomes a little more analytical, but it’s not hard to comprehend or absorb. The tools are simple and I’ve found them very handy. The thing I like about it too is that our group is not just alcoholics. We have a gambler in there as well. It all really has to do with behavior.”Sunshine Coast Health Centre’s Meaning-Centered Therapy helped Jeff find a solution to his addiction. The program they offer recognizes each client as having a unique set of needs and experiences. They understand that what works for one person may not work for another. Jeff left us with a final statement on his experience finding recovery at Sunshine Coast Health Centre. He concisely reflects that, “In every program, whether you like it or not, there's one or two little nuggets in there.” Well said, Jeff! If you’re battling addiction, just keep an open mind. It could radically change your life!

The Fix Craft Interview with "Godfather of Harlem's" Giancarlo Esposito

Giancarlo Giuseppe Alessandro Esposito was born in Copenhagen to Elizabeth Foster, an African-American opera and nightclub singer from Alabama, and Giovanni Esposito, an Italian stagehand and carpenter from Naples. After spending his first seven years in Denmark, his family moved to Manhattan. As an actor, Giancarlo Esposito has played a wide range of roles, although he’s best known for playing people on the fringes of society such as notorious drug dealer Gustavo “Gus” Fring in Breaking Bad and Better Call Saul. Esposito won Best Supporting Actor in a Drama at the 2012 Critics' Choice Television Awards for that role. He was nominated for Outstanding Supporting Actor in a Drama Series at the 2012 Primetime Emmy Awards, but lost to Breaking Bad co-star Aaron Paul. He’s also taken on roles such as Buggin’ Out in Spike Lee’s Do The Right Thing, Jack Baer in The Usual Suspects, and Congressman Adam Clayton Powell Jr. in the new Epic crime drama, Godfather of Harlem.The Fix was thrilled to have the opportunity to sit down with Giancarlo Esposito and discuss the challenges of portraying drug users and dealers. How did playing Adam Clayton Powell Jr. in Godfather of Harlem challenge you as an actor? Was he playing a game of being different with a drug dealer like Bumpy Johnson in private as opposed to in public? Is this a dangerous dance?It is a dangerous dance, and that dance is one reason why I love this role, and I love the scripts that bring Godfather of Harlem to life. I love the conflicts that come up between politics and crime. I know Adam Clayton Powell really respected Bumpy Johnson, and he recognized the time he did. Bumpy went away for ten years, and he did not snitch on the Italians. After coming back to Harlem, he wanted to get back in the game and regain what was his before he went to prison. However, he found out that two different Italian crime families were fighting for control of what was once his territory in Harlem. Although Adam respects Bumpy as a man, he will not let Bumpy take advantage of their friendship. Bumpy expects Adam to give him the brother nod as one black man to another, and offer him a pass. However, it doesn’t happen that way when Adam Clayton Powell realizes that Bumpy also is a part of the problem. When Adam went after the Italians, Bumpy got off by the skin of his teeth because Adam knew Bumpy did do some good things for the community. It also helped that Adam was taken with Mayme, Bumpy’s beautiful wife, who was a member of his congregation and a close friend. She pleaded for her husband to be spared, and Adam spared him. What was most challenging about playing Gus Fring in Breaking Bad and Better Call Saul? Since he’s often so reserved, did you feel the part demanded greater precision? Do you see the character as being evil?When I had the opportunity to play that role, I knew I didn’t want to play it like the Italian mobster we had seen so many times before, petting the little dog, making threats, and being mean with a cigar in his mouth. When I looked at this character closely, I realized I wanted to play someone who was part of the community. In our conversations, I suggested this idea to Vince Gilligan. I told him that I wanted to play a man that was hiding in plain sight. It was based on a stage direction written by Vince, and it became my inspiration for the character.I thought the character needed to have precision because he was a guy who could be selling toothpaste. It didn’t matter. He was going to be successful no matter what he sold. He was a man who respected other human beings and wanted to use their abilities to achieve his ends. At the same time, he also wanted to reward them if they followed to the T the path that he laid out for them. He knew how to create a successful business venture, and his word was final. Gus was clearly measured, and he had this idea that he could do it better than anyone else, including the cartel. It’s why he starts to make moves to take over the cartel. He believes the business is not being run in such a way to ensure the maximum profit. In many ways, Gus is an entrepreneur who believes in his way of doing business above all else. Your role of Congressman Adam Clayton Powell is so different than your role as Gus. However, the two characters feel similar in how they deal with the world and smoothly handle the politics of being a powerful man of color. Do you find similarities in playing the two characters? Did the role of Gus help to inform your performance as Powell?No, not at all. I look at every character I create as a completely new entity unto me. Since Adam Clayton Powell is a historical character, it makes a complete difference in the way I’m playing him. Such a role requires a different level of research because he was a real person of historical importance. Thus, I put the building blocks together that tell that particular character’s story in a different manner. Adam Clayton Powell was a living, breathing human being who had a tremendous impact on this country. He had 865 bills with his name on them that he passed in Congress. He also was a man who was on the pulpit on Sunday morning. He also was a man who was a womanizer and who knew so many major criminals on a first-name basis. However, his willingness to work with them would only go so far. In Godfather of Harlem, he really wants Bumpy Johnson to do the right thing, and he respects the fact that Bumpy is about African-American people and doing the best for them. Bumpy wants to change the tide of the Italian stronghold on Harlem at that time. Although there might appear to be similarities, in creating these characters, they were completely different because playing a character based on a real person has different responsibilities than playing a fictional character. When I have a historical context in which to work, I want to honor that context in regards to how it affects the character I’m playing. A desire for equality motivates Adam Clayton Powell. He wanted the same things that Malcolm X wanted, but he didn’t go about it the same way. He wanted to be treated in just the same way as the white Dixiecrats in Washington were being treated. He came to see that such equality simply wasn’t there, so he pushed harder to make that level of equality possible. Using his brains and his training as a lawyer, he did everything he could to effect the change that he hoped could be achieved. You have played both drug users and drug dealers in different television shows and feature films. Does playing a drug user give you greater insight into playing a drug dealer? How do the different sides of that fence affect your performance?I believe they are two different things. Playing a drug dealer allows you to have control and power, but it also forces you to be conscious and deal with your conscience. It’s hard for drug dealers not to face questions like, “What are you doing to your people and to other people? What are you doing to a human being?” For Gus to be selling drugs in Breaking Bad and Better Call Saul on a larger scale, it takes away the ability to see the consequences of what it does on the streets, human to human. It’s a powerful experience to play a drug dealer, but it’s even more powerful to experience that casual disregard for the lives of other human beings for your economic success. When you play a drug user, it’s a much more vulnerable position to experience firsthand. If you are a drug user, particularly a drug addict, you have no choice; you can’t control yourself. Since you have to have it, it’s a very vulnerable and sensitive position. It must feel like a catch-22. Why do you have to have it? It’s because you are killing some kind of pain, or else you are locked in that process of feeding that dragon that you have created by repeatedly using the drug. You cannot escape the pull of the drug that anesthetizes you because you are unable to handle life. Perhaps one of your most undervalued performances is Esteban in Fresh (1994), a compelling film written and directed by Boaz Yakin. I know it was over a quarter of a century ago, but can you recall what it was like playing that role? Esteban was visceral and menacing. Did that role help to inform your later performance as Gus?I love the role of Esteban, and I love Boaz Yakin. Fresh was a truly powerful film with an amazing cast that included Sean Jackson, Samuel L. Jackson, N'Bushe Wright, and myself. I really enjoyed playing that particular character. I think he’s very, very different from Gus in that he hadn’t thought out his moves, and there is a sense that anything can happen with him. Gus is very calculated, and, in contrast, Esteban is flying by the seat of his pants. A very menacing guy, he somehow cared about this kid, who was working for him as a drug runner. Esteban is not at all ready when the kid manages to turn the tables on him. Unlike Gus, he’s a man at such a low level in the drug trade who’s desperately trying to protect his business and his little piece of turf. He doesn’t have the sense of a larger business acumen that makes Gus so distinctive. Esteban certainly was a wonderful role for me to play because he was completely unpredictable. The danger was that he could do anything at any time. In contrast, Gus holds his cards close to the vest. He’s much more calculated in his moves and in what he does to extend his business. Check out Giancarlo Esposito in The Mandalorian, streaming now, and in Better Call Saul, returning next month to AMC. 

Benzodiazepines: Another Prescription Drug Problem

May 30, 2019This tip sheet, originally published in 2018, has been updated to include more recent statistics and additional information.Benzodiazepines, a class of anti-anxiety drugs, are commonly-prescribed medications with the potential for abuse, addiction and overdose. Sound familiar? The parallels to the opioid epidemic are apparent; some physicians have taken to calling it “our other prescription drug problem” as they warn of potential dangers.“People don’t appreciate that benzodiazepines are addictive and that people abuse them,” said Dr. Anna Lembke, a psychiatry professor at Stanford Medical School. In a phone call with Journalist’s Resource, she said that, just as with alcohol, benzodiazepines can be taken to achieve a state of intoxication.Lembke is the program director for the Stanford University Addiction Medicine Fellowship and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published research in JAMA Psychiatry, Molecular Psychiatry, the Journal of Substance Abuse Treatment, Addiction and other journals. In 2016 she published Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, a book on the prescription drug epidemic. Journalist’s Resource spoke with Lembke to learn more about the drugs and factors that have spurred current prescribing trends.For context, a few recent studies put numbers to these trends: A new study that focuses on Sweden finds that benzodiazepines and benzodiazepine-related drug prescriptions increased 22 percent from 2006 to 2013 among individuals aged 24 and younger.A study published in 2016 in the American Journal of Public Health finds that from 1996 to 2013, the number of adults in the United States filling a prescription for benzodiazepines increased 67 percent, from 8.1 million to 13.5 million. The death rate for overdoses involving benzodiazepines also increased in this time period, from 0.58 per 100,000 adults to 3.07.What Are Benzodiazepines?Benzodiazepines are a class of drugs with sedative and anti-anxiety effects. A few of the most commonly prescribed benzodiazepines include diazepam (brand name: Valium), alprazolam (brand name: Xanax; street names: bars, xannies), clonazepam (brand name: Klonopin) and lorazepam (brand name: Ativan). These drugs differ with respect to how long they take to start working and how long they last, but all have similar effects, since they work by the same mechanism.How Do They Work?Benzodiazepines bind to gamma-aminobutyric acid (GABA) receptors in the brain. GABA is an inhibitory neurotransmitter; in other words, it inhibits brain activity. Turning the power down in the brain feels like sleepiness and calm.What Are They Prescribed For?They can be prescribed for a number of concerns, including anxiety, insomnia and seizures.How Can They Be Dangerous?Benzodiazepines are accompanied by a number of side effects, including tolerance (reduced sensitivity) for the drug, cognitive impairment, anterograde amnesia (the inability to remember events that occurred after taking the drug), increased risk of Alzheimer’s disease, increased risk of falls (particularly among the elderly, who, according to a study in JAMA Psychiatry, comprise the age group in the U.S. most likely to use the drugs, and use them over the long term), and, most notably, dependence, abuse and overdose. Benzodiazepines are similar to opioids, cannabinoids, and the club drug gamma-hydroxybutyrate (GHB) insofar as the same neural mechanism underlies their addictiveness, according to research published in Nature.Even taking benzodiazepines in adherence to a prescribing physician’s instructions can lead to dependence. Withdrawal symptoms are likely among patients who have taken benzodiazepines continuously for longer than a few weeks, according to a study published in Australian Prescriber.For people who are looking to discontinue their use of benzodiazepines, Lembke noted that withdrawal could be potentially life threatening. “You can have full-blown seizures and die just from the withdrawal,” she said.“The way that they’re prescribed and continued is contrary to the evidence in the medical literature,” Lembke said. She noted that the evidence indicates benzodiazepines are effective and useful only in the short term, and typically at low doses. “There’s no evidence that benzodiazepines taken long term work for anxiety,” she said. “Nonetheless, it is common practice to prescribe and continue those prescriptions for months to years to decades. Somehow there’s a disconnect between the evidence and what the practice is.”Given These Risks, Why Are Prescriptions on the Rise?“No one knows for sure,” Lembke said. She did, however, offer a few possible explanations.She mentioned changes over the past three decades in the way healthcare is delivered.As more physicians have shifted from private practice into integrated health care centers, they might feel pressure to adhere to standard protocols or perform procedures and prescribe pills like benzodiazepines, because “that’s what pays.”She added that the way medicine is currently practiced separates patients into parts: “Patients have a different doctor for every body part … The right hand doesn’t know what the left hand is prescribing.”Frequent changes in insurance coverage, or churn, means that individuals bounce from one coverage source (and care provider) to another. This eliminates the possibility of a sustained, caring and trusting relationship that might allow for more efficacious, long-term health interventions, Lembke added.Other changes to the health care system have also occurred: “In many ways, doctors are like waiters and patients are customers,” Lembke explained, adding that some doctors feel the need to respond to patients’ requests and provide short-term relief or “customer satisfaction.”A cultural shift might be at work here, too, “Patients expect it,” Lembke said. “We now think pain in any form is dangerous … We’ve also got a whole generation of individuals raised on Prozac, Adderall, Xanax thinking there isn’t anything wrong with using chemicals to change the way you feel.”Benzodiazepines and OpioidsAs Lembke pointed out, rising pharmaceutical use isn’t limited to benzodiazepines. And as the United States grapples with widespread opioid use, research points to a dangerous link between these drugs and benzodiazepines.A study of over 300,000 patients receiving opioid prescriptions between 2001 and 2013 finds that by 2013, 17 percent also received benzodiazepine prescriptions -- up from 9 percent in 2001.Moreover, a study that looked at U.S. veterans who received opioid prescriptions finds that those who received benzodiazepines as well experienced increased risk of drug overdose death; the risk increased along with the dose. Another study finds that the overdose death rate among patients receiving opioids and benzodiazepines was 10 times higher than among those receiving opioids alone.According to statistics from the National Institute of Drug Abuse (NIDA), from 1999 to 2017, there was a 10-fold increase in the number of overdose deaths involving benzodiazepines in the United States -- a rise from 1,135 in 1999 to 11,537 in 2017. Most of the increase has been driven by the use of benzodiazepines in combination with opioids (since 2014, the number of overdose deaths involving benzodiazepines but not any opioids has held steady). As opioids contribute increasingly to benzodiazepine overdose deaths, benzodiazepines too are increasingly present in opioid overdose deaths -- the powerful combination of drugs is present in over 30 percent of opioid overdoses, NIDA reports.Benzodiazepine abuse on its own can lead to overdose and death, but overdose deaths typically occur in combination with other substances -- generally other central nervous system depressants, which, like benzodiazepines, can lead to the life-threatening effect of slowed or stopped breathing.In August 2016, the Food and Drug Administration issued a requirement that opioids and benzodiazepines carry a black-box warning about the risks associated with using these substances together.Now that you have the background, here are some story ideas, courtesy of Lembke:Look into the latest wave of benzodiazepines: super-potent, designer, synthetic varieties made in illicit labs.Investigate the growth of benzodiazepine-related patient advocacy organizations as a phenomenon.Probe Big Pharma’s role in prescription trends and look at socioeconomic variations in benzodiazepine prescriptions (e.g., Medicaid prescribing rates).Journalist’s Resource also has explainers on other drugs, including fentanyl and meth.This photo, property of the United States Department of Justice, was obtained from Wikimedia Commons and used under a Creative Commons license.This article first appeared on Journalist's Resource and is republished here under a Creative Commons license. 

Why It’s Hard to Remove, or Even Diagnose, Mentally Ill or Unstable Presidents

In the wake of President John F. Kennedy’s assassination, members of Congress set out to update the procedures for handling an unable president. They soon realized that some situations would be far more challenging than others.Famed political scientist Richard Neustadt emphasized one of the most ominous of those situations when he testified before the Senate. “Constitutions,” he warned, cannot “protect you against madmen. The people on the scene at the time have to do that.”Congress’ reform effort culminated with the 25th Amendment. It provides essential improvements to the Constitution’s original presidential succession provisions. But a novel released in 1965, the same year Congress approved the amendment, makes a strong case that Neustadt’s insight was spot on.The recently reissued “Night of Camp David” by veteran D.C. journalist Fletcher Knebel illuminates the daunting challenges that arise when the commander in chief is mentally unfit and unwilling to acknowledge it.Flexibility an Important Part of 25thThe novel follows the fictional Senator Jim MacVeagh, who concludes that a paranoid President Mark Hollenbach is “insane” after he witnesses the president plot to abuse law enforcement powers and to establish a world government. Unbeknownst to MacVeagh, Defense Secretary Sidney Karper reaches the same conclusion. Karper remarks, “Congress did its best on the disability question, although there’s no real machinery to spot mental instability.”The framers of the 25th Amendment did intend for it to cover cases of psychological inability. One of the principal authors, Rep. Richard Poff (R-Va.), envisioned a president who could not “make any rational decision.”But the term “unable” in the amendment’s text was left vague to provide flexibility.Additionally, the 25th Amendment is intentionally hard to use, with procedural hurdles to prevent usurpation of presidential power. Two-thirds of both houses of Congress must ratify an inability determination by the vice president and Cabinet when the president disagrees. Otherwise, the president returns to power.Some believe these protections create their own challenges. As Harvard Law Professor Cass R. Sunstein observes in “Impeachment: A Citizen’s Guide,” “The real risk is not that the Twenty-Fifth Amendment will be invoked when it shouldn’t, but that it won’t be invoked when it should.”This risk is heightened when the president may be psychologically unfit. Psychiatric assessment is descriptive and less evidence-based than other areas of medicine. In the novel, President Hollenbach’s doctor reports no evidence of a mental ailment. And there is a reason for that: Psychiatric illness is not beyond conscious manipulation. A deft politician, President Hollenbach knew enough to hide his paranoia. While he seems overtly paranoid in the solitude of Aspen Lodge at Camp David when he is sharing his delusions with MacVeagh, he appears completely sane, dare we say presidential, in public appearances. There is a long history of presidents hiding their ailments from the public, including Presidents Lyndon Johnson and Richard Nixon, who both grew paranoid in private.What Psychiatry Can ContributeTo further complicate assessment, the more subjective nature of psychiatric diagnoses introduces potential political biases among clinicians who might be asked to evaluate a president.As critically, the American Psychiatric Association’s Goldwater Rule expressly prohibits armchair analysis by psychiatrists who have not directly examined the president. Those who had the opportunity would be equally constrained by patient confidentiality. This creates an ethical Catch-22.Yale psychiatrist Bandy X. Lee and colleagues in “The Dangerous Case of Donald Trump” eschew this prohibition and feel it their ethical obligation to share their professional insights, invoking a duty to warn responsibility. One of us (Joseph) has suggested that while psychiatric diagnoses cannot be made from afar nor confidences breached, physicians have a supererogatory obligation to share specialized knowledge.This is especially important when discussing psychiatric conditions, which may be hard to apprehend. The objective for mental health professionals is not diagnosis from afar but rather to educate the citizenry about these conditions so as to promote deliberative democracy.Beyond these issues is the bias of any president’s advisers and allies. Their loyalty may blind them to presidential inabilities and have them protect an unfit president.Then could be the political disincentive to acknowledge what presidential incapacity means. After all, Cabinet members serve at the pleasure of the president. Beyond that, it is just too frightening to imagine that there might be a madman in the White House in the nuclear age. So the tendency is to look away.Officials hoping to avoid a direct challenge to presidential authority might engage in harm reduction, a concept drawn from public health where certain harms are accepted to reduce more harmful consequences: for example, needle exchange. This is the workaround that the fictional Defense Secretary Karper takes in “Night of Camp David.” Instead of attempting to convince the president’s allies of his concerns and invoking constitutional means to remove the president, he convenes a top secret task force to consider checks on the president’s power to use nuclear weapons.Karper’s steps to limit the president’s unilateral authority have real-world precedent.Amid President Nixon’s emotional turmoil during the depths of Watergate, Defense Secretary James Schlesinger instructed the military to check with him or the secretary of state before following orders from Nixon to launch nuclear weapons. More recently, former Defense Secretary James Mattis was reportedly among White House officials attempting to frustrate President Trump’s impulses.The fictitious Senator MacVeagh goes down a different, more perilous and isolating path. He seeks the president’s removal and, as a result, experiences retribution. Top officials view him as paranoid, prompting them to order his involuntary psychiatric hospitalization. Instead of worrying about an impaired president, Washington’s political elite punish the young senator.The bottom line: it is almost impossible to reverse the results of the electoral process and oppose entrenched power even when one is paradoxically trying to preserve the republic.In “Night of Camp David,” the nation’s fortunes only begin to turn when MacVeagh and Karper overcome the collective action challenge and the compartmentalization of knowledge. Officials can overcome these obstacles by coming together and realizing their common purpose.It was only after a group of senior Republican lawmakers, led by Sen. Barry Goldwater – ironically of the eponymous Goldwater Rule – banded together and confronted President Nixon during Watergate that the 37th president resigned. More drama ahead?The current White House drama is still in manuscript form, but the plot has thickened. Worrisome tweets are prompting fresh concerns about presidential fitness, even from prominent members of President Trump’s own party.Are these warnings the real-life equivalents of those from MacVeagh and Karper? Time will tell. But in this national drama, we are more than readers of fiction; we too are characters.Richard Neustadt had it right. The “people on the scene” must be ready to place the interests of the nation above their own. Constitutions cannot protect against madmen, as he warned, because they create rules and institutions that are only as strong as the people tasked with protecting them.Both the object of any intervention and its proponents are prone to human foibles, courage and timidity, grandiosity and prudence. When darkness descends, whether on Camp David or other halls of power, the nation is left to rely on the integrity and judgment of its leaders and its citizenry. This article was written by John Rogan, Fordham University, and Joseph J. Fins, Cornell University and was originally published in April 2019 at The Conversation.

What Do You Do When the Cravings Hit?

When you first got sober, you might have thought that going through treatment would be the hardest part of recovery. And while getting sober is no walk in the park, staying sober can be equally challenging. That’s because even after substances have left your body (sometimes for years) you can still experiencing cravings and the urge to use. So, how do you deal with addiction cravings, or the urge to use? Learning about the biology of addiction cravings and understanding the power you have to overcome the urge to use can help you stay sober. Understanding the Urge to UseMost people who are in recovery occasionally experience the urge to use, or drug cravings. That’s true for people who are well-established in sobriety, and those who are relatively new to being clean and sober. One scientific review described cravings as “a very real phenomenon,” that “often intrudes into [people’s] daily lives, at times dominating their thoughts and generating considerable distress.”When you stop using drugs or alcohol, your body is still out of equilibrium. Your brain is used to the intense highs brought about by drugs, and it’s unable to get those good feelings from everyday activities like hugging a loved one or exercising. Because of that, your body might crave drugs, in order to return to the “normal” that it has experienced during your addiction. In addition, many people experience the urge to use when they’re in a bad situation. Many people with substance use disorder have used substances as a coping mechanism to deal with fear, disappointment or anger. When you encounter these negative emotions when you’re sober, you might still have the urge to use to overcome them. How to Cope With Urges to UseLuckily, it’s entirely possible to overcome the urge to use. After all, you’ve already overcome the pull of substances to get sober and start your life in recovery. Draw on that strength when you experience a craving. Remember, you’re in control, and saying no to a craving moves you closer to the life you want. Here’s what to do when a craving hits:Ask Yourself Why: Oftentimes, there is a reason that you’re experiencing a craving or the urge to use. Naming that reason can help you understand why you’re feeling the way you are, and help put you back in control of your recovery. Maybe you’re experiencing a strong emotion, or you’re in a situation that you find triggering. Recognizing that can give you solutions and empower you.Reach Out For Help: When you’re experiencing a craving, it can feel like you’re on the brink. Sometimes, having someone there with you holding your hand (literally or metaphorically) can keep you safe. Reach out to a sponsor if you’re in a 12-step program, or a trusted friend. If no one comes to mind, call the treatment center that you went to. Talking to someone, or just being in their presence, can help you overcome a craving. Take Your Time: After you’ve detoxed and are in recovery, most cravings come on quickly, but disappear relatively quickly as well. That means time is on your side. You may need to focus to overcome the craving while it’s at its worst, but soon the urge to use drugs will dissipate. The key is just hanging on until it begins to wane. How To Prevent the Urge to UseMany people in recovery would love to never experience a craving or the urge to use again. However, that’s just simply not possible — cravings are part of life in recovery. Still, there are tools that you can use to minimize how often you experience cravings. Staying healthy overall and laying a foundation for recovery can help you avoid triggers and stay in a good mental space. That can help reduce cravings. In addition, some people find that certain activities help when they experience a craving. Instead of using, they exercise, bake, or sip a hot drink — anything to stay focused on the here and now, rather than a craving that could pull you into the past. Learn more about Oceanside Malibu at http://oceansidemalibu.com/. Reach Oceanside Malibu by phone at (866) 738-6550. Find Oceanside Malibu on Facebook.

Hangovers Happen as Your Body Tries to Protect Itself from Alcohol's Toxic Effects

Debaucherous evening last night? You’re probably dealing with veisalgia right now. More commonly known as a hangover, this unpleasant phenomenon has been dogging humanity since our ancestors first happened upon fermentation.Those nasty vertigo-inducing, cold sweat-promoting and vomit-producing sensations after a raucous night out are all part of your body’s attempt to protect itself from injury after you overindulge in alcoholic beverages. Your liver is working to break down the alcohol you consumed so your kidneys can clear it out ASAP. But in the process, your body’s inflammatory and metabolic reactions are going to lay you low with a hangover.As long as people have suffered from hangovers, they’ve searched in vain for a cure. Revelers have access to a variety of compounds, products and devices that purport to ease the pain. But there’s a lot of purporting and not a lot of proof. Most have not been backed up well by science in terms of usefulness for hangover treatment, and often their effects don’t seem like they’d match up with what scientists know about the biology of the hangover.Working Overtime To Clear Out the BoozeHangovers are virtually guaranteed when you drink too much. That amount varies from person to person based on genetic factors as well as whether there are other compounds that formed along with ethanol in the fermentation process.Over the course of a night of heavy drinking, your blood alcohol level continues to rise. Your body labors to break down the alcohol – consumed as ethanol in beer, wine or spirits – forming damaging oxygen free radicals and acetaldehyde, itself a harmful compound. The longer ethanol and acetaldehyde stick around, the more damage they can do to your cellular membranes, proteins and DNA, so your body’s enzymes work quickly to metabolize acetaldehyde to a less toxic compound, acetate.Over time, your ethanol levels drop through this natural metabolic process. Depending on how much you consumed, you’re likely to experience a hangover as the level of ethanol in your blood slowly returns to zero. Your body is withdrawing from high levels of circulating alcohol, while at the same time trying to protect itself from the effects of alcohol.Scientists have limited knowledge of the leading causes of the hangover. But they do know that the body’s responses include changes in hormone levels to reduce dehydration and cellular stress. Alcohol consumption also affects a variety of neurotransmitter systems in the brain, including glutamate, dopamine and serotonin. Inflammation increases in the body’s tissues, and the healthy gut bacteria in your digestive system take a hit too, promoting leaky gut.Altogether, the combination of all these reactions and protective mechanisms activated by your system gives rise to the experience of a hangover, which can last up to 48 hours.Your Misery Likely Has CompanyDrinking and socializing are cultural acts, and most hangovers do not happen in isolation. Human beings are social creatures, and there’s a high likelihood that at least one other individual feels the same as you the morning after the night before.Each society has different rules regarding alcohol use, which can affect how people view alcohol consumption within those cultures. Drinking is often valued for its relaxing effect and for promoting sociability. So it’s common to see alcohol provided at celebratory events, social gatherings and holiday parties.In the United States, drinking alcohol is largely embraced by mainstream culture, which may even promote behaviors involving excessive drinking. It should be no surprise that overindulgence goes hand in hand with these celebratory social events – and leads to hangover regrets a few hours later.Your body’s reactions to high alcohol intake and the sobering-up period can influence mood, too. The combination of fatigue that you experience from sleep deprivation and hormonal stress reactions, in turn, affect your neurobiological responses and behavior. As your body is attempting to repair itself, you’re more likely to be easily irritated, exhausted and want nothing more than to be left alone. Of course, your work productivity takes a dramatic hit the day after an evening of heavy drinking.When all is said and done, you’re the cause of your own hangover pain, and you’re the one who must pay for all the fun of the night before. But in short order, you’ll forget how excruciating your last hangover was. And you may very soon talk yourself into doing the things you swore you’d never do again.Speeding Up RecoveryWhile pharmacologists like us understand a bit about how hangovers work, we still lack a true remedy.Countless articles describe a variety of foods, caffeine, ion replenishment, energy drinks, herbal supplements including thyme and ginger, vitamins and the “hair of the dog” as ways to prevent and treat hangovers. But the evidence isn’t really there that any of these work effectively. They’re just not scientifically validated or well reproduced.For example, Kudzu root (Pueraria lobata), a popular choice for hangover remedies, has primarily been investigated for its effects in reducing alcohol-mediated stress and hangover. But at the same time, Kudzu root appears to inhibit the enzymes that break down acetaldehyde – not good news since you want to clear that acetaldehyde from your system quickly.To fill this knowledge gap, our lab is working with colleagues to see if we can find scientific evidence for or against potential hangover remedies. We’ve focused on the benefits of dihydromyricetin, a Chinese herbal medicine that is currently available and formulated as a dietary supplement for hangover reduction or prevention.Dihydromyricetin appears to work its magic by enhancing alcohol metabolism and reducing its toxic byproduct, acetaldehyde. From our findings in mice models, we are collecting data that support the usefulness of dihydromyricetin in increasing the expression and activity of enzymes responsible for ethanol and acetaldehyde metabolism in the liver, where ethanol is primarily broken down. These findings explain one of the several ways dihydromyricetin protects the body against alcohol stress and hangover symptoms.We are also studying how this enhancement of alcohol metabolism results in changes in alcohol drinking behaviors. Previously, dihydromyricetin was found to counteract the relaxation affect of drinking alcohol by interfering with particular neuroreceptors in the brain; rodents didn’t become as intoxicated and consequently reduced their ethanol intake. Through this combination of mechanisms, we hope to illustrate how DHM might reduce the downsides of excessive drinking beyond the temporary hangover, and potentially reduce drinking behavior and damage associated with heavy alcohol consumption.Of course, limiting alcohol intake and substituting water for many of those drinks during an evening out is probably the best method to avoid a painful hangover. However, for those times when one alcoholic beverage leads to more than a few more, be sure to stay hydrated and catch up on rest. Your best bet for a smoother recovery is probably some combination of nonsteroidal anti-inflammatory drug like ibuprofen, Netflix and a little downtime. [ Deep knowledge, daily. Sign up for The Conversation’s newsletter. ]This article is republished from The Conversation under a Creative Commons license. Read the original article.

A Young Immigrant Has Mental Illness, and That’s Raising His Risk of Deportation

When José moved his family to the United States from Mexico nearly two decades ago, he had hopes of giving his children a better life.But now he worries about the future of his 21-year-old-son, who has lived in central Illinois since he was a toddler. José’s son has a criminal record, which could make him a target for deportation officers. KHN is not using the son’s name because of those risks and is using the father’s middle name, José, because both men are in the U.S. without legal permission.José’s son was diagnosed with schizophrenia and bipolar disorder last year and has faced barriers to getting affordable treatment, in part because he doesn’t have legal status. His untreated conditions have led to scrapes with the law.Mental health advocates say many people with untreated mental illness run the risk of cycling in and out of the criminal justice system, and the situation is particularly fraught for those without legal status.“If he gets deported, he’d practically be lost in Mexico, because he doesn’t know Mexico,” said José, speaking through an interpreter. “I brought him here very young and, with his illness, where is he going to go? He’s likely to end up on the street.”Legal TroublesJosé’s son has spent several weeks in jail and numerous days in court over the past year.On the most recent occasion, the young man sat nervously in the front row of a courtroom in Illnois’ Champaign County Courthouse. Wearing a white button-down shirt and dress pants, his hair parted neatly, he stared at the floor while waiting for the judge to enter.That day, he pleaded guilty to a criminal charge of property damage. The incident took place at his parents’ house earlier this year. He had gotten into a fight with his brother-in-law and broke a window. His father said it was yet another out-of-control moment from his son’s recent struggles with mental illness.Before beginning proceedings, the judge read a warning aloud — a practice that is now standard to make sure noncitizens are aware they could face deportation (or be denied citizenship or reentry to the U.S.) if they plead guilty in court.José’s son received 12 months of probation.After the hearing, he said that his life was good just a couple of years ago: He was living on his own, working and taking classes at a community college. But all that changed when he started hearing voices and began struggling to keep a grip on reality. He withdrew from his friends and family, including his dad.One time, he began driving erratically, thinking his car was telling him what to do. A month after that episode, he started having urges to kill himself and sometimes felt like hurting others.In 2018, he was hospitalized twice and finally diagnosed with schizophrenia and bipolar disorder.José said that during this time, his son — who had always been respectful and kind — grew increasingly argumentative and even threatened to hurt his parents. The psychiatric hospitalizations didn’t seem to make a difference.“He asked us for help, but we didn’t know how to help him,” José said. “He’d say, ‘Dad, I feel like I’m going crazy.'”José’s son said he met with a therapist a few times and took the medication he was prescribed in the hospital. He was also using marijuana to cope, he said.The prescribed medication helped, he said, but without insurance he couldn’t afford to pay the $180 monthly cost. When he stopped the meds, he struggled and continued having run-ins with the police.Undocumented and UninsuredFor people who are both undocumented and living with a mental illness, the situation is “particularly excruciating,” said Carrie Chapman, an attorney and advocate with the Legal Council for Health Justice in Chicago who represents many clients like José’s son.“If you have a mental illness that makes it difficult for you to control behaviors, you can end up in the criminal justice system,” Chapman said.People with mental illness make up only a small percentage of violent offenders — they are actually more likely, compared with the general population, to be victims of violent crime.Chapman said the stakes are extremely high when people without legal status enter the criminal justice system: They risk getting deported to a country where they may not speak the language, or where it’s even more difficult to obtain quality mental health care.“It could be a death sentence for them there,” Chapman said. “It’s an incredible crisis, that such a vulnerable young person with serious mental illness falls through the cracks.”An estimated 4.1 million people under age 65 who live in the U.S. are ineligible for Medicaid or marketplace coverage under the Affordable Care Act because of their immigration status, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)Among them are those who are undocumented and other immigrants who otherwise do not fall into one of the federal categories as a lawful U.S. resident. People protected from deportation through the federal government’s Deferred Action for Childhood Arrivals policy, or DACA, also are ineligible for coverage under those programs.For many people in all those groups, affordable health care is out of reach.Some states have opened up access to Medicaid to undocumented children, including Illinois, California, Massachusetts, New York, Oregon, Washington and the District of Columbia, according to the National State Conference of Legislatures. But residents lose that coverage at age 19, except in California, which recently expanded eligibility through 25.For those who can’t access affordable health insurance because of their undocumented status, medical care is largely limited to emergency services and treatments covered by charity care or provided by community health centers.It’s unclear how many people have been deported because of issues linked to mental illness; good records are not available, said Talia Inlender, an attorney for immigrants’ rights with the Los Angeles-based pro bono law firm Public Counsel. But estimates from the American Civil Liberties Union suggest that tens of thousands of immigrants deported each year have a mental disability.Inlender, who represents people with mental disabilities in deportation hearings, said that when the lack of access to community-based treatment eventually leads to a person being detained in an immigration facility, that person risks further deterioration because many facilities are not equipped to provide the needed care.On top of that, she said, immigrants facing deportation in most states don’t generally have a right to public counsel during the removal proceedings and have to represent themselves. Inlender points out that an immigrant with a mental disability could be particularly vulnerable without the help of a lawyer.(Following a class action lawsuit, the states of Washington, California and Arizona did establish a right to counsel for immigrants with severe mental illness facing deportation. For those in other states, a federal program is designed to provide the same right to counsel, but it’s only for certain detained immigrants.)Medicaid For More People?Chapman and other advocates for immigrants’ rights say expanding Medicaid to cover everyone who otherwise qualifies — regardless of legal status — and creating a broader pathway to U.S. citizenship would be good first steps toward helping people like José’s son.“Everything else is kind of a ‘spit and duct tape’ attempt by families and advocates to get somebody what they need,” Chapman said.Critics of the push to expand Medicaid to cover more undocumented people object to the costs, and argue that the money should be spent, instead, on those living in the country legally. (California’s move to expand Medicaid through age 25 will cost the state around $98 million, according to some estimates.)As for José’s son, he recently found a pharmacy that offers a cheaper version of the prescription drug he needs to treat his mental health condition — and he’s feeling better.He now works as a landscaper and hopes to get back to college someday to study business. But he fears his criminal record could stand in the way of those goals, and he’s aware that his history makes him a target for immigration sweeps.José said his greatest fear is that his son will end up back in Mexico — away from family and friends, in a country he knows little about.“There are thousands of people going through these issues … and they’re in the same situation,” José said. “They’re in the dark, not knowing what to do, where to go or who to ask for help.”Christine Herman is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @CTHerman.This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Common Sense Recovery: An Atheist's Guide to Alcoholics Anonymous

An audio version of Common Sense Recovery is now available on Audible. Science Is Not a Four-Letter WordA lot has been learned since Bill and Bob first met. I like to think that they did not so much set things in stone as set them in motion.But we must always keep in our minds that the deep roots of AA in religion have set into our fellowship a long standing tone of anti-science and anti-learning. Religious organizations such as Alcoholics Anonymous tend to be subtly, if not overtly, hostile to new ideas, to science, to change, and to anyone or anything which calls into question their traditional view that the big and important questions have all been answered, and the answer is God.I am not an expert on the subject matter, and this is not going to be a science paper. Yet we would be doing ourselves and all the suffering alcoholics, now and in the future, in and out of the rooms, a huge disservice if we failed to recognize the ways in which a rapidly expanding body of knowledge might enhance our efforts. So, for example, there is an ever-growing body of scientific data to support the view that positive thinking and associated actions can literally re-wire the brain’s circuitry.So let’s consider just one important area of investigation which will suggest the kind of exploration I think we have an obligation to more diligently pursue. Recent findings in the neurosciences suggest that the human brain is more malleable than once thought to be. Our experiences can actually rewire our “plastic” brain. Simply put, when we form habits of behavior, such as drinking or any of the destructive habits of thought associated with the alcoholic lifestyle, we forge strong pathways in our brain, neural connections that are reinforced over and over again, becoming stronger and stronger each time we repeat the patterns of thought and behavior.The good news is that change is possible. The even better news is that positive change, consistently different thoughts and actions, will re-wire our neural pathways, literally changing our brain’s structure. The more we engage in the new behavior, the more that particular set of neurons fires together and wires together. The new connections, perhaps very tenuous at first, grow stronger and stronger with each reinforcing positive thought and activity. Meanwhile, the old pathway literally begins to atrophy from non use. The old habits fade, while the new ones become stronger and stronger with each repetition.I find it encouraging that we have this growing body of evidence supporting many of our traditional teachings. Repeated alternate behavior choices can actually restructure our mental map. “Fake it till you make it” is scientifically verifiable. “Living our way into right thinking” is not a mere slogan on the wall, but an empirically verifiable technique for altering our brain chemistry and, thereby, our entire lives. How encouraging to know that, as hard as it may be at first to have an “attitude of gratitude”, habitually cultivating one through practice and repetition can, over time, literally change the way we see the world at the most basic level.One of the more influential books I have ever read in my own personal recovery is an old school classic called A New Pair of Glasses, by Chuck C. Amongst many other insights, the book offered up the idea that god was in fact, simply, a new way of seeing the world, a new pair of glasses. This idea is suggested throughout the Big Book. The whole point of the AA experience is to initiate a “psychic change” (p. xxix), one which will “revolutionize our whole attitude toward life” and “toward our fellows”. (p. 25. Here, as in many places, I intentionally edit out Bill and the old timers’ copious references to god, spirit or higher power. This is quite intentional, and represents in fact a main thrust of my argument: Alcoholics Anonymous is replete with a wonderful and useful toolkit that can help anyone stay sane and sober if they are willing, even after we take out all the unnecessary, distracting, obfuscating religious language.) They may no longer be with us, but I suspect that Bill and Bob, Carl Jung, Dr. Silkworth and Chuck C. would all have been impressed by the correlation between this focus on a new pair of glasses and contemporary findings in the brain and behavioral sciences.So, scientific findings support our experience: we can act our way into right thinking. We can ultimately enjoy lasting, whole scale changes in our personalities through seemingly small, incremental changes in behavior. Every time we experience a desire to drink and, instead, go to an AA meeting, call a friend, or work with a newcomer, we weaken that demon and strengthen that angel. We do the next right thing and, at some point, we realize that all these slow incremental steps have produced a significant, “miraculous” transformation. Our brain is literally being rewired, slowly but surely reprogrammed.The AA tradition is to call this kind of change “spiritual” for two reasons. First, because of tradition. This sort of personal transformation, prior to the last couple hundred years of human history at least, was generally considered the sole province of religion, the handiwork of angels and deities.Second, the caulk thing again. We find the radical change inexplicable, so we apply the magic, one-size-fits-all explaining power of theism as a metaphysical caulk in order to satisfy the never-ending human thirst for understanding or explanation.Most importantly, these responses are not merely unnecessary; they are demeaning and disempowering in a very important sense. Our recovery is not up to angels, demons, or gods. It is up to us. We are responsible for taking the necessary actions that ensure the necessary changes which make for lasting, contented sobriety. Furthermore, supernatural explanations such as this give the false impression that we know all we need to about the phenomenon in question. As such, they tend to stand in direct conflict with the kind of curiosity and exploration which will grow the recovery sciences and our understanding of the relevant social and psychological processes.The Real Higher PowerThe most miraculous and inexplicable force at work in Alcoholics Anonymous may be fellowship itself. Even the most devoutly religious members depend upon our society, upon the power of the group. Often they will describe their fellow AAs, in a typical example of religious interpretation, as the mouthpiece through which god speaks to them. The fellowship is understood as a mere vehicle, or as a temporary expedient to be replaced by the real Higher Power when the newcomer finally “comes to” or “comes to believe”. But the experience of most recovering alcoholics is that, what guides and sustains us on a day-by-day basis are peer support, empathy, mentor guidance, and the emotional reinforcement of group membership. In short, what keeps us sober from day to day is fellowship. Consider these three suggestions, probably the most common ones made to an alcoholic who is suffering:Go to a meetingCall your sponsorWork with another alcoholicWhat do all three have in common? They all entail immersion in the society of recovering peers, a meaningful connection with our newfound tribe. Reams of data from social psychology, evolutionary biology and a host of other disciplines attest to the essential role played by peer groups and societies in determining both our values and our action choices, in shaping our thoughts and behaviors. Scientifically, mounting evidence suggests that the social group is the source of an important kind of basic emotional nurturance that is fulfilling to tribal hominids such as we at a most fundamental level.Our brain evolved to be what it is over the course of five million years spent in small, familial tribes, within which complete immersion and total dependence were essential for our very survival. We are, at our core, not so much individual animals as we are pack members. Gathering in fellowship is the most important practical tool we have borrowed from religion and the church. But, in the end, the power of the group is undoubtedly a little less miraculous, a little more ancient, and a little more explicable, than once thought.The tribe functions as the disseminator and teacher, the source of encouragement and reinforcement, that which empowers the addict to live a better life on a daily basis. The fellowship offers new ideas, role models who practice them, wise guidance and counsel, reinforcement of values and goals, and essential emotional rewards to its members. It empowers us to practice new and different behaviors until they become new and different habits. As time passes our membership within the tribe is the source of life enriching friendships.But it also becomes an important source of a newfound sense of value and purpose as, over time, we transform into seasoned members who reap significant benefits from passing guidance and support on to the next member in need. This life sustaining mutual exchange is a huge part of recovery. It builds a web which sustains us all, a web of support that is fundamentally tribal. Our lives are saved, shaped and defined by the herd. We survive by running with the pack. The fellowship is the most tangible instantiation of a “higher power” in our lives. I would argue that we need seek no further.For humans, isolation is death. Community is life. We overestimate the value of religious belief and faith in god: in fact, the community of fellows is the vehicle, whether it is church, temple, ashram, therapy group, mosque, sangha, a meeting of Alcoholics Anonymous, or the meeting after the meeting.Keep in mind how miserable and close to disaster Bill Wilson was in spite of his life-changing experience at Towns Hospital. AA lore unwisely exaggerates his alleged spiritual experience. This was, in all probability, merely a side effect of the quasi-toxic, hallucinogenic Belladonna cure being administered at the time.But when Bill went out into the world and engaged with other alcoholics, he ultimately found what he was looking for. It was not more white light, or god, or a higher power that he found, but a drunken country doctor named Bob. The lasting good they created is a society of peers who gain synergetic strength in numbers, loving support from each other, and much wisdom gleaned from years of collective experience.The above is an excerpt from the book Common Sense Recovery: An Atheist's Guide to Alcoholics Anonymous. The book was originally written as a journal by long-term member Adam N., as he sought to bridge the gap between the religious language and perspectives of AA, and his own increasingly secular, atheistic understanding of the fundamental principles of recovery. Now in its third edition, this work continues to be a valuable guide for many who struggle with the religious nature and language of AA and contains important insights for the future of the fellowship.