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The Thirteenth Step

The Thirteenth Step: Addiction in the Age of Brain Science

Copyright Date: 2015
Pages: 320
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  • Book Info
    The Thirteenth Step
    Book Description:

    The past thirty years have witnessed a revolution in the science of addiction, yet we still rely on outdated methods of treatment. Expensive new programs for managing addiction are also flourishing, but since they are not based in science, they offer little benefit to people who cannot afford to lose money or faith in their recovery.

    Clarifying the cutting-edge science of addiction for both practitioners and general readers, The Thirteenth Step pairs stories of real patients with explanations of key concepts relating to their illness. A police chief who disappears on the job illustrates the process through which a drug can trigger the brain circuits mediating relapse. One person's effort to find a burrito shack in a foreign city illuminates the reward prediction error signaled by the brain chemical dopamine. With these examples and more, this volume paints a vivid, readable portrait of drug seeking, escalation, and other aspects of addiction and suggests science-based treatments that promise to improve troubling relapse rates. Merging science and human experience, The Thirteenth Step offers compassionate, valuable answers to anyone who hopes for a better handle on a confounding disease.

    eISBN: 978-0-231-53902-9
    Subjects: Health Sciences, Psychology, Sociology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
    (pp. vii-xii)
  4. 1 US AND THEM
    (pp. 1-10)

    As the nurse on the floor picked up the chart to read the transfer note, she thought there must have been a mix-up. She sighed. It was a Friday afternoon, and, like her colleagues, she was getting ready to get off her shift and go home. She was a good nurse, one of many in the underappreciated army who keep hospitals going by juggling a job and family. On any other day, she did not mind unexpected work. In fact she enjoyed it, thriving on getting things right, offering comfort to patients, and keeping physicians in line. After fifteen years...

    (pp. 11-17)

    Friday night to Saturday was the most unattractive tour of duty in the psychiatric emergency room of the old mental hospital, keeping doctors and nurses cloistered while everyone else was enjoying weekend pleasures. Weekday shifts did not mess up weekends, so they were more desirable. From noon Saturday through the rest of the weekend, comp time was offered at twice the hours worked, so it quickly accumulated and offset some of the pain of missing out on weekend fun. But the Friday night tours really had no redeeming features. So it should come as no surprise that, being the youngest...

    (pp. 18-31)

    Dependence, abuse, substance use disorders, addiction. There are so many terms, used by professionals and laypeople alike, that do not necessarily have a clear meaning. Each attempts to capture substance use that is harmful, but drugs can be harmful in different ways. To build an understanding of the kind of substance use that gives rise to clinical problems, we need to know what we are talking about.

    So let’s step back a little. A desire to chemically alter brain function and the mind states it produces is probably as old as humankind itself. We know that the ancient Greeks considered...

    (pp. 32-40)

    It was 1997. I had just been appointed director of a large, newly created addiction medicine service in the Swedish capital city of Stockholm. We had a staff of about four hundred, close to a hundred inpatient beds, an emergency room of our own in the city center, and clinics scattered across several locations in the most drug-infested part of the region. There was just one problem. Although we were affiliated with the famous Karolinska Institute, we had no idea what we were doing.

    The patients were mostly poor, severely addicted, and socially marginalized people. Many were homeless or, as...

    (pp. 41-48)

    In an encounter with a patient, every clinician is faced with a fundamental dilemma. Although present in all areas of medicine, this issue becomes most acute in psychiatry and behavioral health. In these fields, feelings, intentions, and decisions are at the core of the clinical disorders that bring patients to treatment. So the question cannot be avoided: should what happens in the patient’s mind be viewed as yet another set of physiological processes, possible to register from the outside in an objective manner and to predictably manipulate with interventions such as drugs, similar to what we expect of blood pressure...

    (pp. 49-56)

    The small band of hunter-gatherers had been traversing the savannah for days, making good headway in the low morning light, resting in a patch of high grass through the hottest midday hours, and then moving on again, until the fall of darkness. A few days before, waving sticks and throwing stones, they had been able to chase off two hyenas and scavenge what remained of several antelope carcasses, left behind by some unknown predator. They had stayed at the site and feasted until no one could eat any more, and then used sharp stone tools to cut off the meat...

    (pp. 57-74)

    On july 4, 1776, the Second Continental Congress adopted Thomas Jefferson’s view that the pursuit of happiness is one of the inalienable rights with which all men are endowed by their creator. The concept has been around longer than that, of course—for instance, as expressed here in a four-thousand-year-old Egyptian song:

    Let thy desire flourish,

    In order to let thy heart forget the beatifications for thee.

    Follow thy desire, as long as thou shalt live.

    Put myrrh upon thy head and clothing of fine linen upon thee,

    Being anointed with genuine marvels of the god’s property.

    Set an increase...

    (pp. 75-88)

    It was a slow Thursday afternoon. Perched in my office, I had finished up the paperwork earlier than expected and hoped to get to work on our latest research report. But a kind of weariness held me back. Instead I remained seated behind my desk, watching the gray daylight wane and turn into November dusk. The street below my window got busier and busier as the afternoon neared its end. There was a feeling of emptiness to what I was doing, one that has remained with me through the years and easily comes over me if I don’t keep busy...

    (pp. 89-103)

    The little girl’s birthday was less than a week away. Through the haze of cheap booze, her father dreaded the day. For months Carlos had not had a steady job. Instead he had been out on the street corner in Gaithersburg, where the jobless men gathered at six o’clock every morning, waiting for the beaten up trucks to come by and pick up a few of them for the odd job. He was drinking almost every day, but these were the times when there was still a lot of construction going on in the Washington, D.C., suburbs. The builders were...

    (pp. 104-112)

    When i first met him, it was hard to imagine that for almost a decade, Peter had been chief of police in one of Sweden’s major cities. After two weeks of having been listed as a missing person, he was found, disheveled and disoriented, in the rough streets behind the main train station in Denmark’s capital, Copenhagen. When he was first picked up, I read in the Danish transfer notes, his clothes were dirty and torn, his body was bruised, and he was unable to identify himself. He was finally able to produce a name, a telephone number, and an...

    (pp. 113-122)

    As i walk down the street in downtown Bethesda on a warm Thursday evening, an inexplicable, intense urge to smoke hits me out of the blue. This is quite strange. I have not smoked more than the occasional cigarette in the close to twenty years since I met my wife. Yet in an instant, it is all upon me. I have the intense feeling that something is missing. My mouth is wetting in anticipation of the taste of a smoke, and I’m almost feeling a miniature preview of that taste, out of thin air. Similarly, my head is going just...

    (pp. 123-134)

    It is twelve noon on a scorching weekday in the summer. You are stationed at the Miramar Naval Air Base outside San Diego. It is your day off, and you and your comrades are driving to the beach. Pete is driving, and you are in the passenger seat. Phil, Matt, Bob, and Chris are in the back. You narrow your eyes to block out the blazing sun. Suddenly you smell smoke. Your heart quickens. You drive a little farther and see an accident about 150 yards away. You tense the muscles in your face and forehead. You think, “My God,...

    (pp. 135-162)

    The caller, a father of two boys, was a leading Swedish industrialist. People spoke of him as a good man, but even so, I found these referrals somewhat awkward. Most of our patients were disadvantaged; many were homeless. All had neglected medical needs. I had mixed feelings about treating or advising people who had vast resources available to them, and who expected us to give them special attention. We just didn’t do VIP treatment. When the caller asked if I could please see him and his sons in my private practice, I explained I didn’t have one. He insisted he...

    (pp. 163-184)

    By now we should finally be ready to spend some time talking about drugs themselves. I have outlined much of the brain machinery that addictive substances hook into, and the inherited vulnerabilities that lead to different levels of risk between people. I have also described enough of the behavioral phenomena that result. That allows me to now shift focus and let a few of the molecules that people actually become addicted to take center stage. In doing so, it is my intention to be quite selective. This is not primarily a book about drugs as such—excellent descriptions of those...

    (pp. 185-193)

    I am at the gym, staring at a television to break the monotony of the treadmill. A man, whose name I have since learned is Chris Prantiss, looks at me from the screen, slim and good-looking with his gray hair, suntan, and dark suit. He is standing next to his son, Pax, just as elegant himself. The older man has his hand affectionately placed on the younger man’s shoulder. I hear him talk about the book he has written.

    I wroteThe Alcoholism and Addiction Cureto give you hope and to share with you what works. Within the covers...

    (pp. 194-205)

    For me, a general framework called motivational interviewing is a good bridge between the dialogue with the patient and the specific methods aimed at behavioral change. Motivational interviewing is, in its simplest form, a basic technique that should be used by anyone working with patients who have addictive disorders. Motivational enhancement therapy is an application of this technique toward specific treatment goals. Beneficial effects from these approaches are well supported by research.¹ In either shape, they are almost an antithesis to various confrontational methods. They bring together empathy and relationship-building principles that will be familiar to anyone with old-fashioned psychotherapy...

    (pp. 206-230)

    When i was still in medical school, one of my instructors asked me what I wanted to do after I finished my training. I answered that I wanted to develop better treatments for people with addiction. He said, “Oh, you want to be a psychotherapist? Do you really need medical school for that?” I said no, I had seen people attend therapy for years while continuing to take drugs, and ultimately succumbing to them. I wanted to understand the brain mechanisms gone awry in addiction and see if we could do better, by finding medications that could somehow help those...

    (pp. 231-255)

    The woman across my office table was visibly upset. She had asked to be discharged against medical advice, and her bags were already packed. Before sending her home, the attending physician alerted me to the situation, and I offered to meet with the patient. I guess listening to her concerns was a way of trying to show her respect. Maybe she would find the conversation helpful. Maybe there could be lessons for us to learn as well. I asked for the chart ahead of time and read up. This was an Ivy League–educated lawyer, in her early fifties. After...

    (pp. 256-264)

    The amount of pain, suffering, and cost to society caused by addictive disorders is beyond imagination. I hope that the patient vignettes I have sketched from my years of practice have helped get past the statistics and put faces of real people on the numbers. The consequences of addiction affect patients, their families, and their communities. As if that were not bad enough, they are frequently passed on to future generations, through violence, disrupted families, and poverty. Given the disease and economic burden to people and society associated with addictive disorders, the resources devoted to addressing these conditions are woefully...

  23. NOTES
    (pp. 265-286)
  24. INDEX
    (pp. 287-303)