Why care for addicts?

I posted this in November, 2015. I am reposting it.

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Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

adaptive theory of PANS/PANDAS

This is my working theory on PANS/PANDAS. Pediatric autoimmune neuropsychiatric syndrome/Pediatric autoimmune neuropsychiatric disorders associated with Strep A.

Four or more antibodies. The antibodies can take different patterns in different people.

  1. Antibodies to dopamine 1 and dopamine 2 receptors.

The antibodies are like keys fitting in a lock. The key may fit in the lock and BLOCK or fit in the lock and OPEN IT. So, there are a very large number of patterns that could arise from this, especially when we remember the rat neuron with 300 different receptors for serotonin in one neuron. Think of the possibilities here.

If this antibody BLOCKS, an ANTAGONIST, it will cause slowing/brain fog/depression/and I don’t know what all.

If this antibody is an AGONIST and the key turns, it apparently can cause mania, ADHD, OCD, oppositional defiance, clinginess, separation anxiety, anxiety, etc.

We do not know what causes psychiatric disorders. Now we have a category called neuropsychiatric, where it is caused by an antibody. Or antibodies. What percentage of psychiatric disorders are caused by this? I am betting high rather than low.

  1. Antibodies to tubulin.

If the antibody is an ANTAGONIST, blocking, then slow or fast twitch muscles won’t function correctly. It could block both. I think if it blocks both, that is the severe lie in bed chronic fatigue. I have trouble with my fast twitch muscles but my slow twitch ones work just fine.

If the antibody is an AGONIST, you get some super athletes. I know a number of people that I would suspect fall into this category. I can name five off the top of my head, friends.

  1. Antibodies to lysoganglioside.

This one worries me. Lysogangliosides lyse ganglions. These antibodies are used in soap making, among other things. They break down fatty cell walls.

When I have a high antibody level, I have trouble eating any carbohydrates. As I improve, I have trouble mostly with sucrose, fructose and gluten but not lactose. Also, when I eat gluten, I get acidic. When you get acidic, your body tries to compensate by slowing your breathing to hold on to CO2, because you need to balance the acid H+ with a base, OH-. So: triple whammy. Acidic I automatically breathe slower, which is not helpful when I am already hypoxic and tachycardic.

I have not figured out whether my antibody is an agonist or antagonist.

An agonist would lyse more ganglions. This could be bad for the brain and for peripheral nerves. Neuropathy and dementia.

An antagonist would stop ganglion lysing. Um, in theory, cancer. Lysogangliosides are supposed to clear out bad cells.My guess is that I have an antagonist because of the family history. At least, on my mother’s and sister’s side. My father smoked two packs of Camels for 55 years and did not get cancer: tough bugger, right? Or did he have an Agonist? This line of thinking makes me very highly motivated to eat in whatever way the antibodies want me to. I do not understand why gluten would trigger this and why the gluten effect in me lasts longer than the fructose and sucrose effect. Gluten intolerance and other gut problems are on the rise and this would certainly explain that. This is the cause of at least some fibromyalgia patterns. Not only does eating gluten screw up my breathing, but it makes any muscle that I have used recently hurt like hell. I ate some meatballs without reading the stupid package back in April. Two hours of chest wall muscle pain and honestly, heart pain. I dug the package out and duh: bread crumbs. Gol dang it, I hate it when I am stupid. However, it hurts like hell but at it’s worst I had normal cardiac enzymes and no heart attack. Weird.

Ok, but WAIT, you said ADAPTIVE. How can this nightmare be adaptive?

Sure, adaptive. Remember the back up system for when we are starving? We switch from metabolizing glucose to metabolizing protein and fats, our own if necessary. We go from glycogen metabolism to protein/fat metabolism which produces ketones.

This is the crisis shit hits the fan emotionally and in plagues system.

So, can be caused by stress or infection or a combination.

Why why why?

Because if the stress gets too high or the infection gets too bad, our body switches gears and runs a back up system. I’ve thought of chronic fatigue as some sort of switch the body throws for years, because it’s the hypercrazy work too hard workaholic Type A people who get it. Type B people do not get it or don’t notice or don’t care. Type B people just say, wow, I’m tired, I think I will rest. The Type A people flip out and say “Put me back like I was!!!!” and then they go to 47 doctors and refuse to do anything the doctors say and do internet research and see any kind of quack you can imagine and they are the most exhausting patients.

Why the psychiatric stuff? Ok, take mania. If there is plague or you are in a really dangerous abusive situation, mania suddenly makes sense. Overnight you are different and what’s more, it scares the hell out of everyone. You are shunned. You are alone. You may get thrown out of a job, family, friend group or all of the above. This would tend to protect you against both plague and the really dangerous abusive situation. Whether you like it or not.

And how clever of the brain/body. Here is a back up system. It changes at least four systems, so you are now a different person. You freak your employer, friends and family out. AND you are sick as shit and they won’t listen. You have to get out and go elsewhere for help or hide in your castle or house or whatever. You can’t move or you have super muscles. And every single person has a different pattern.

I look at the long haul covid. The most common symptoms are psychiatric, shortness of breath and fatigue. Sound familiar?

Now, will someone PLEASE fund my NIH west?

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Guidelines for treating PANS/PANDAS: https://www.pandasppn.org/jcap2017/

Email quack spam: try CBD oil for free!

Lovely email QUACK spam. TRY CBD OIL FOR FREE!

The Miracle Molecule! Everything You Need To Know About the Health Benefits of CBD Oil“. The link implies that the article was in Reuters. I ain’t pressing no spam link. Internet search on Reuters Everything You Need to Know About the Health Benefits of CBD Oil does not bring up a Reuters article.

“All natural formula. All CBD products use proven, organic all natural ingredients that are toxin-free.”

Ok, now WAIT a minute. Proven? By what the hell method? We dropped some and got high so it’s good? And don’t get me started on toxin-free. Sure, and they’ll sell you a bridge too.

Let’s discuss all natural.

Is CBD oil “all natural”? Um. Well, it could be organically grown, I will give them that. There have been pesticide poisonings from illegal pot and the laws for growers vary state by state. Check your state laws re whether they have specified what the growers can use on the marijuana plants. Paraquat is very strongly implicated in Parkinson’s (https://pubmed.ncbi.nlm.nih.gov/20094060/) and you don’t want that, do you?

How do you define “all natural”? Innocent virgin farmer girls and boys, skipping through the pot plans and milking the oil out gently? Oh, ye innocent and foolish peoples. Here is a nice article about fires in CBD processing plants: https://www.sandiego.gov/sites/default/files/dsdfire-38-1.pdf. They burn real good, it turns out.

The National Fire Protection Agency (NFPA) has guidelines: https://www.firefighternation.com/prevention/nfpa-approves-420-standard-on-fire-protection-of-cannabis-growing-and-processing-facilities/. You do keep up with the NFPA, don’t you?

An older article illustrating the problem: https://www.politico.com/story/2019/02/18/marijuana-factories-explosions-safety-issues-1155850.

And the title of this seems pretty self explanatory: https://extraxx.com/the-top-five-safety-concerns-in-a-cannabis-extraction-facility/. “Let’s begin with the obvious. When dealing with flammable gasses or liquids in extract production, there is a risk of fire or explosion during the handling process. The easiest way to understand the risk of fire or explosion is to consider the fire triangle. Essentially, a fire needs three things to start: a fuel source, oxygen, and an ignition source. The basic philosophy here is that by removing legs from the fire triangle, we can make the process safer; by removing two legs, an operator can make their extraction process significantly less incident-prone.” Later in the article: “there are two tools that should be kept on site to make known the presence of unnoticed flammable vapors: a permanent LEL, or Lower Explosive Limit, monitor should be installed in the extraction room; and a handheld two or four gas portable monitor should be on site as well.”

I don’t have much experience with LFL monitors. Now I want to buy some of the gummies and try lighting them on fire. Does the smoke make one high? Well, I think it depends what it is suspended in. I thought vaping was insane when I read that some of the nicotine vapes suspended the product in antifreeze. Um, your dog may die if they drink it. Absorption in the lungs just does not seem wise. Also, some of the vapes get so hot that heavy metals get in the lungs. You know, lead and stuff. When I researched it last, China was turning out 500 different kinds of vape machines. Uh, ick, don’t do that. Sugar burns so the gummies might. I have some “Annie’s organic fruit gummies” so I can check whether they burn. Though they shouldn’t contain CBD oil. Now you know what I am doing while disabled. Home chemistry and on line research.

Cognitive behavioral therapy

Dr. Aaron Beck, father of cognitive behavioral therapy, died this week, November 2021, at age 100.

Oddly enough, the best explanations of cognitive behavioral therapy that I’ve read is on a writing website. It talks about writing down all of the horrible thoughts and then going back and writing counter thoughts. Psychologists have been talking at me at medical conferences for years about cognitive behavioral therapy, but they never explained it. They said we could do it in clinic. I thought cynically that maybe I could if I knew what the hell it was.

And the explanation by the author is oddly similar to what I think of as the angel and devil on my shoulders. It turns out that I do do it in clinic.

When I react to some event, I let the devil out first. It has a fit about whatever is happening, writes poems, is reactive, paranoid and full of anger and grief. It often imagines over the top terrible things happening to the person or people that did whatever it is. Then the angel wakes up and says, wait. What are you saying? What you are imagining and cursing that person with is WAY worse then what they did. The angel writes the poems of forgiveness.

So I have been doing a homemade form of cognitive behavioral therapy.

However, I would say that it can be overused. We need to listen to patients carefully. If they are in an abusive relationship, it should not be papered over with cognitive behavioral therapy. A friend and I have been comparing terrible childhoods. His involved being beaten without reason.

I said recently that what people hit with in my family is words. They make grief and fear into stories, funny stories, that make people laugh. Shame and humiliation and reliving the feelings. I said that I am reactive and pay close attention to words. But I have reason, back to age 2. I said that books are my refuge because the words are not about me, they don’t shame me, they do not humiliate me, and if I read a book twice, it has the same words. Home, love and safe.

In my maternal family, if I said that I was not comfortable with a comment, I was told that I took things too seriously, that I have no sense of humor, that I can’t take a joke. Gaslight and then dismiss any objection. That is how one side of my family loves. I do not like it. Unsurprisingly, they do not love me, or at least I do not feel loved.

And my friend said, your family, your childhood, was worse than mine.

One of my talents in clinic is that I can listen to insane family stories. I can listen because my family is insane. They are cruel. At least, it feels like cruelty and horror to me. I didn’t ever try to find out if a family story is true. I listen and then say, yes. I think it is appropriate for you to feel angry/sad/horrified/appalled/scared/hurt/whatever.

Somehow that listening and validation is huge. I have people come in and say, “I NEED AN ANTIDEPRESSANT.” They want to supress the feelings. So I had time in my clinic: why do you need an antidepressant? Tell me the story. Fill me in. What are you feeling and why?

And more than half the time after the story, after validation, I ask, “Do you need an antidepressant?”

The person thinks. “No. I don’t think so. Let me think about it. I feel better.”

“Ok. Do you want to schedule a follow up?”

Half do. Half say: “No, let me wait and see. I will if I need it.”

Mostly they don’t need it. They have emptied out the awful feelings in the exam room and they aren’t so awful after all. I say that it sounds like a pretty normal response and I would feel that way too. Because I would. Once the feelings, the monstrous feelings, are in the light of day, they relax and evaporate, dissipate like mist, fly home to the Beloved. Goodbye, dark feelings. You are appropriate and you are loved.

Blessings, Dr. Beck, and thank you.