Separation distress and the importance of valued people

I stumbled onto two interesting authors, Jaak Panksepp and Douglas Watt…

“‘Big Pharma,’ as big business, seeks antidepressants that may become billion-dollar blockbuster drugs. Accordingly, it may neglect drugs that are off-patent (e.g., buprenorphine) as well as those that only serve a small subset of the population. Many authors (ever since Valenstein, 1998) have argued that the pharmaceutical industry may be exercising an increasingly distorting influence on prescription and treatment landscapes for the whole of medicine in the United States. This may be particularly true in relationship to depression, where many depressed patients are never referred to psychotherapy and instead are only put on first-line antidepressant drug regimens under the simplistic aegis that depression is “just a chemical imbalance.” These trends take place despite evidence that pharmacology is often only partially effective in depression (see recent STAR*D reports: Rush, 2007; Rush, Trivedi, & Fava, 2003) and despite evidence that patients suffering from trauma-related depressions do quite poorly treated alone with psychopharmacology without psychotherapy”

 Far be it from me, an academically untrained but round-eyed acolyte of the big world, to feel at all qualified to take on the authors’ implication that depression may be the result of anything but “a chemical imbalance” though an initial “trauma” may have initiated the process, and the chemical imbalance following the trauma can’t be fixed wholly pharmacologically. But I’ll state modestly that some day soon, almost every state of depression, whatever the cause, will be cured chemically sans psychotherapy…

…psychotherapy definitely has a purpose… probably always will; intelligent people understand that they have subjective limitations regarding self-awareness, and some have an interest in resolving recurring, stunting issues, or simply gaining insight for the sake of growth with the help of trained facilitators. But some day drugs will blow away our depression, regardless, with remaining only a curious interest in why we do the things we do and think what we think, for the sake of treating ourselves and others better.

~But my little declaration is not the reason for this post. Jaak Panksepp and Douglas Watt really have their stuff goin’ on, and are speaking my language. My personal theory of depression (…depression not caused by an innate anomaly) involves three roots: an unsuitable industrial diet, inappropriate exercise (not enough and chronic cardio), and stressors, including modern stressors (pollution, lifestyle etc). In this piece, the authors deal with separation stressors leading to a “protective” state of depression (do I smell the pernicious stench of dynorphin again?).

Whether or not this thesis is correct, the thing that jumps out and reminds me is the importance of keeping one’s self as engaged and socially involved as possible. Clearly (if only for the production and cultivation of calming oxytocin, which is known to sustain opioid reward in the brain), the importance of maintaining and nurturing relationships with people we value and who give us value in return can’t be overstated in a world that increasingly creates and promotes options for insularity and “aloneness”.

Equally, one must have a healthy hierarchy of values…

…if not, being depressed and alone might actually be a better situation than being depressed with people who don’t elevate us… don’t challenge us to go higher, but erode our quality of life, sense of self-esteem and our quest for happiness. In this case, until one has redeveloped a healthy sense of worth through proper diet, appropriate exercise, a low-stress lifestyle, and insight perhaps helped by psychotherapy, I think sometimes we can wait until we are in a better state to nurture rewarding relationships with quality people…

…just relax, and be good to yourself first.

Addiction & dependence are not the same

I don’t crave opium. I know it sounds like delusion and denial, but it’s true. I don’t seek the euphoria, and when I feel the wd’s coming on, I don’t crave O. Whenever I have to taper off for some reason, I just taper off. Yes, there’s that PAWS “hole” in my life for a while that users talk about that’s hard to fill with something else, but otherwise, no; I just spend more time mountain climbing and backpacking, my favourite hobbies, and being with my valued people. If there ever came a time when I was forced to go cold turkey and, say, some kind of benzodiazepine or tranquilizer was available to deal with the anxiety and a pain-killer for the aches, cramps and kicks, I would feel no pull toward opiates.

I think I can understand people with big gaping holes in their lives who just simply crave an altered state. I’ve seen them. We all long for beauty, don’t we? I know I do, and when I see the way some others live, where they live and their circumstances, whether in a semi-derelict state in a rented apartment/hovel or middle class but painfully empty state in a moneyed situation, I think they have an unusual “need” to fill these big gaping holes of “ugly” any way they can. Do they lack an imagination, or capacity for just filling the gaping hole with beautiful things and edifying activities and experiences instead of drugs?…

…or is there something biological that compels them to seek drugs? Maybe, but I’m not so sure about this.

Then we have ones for whom drugs have little appeal. These are people who acquire scripts for pain, or have tried opies and other drugs recreationally and find no inspiration in them. They are many. I’m one. If it was not for O’s incredible efficacy for my particular depression, I wouldn’t use it. I know a guy at work who was on a ten-year morphine run for back pain at inhumanly high doses, until he got sick of it, took a year off and used that time to taper off. He never craves, and “good riddance.”

We’re not the only ones who know that the whole “addiction” thing is pure bullshit. There is a difference between addiction and physical dependence, and you will never hear this from anyone in a position of governmental authority or with a “drugs-are-scary” agenda.

[all block quotes from Wikipedia]

~”severely distressed animals, like severely distressed people, will relieve their distress pharmacologically if they can.”

And this is absolutely correct… and, know what? Any rational person would. Why in hell, in this age of relief, would man or mouse not under the spell of phony machismic or masochistic convictions “man up” and crawl through the devil’s rat-cage of pain instead? Explain the dignity in this, please. The above quote is from Canadian psychologist Bruce K. Alexander, referring to Rat Park, a happy little place wherein once lived a happy little colony of lab rats, about which an experiment was carried out to test his own suspicions and find out if the disease hypothesis of drug addiction was a load of rat poop.

To test his hypothesis, Alexander built Rat Park, an 8.8 m2 (95 sq ft) housing colony, 200 times the square footage of a standard laboratory cage. There were 16–20 rats of both sexes in residence, an abundance of food, balls and wheels for play, and enough space for mating and raising litters. The results of the experiment appeared to support his hypothesis. Rats who had been forced to consume morphine hydrochloride for 57 consecutive days were brought to Rat Park and given a choice between plain tap water and water laced with morphine. For the most part, they chose the plain water. “Nothing that we tried,” Alexander wrote, “… produced anything that looked like addiction in rats that were housed in a reasonably normal environment.” Control groups of rats isolated in small cages consumed much more morphine in this and several subsequent experiments.

Rats are valued for research because we share an almost identical genetic compatibility. This gives us some measure of confidence despite that rats have no conscious sense of purpose, aesthetics, values, goals, self-esteem or other human traits that might set motives for drug use and abuse. Doctors in the UK with experience scripting heroin feel little trepidation regarding most patient’s motives because, well, most patients aren’t at risk to divert from their purpose; so, apparently we and rats share many of the same attitudes toward drugs.

According to Alexander, the disease model makes either of two claims:

  • Claim A: All or most people who use heroin or cocaine beyond a certain minimum amount become addicted.
  • Claim B: No matter what proportion of the users of heroin and cocaine become addicted, their addiction is caused by exposure to the drug.

Several decades of animal studies have been seen as supporting these claims. Avram Goldstein wrote in 1979: “If a monkey is provided with a lever, which he can press to self-inject heroin, he establishes a regular pattern of heroin use — a true addiction — that takes priority over the normal activities of his life … Since this behavior is seen in several other animal species (primarily rats), I have to infer that if heroin were easily available to everyone, and if there were no social pressure of any kind to discourage heroin use, a very large number of people would become heroin addicts.

Against this, Alexander argues that the main evidence for the belief in drug-induced addiction comes from “the testimonials of some addicted people who believe that exposure to a drug caused them to ‘lose control’,” and from some “highly technical research on laboratory animals”. He argues that this weak evidence has been embellished in the news media to the point where it has acquired the status of an unassailable fact, whereas the great bulk of historical and clinical evidence, he says, runs against it. He writes that, although the use of opiates in the United States and England during the 19th century was greater than it is now, the incidence of dependence and addiction never reached one percent of the population and was declining at the end of the century. In Britain, he writes that heroin has been widely used in medication for coughs, diarrhea, and chronic pain until the present day; in 1972, British doctors prescribed 29 kilograms of heroin to patients, which he writes amounts to millions of doses, yet a 1982 study of the statistics on iatrogenic addiction in the UK showed a “virtual absence” of such addicts. Recent research confirms that many people use heroin regularly for years, for either recreational or medical purposes, without becoming addicted.

I have refractory depression and must supplement with opiates, understanding that they facilitate the things I enjoy and value and motivate me to partake in them.

Opiates don’t addict people. Attitudes addict people. Also, withdrawal is a nasty business, but is not addiction. If one has an addiction problem, one must do his best to change his financial/social circumstances, environment, and most of all, head space…

…find instead beauty in the world and in life, not in a drug. The drug is for enhancement of these, not an end in its self.

SSRI fail…

I stumbled onto this 2008 meta-analysis regarding the efficacy of fluoxetine (Prozac) and related SSRI antidepressants…

Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included [!!!], the benefit falls below accepted criteria for clinical significance. Yet, the efficacy of the antidepressants may also depend on the severity of initial depression scores. The purpose of this analysis is to establish the relation of baseline severity and antidepressant efficacy using a relevant dataset of published and unpublished clinical trials.

(my emphasis)

This study was looking for a depression baseline for efficacy: the researchers concluded that how down you feel is positively correlated with how well the drugs work… sort of.

If you’re moderately depressed, you can pretty much forget it and save your cash. Spend it on candy or unicorn rides or whatever it is happy people spend their money on; if you’re severely depressed, you might get something out of it… maybe; and if you’re muttering-to-Jesus-walking-in-the-middle-of-a-busy-road-in-pajamas, severely, with whipped cream and chocolate sprinkles depressed, there’s a fair chance you’ll get something out of it. But here’s the kicker… the efficacy of treatment for this extreme type of depression was attributed not as much to the drugs as to decreased responsiveness to placebo.

…hope you have faith in your doctor’s dope.

Too bad looking for answers for depression outside of the serotonin/norepinephrine/dopamine axis and studying the endogenous opioid system seem to be evil and taboo. Or something…

…too bad I had to turn my back on the Establishment and find my own answers.