Fentanyl Part 4: The Brain
“Addiction is a brain disease. This is not a moral failing. This is not about bad people who are choosing to continue to use drugs because they lack willpower.” – Michael Botticelli
I was 9 years old in 1987 when I saw a commercial on TV with a man – who looked like my friend’s dad – crack an egg into a hot, cast-iron frying pan and say, “This is your brain. This is your brain on drugs. Any questions?”
At the time, no. Not really. My biggest concern was if the batteries in my Cabbage Patch Kids Hide-and-Seek game still worked. And I wasn’t a huge fan of eggs either, so that commercial didn’t really speak to me.
Now, I’m fascinated. The metaphor of the commercial was simple: Drugs destroy your brain. But it’s more complicated than that. And for teenagers, whose brains are still developing, it’s even more complex.
I wanted to understand the science behind drug addiction, so I began researching Judith Grisel’s work.
Grisel is a neuroscientist, a professor at Bucknell University in Bucknell, Penn., a recovering addict and the author of “Never Enough: The Neuroscience and Experience of Addiction.” In February 2020, Penn State University invited her to speak at its Ted Conference where she said this: “By the time they graduate from high school, 70 percent of kids will have drunk alcohol, half will have tried an illegal drug and about close to that many will have smoked or vaped nicotine and one in five will have used prescriptions off label.” She added, “It’s a fact that most people who have a substance abuse disorder will have used before they were 18.”
If I could insert the mind blown emoji here, I would. My mom fear just kicked into high gear.
Law enforcement officials say that nearly all illicit drugs in Baton Rouge are laced with fentanyl so if a person became addicted to a specific drug, inevitably that person would become addicted to fentanyl. And if a tiny amount of fentanyl could kill anyone, it seemed to me there were only two options:
Death. Or an uphill battle to stop using.
I wanted to understand how a person could get so easily addicted to drugs, why it was so difficult to stop using them, and what help was available in Baton Rouge.
I reached out to Brandy Klingman, owner of St. Christopher’s Addiction Wellness Center in Baton Rouge, Legacy Behavioral Health in Baton Rouge and New Orleans and Lifeworks Psychiatry in Baton Rouge, specifically for people who use Medication assisted treatment or MAT.
“This is a disease that corrupts your brain,” Klingman says. “It makes you lie, cheat and steal when you’re not a lie, cheat and steal kind of person.”
Addiction is a brain ailment, experts say, a disease that attacks the brain. But unlike other brain diseases – like Alzheimer’s disease and Dementia – those suffering from addiction are responsible for seeking their own help. And those two pieces don’t quite add up.
“If we treat addiction like a brain disorder, we wouldn’t release people to their own cognition,” Klingman says. “Opioids shut off that prefrontal cortex portion of the brain that makes decisions like getting help.”
The brain is one of the most intriguing organs of the human body. It’s like a three-pound computer system that sits on the top of your head and has billions of neurons, organized into circuits and networks. These neurons essentially communicate back and forth with different parts of the body via messages, called neurotransmitters, according to the National Institute on Drug Abuse (NIDA).
The prefrontal cortex – located in the front section of the brain – is responsible for planning and executive functioning and is the last portion of the brain to be fully developed. It matures around age 25, sometimes earlier in women and sometimes later in men. This area of the brain is also responsible for understanding that choices have consequences. If teenagers become addicted to drugs, especially opioids, this area of the brain can be stunted in its development and highly impacted by the substance abused.
“The prefrontal cortex is still developing in teenagers,” Klingman says. “The problem for kids is that they are buying drugs and making instant decisions, which are dumb, and it’s normal for kids to make dumb decisions at that age. But now they are getting fentanyl and they don’t realize it. So they make a dumb decision and they die.”
When it comes to drug addiction, there are a few other parts of the brain that are especially important – the basal ganglia, the extended amygdala, and the hormone dopamine.
The basal ganglia is located at the top portion of the brain and helps with motivation and pleasurable activities like sex, eating and spending time with friends and family. This is the reward part of the brain that also forms habits and routines and is sometimes called the brain’s “reward circuit,” according to the NIDA. Drugs over activate this circuit, producing the euphoria of the drug high. The trouble happens with repeated drug use when this circuit adapts to the drug and makes it hard to feel pleasure from anything else, except for the drug.
The extended amygdala is found on the left side of the brain and handles the anxious, stressful and irritable feelings human beings all experience. In people suffering from addiction, this area of the brain is active during withdrawal from a drug and motivates the user to seek out the drug to avoid discomfort.
Dopamine is a pleasure-producing hormone in the brain. It’s a type of neurotransmitter that sends messages to different parts of the brain. For example, when we hear the ding of a text on our phone, that sound releases dopamine which sends a message to the basal ganglia and makes us excited to check our phone. Drugs produce larger surges of dopamine which then teaches the brain to seek out the drugs for more pleasure. While human beings are dopamine seekers, we lack the ability to be still and embrace pain. We all experience suffering at some point in our lives, and if we could learn to be still in the pain, we could learn to handle these tough feelings in a more effective way instead of running from our problems, experts say.
Addiction starts as an escape from pain and pain often comes from trauma, Klingman says. But addiction used to be treated separately from mental health disorders. And while some insurance companies will cover the cost of mental health but not addiction. However, clinicians are now treating addiction and mental health issues together, as “co-occurring disorders.”
“A long time ago, mental health and addiction were treated separately,” Klingman says. “But it all stems from trauma and people wanting to escape from the pain associated with trauma. Mental health and addiction are co-occurring conditions. We know that trauma happens early in life and creates addiction, it may start out mild with escapism and maybe some marijuana use, but it quickly develops into something more. That is the same story we hear from all our patients. Divorce, abuse, molestation. All they’re trying to do is cope and they got introduced to a way of coping that was shame inducing. The brain reacts to pain and fear the exact same way and opioids shut off that prefrontal cortex.”
But if that portion of the brain is shut down, how do people make the decision to get help, I asked Klingman.
“Very rarely with fentanyl addiction does someone come in willingly,” she says. “Most come in kicking and screaming. And many are from out of state. It’s harder to leave when you don’t have friends or family close by.”
Addiction is a difficult cycle to break. In a world where we value happiness and optimism, even if we’re not actually feeling that way, we often don’t take time to sit in the uncomfortable feelings of painful situations. We weren’t taught to feel our feelings. Those suffering with addiction typically have turned to drugs as an escape from the pain. The irony is that when they want to quit the drugs, the pain from withdrawal, both physically and emotionally feels unbearable. So pain got people into using drugs and the fear of pain will keep them addicted to the drugs. Opioids specifically are designed to numb the pain. And shame prevents them from talking about the drugs.
I asked Klingman what withdrawal symptoms for opioid users looks like.
“Upset stomach, shakes that last a long time, diarrhea, vomiting,” she says. “Leg and body aches, they feel like they’re walking through wet cement. Anxiety all day and every day. Their regular life feels over stimulating. Hopelessness and depression. Their dopamine and serotine levels don’t come up on their own. And this can last for two weeks and sometimes months later these symptoms are still going on.”
Grisel explains in the Feb. 2020 Ted Talk that the brain adapts to any drugs that alters the way it feels.
“Substance abuse is the number one killer for people under 50. And if we take addictive drugs on a regular basis, they cause feeling states exactly opposite to the ones we want to have,” Grisel says. So if the drug is relaxing, your brain will produce anxiety. If the drug reduces suffering, your brain causes pain.
There is help for those suffering from addiction and their families, but like most health care in our country, it’s not cheap. It’s about $25,000 per month, and 90 days is the recommended amount of time needed to complete treatment, Klingman says. However, while physically people leave rehabilitation centers feeling better, the brain actually takes longer to heal.
“They are going to need six months of treatment to reset that prefrontal cortex,” Klingman says. “We physically release people because they look good, have gained weight and are talking like themselves. But they have this false sense of safety because that prefrontal cortex hasn’t fired up. This is a brain disease, and it needs to be treated like one.”
There are seven main local detox and treatment providers in Baton Rouge with many more popping up all the time, Klingman says. While providers are good at helping people with addiction, they are not often the best businesspeople, Klingman says, and “in our world, it’s shameful to advertise.” So many of the billboards and internet and radio ads are venture capitalists opening pop up treatment centers,” she says. And with opioid settlement dollars starting to trickle down into cities across the country, everyone wants their share.
In October 2021, Louisiana received $325 million from a national opioid settlement for addiction treatment, response and recovery services.
According to an Oct. 6, 2021, article in the Associated Press, Louisiana Attorney General Jeff Landry said, “We want 100 percent of the funds to go to assisting those affected.” However, that money has not yet been divvied out.
Landry did not respond to a request for an interview about the status of the settlement.
Mark Armstrong, chief communications officer for the City of Baton Rouge said in an email on Sept. 21, “There’s not much to share right now about the settlement. We hope to receive an initial payment from the settlement with certain defendants in the case by the end of the year. The precise amount has yet to be finalized.”
When this money starts to funnel down to providers, Klingman worries that it will create even more separation with local treatment providers.
“Baton Rouge is siloed,” she says. “Everyone is worried about protecting their own slice of the pie, but we are not really collaborating well. With all the opioid money that is coming in, everyone wants it and wants to protect their section, and I understand. It’s not bad to want to protect your work but it leads to a silo mentality where we are not talking enough and collaborating enough.”
I ended the interview with Klingman by asking the same million dollar question I have with everyone – What’s the solution?
“Prevention and education,” she said. “And we need to revamp the treatment world to have some sort of standardization and quality. This is a brain disorder. And it needs to be treated seriously. And we need to take the threat of fentanyl very seriously. People are dying every day from this drug. We are losing generations of people.”
The fifth part of this series, “Narcan” will be published Monday, October 17, 2022.
October 10, 2022