By Dr Arnaldo Cruz Igartua 2021
What makes active addictions so mysterious? Why are there so many misconceptions, barriers, and poor funding to prevent and treat people and families with addictions? Several paradoxical explanations damage and make our country's public health control vulnerable to these illnesses. Dr. Cruz Igartua identifies and describes these sources of confusion as "Paradox Traps" and the clarification of them as "Paradox Solution". If we recognize these situations as a Paradox, it will be easier to understand and support the actual evidence-based public health measures.
A paradox is an apparent logic self-contradictory statement. It represents the integration of two opposed concepts in a syncretic way that may result in confusion or mixture of both ideas o in a new harmonious interaction and meaning where both pictures complement each other without a mess. When we enter into complex systems like the human mind the Addiction and mental health stigma may be partially generated as a result of the confusion related to the paradoxical characteristics of these mental illnesses. Understanding these paradoxes, it will be possible to educate and reduce the barriers to evidence-based treatment and prevention.
This blog summarises some of the paradoxes of addictions and contributes to help in solving them:
The Public Health Addiction Paradox
Neither legalization nor prohibition alone reduces the abuse of addictive substances. The business of selling addictive substances has not been balanced with Public Health protective measures to prevent damage to populations. The lobbying of the legal addiction industry had prevented the prohibition of propaganda of alcohol and recently marihuana. If effective public health is implemented is estimated that about 50% of the gains in the industry should be reduced as also 50% or more of the billions of dollars or losses for us as taxpayers. Also the use of pseudoscientific terms that normalize polysubstance as the case of "medical cannabis" for liberalizing the use of dangerous high potency smoked Marihuana (with more than 15% THC). Legalization when compared to prohibition; comes with greater accessibility and with propaganda making tobacco, alcohol, and recently marihuana the most abused substances and the most related to death and to billionaire losses each year. These losses are paid with taxes from citizens so that in an indirect way all taxpayers are supporting the legalized addiction industry. Tobacco losses to the USA are about 300 billion a year (and 480k death a year) and alcohol about 149 billion a year (and 95k death a year) In Colorado for every dollar generated in tax by the marihuana legal industry there are 4.5 dollars lost. A person with active addictions abuses substances in 5-20 times more qualities and frequency than people without this illness. About 80% of people with addictions started abusing substances in adolescence where the risk of developing addictions is 5 times greater than in adulthood due to immaturity of the brain. This severity of use is related to an increase in adverse consequences, risky behaviors, and even death
2. The personal "Free will Paradox" The civil rights and the democracy money-driven government are the base of the second Active addictions Paradox (Dr. Cruz 2021). Addictions are the illness related to most consumption of substances and services. Also is related to brain damage that makes it almost impossible to accept or be receptive to receiving or seeking evidence-based treatment. The people see this as a moral or a legal problem and not as part of the active phase of the illness. So that government ignores these people until they commit illegal acts or put in danger lives. This "emergency style" of response makes use of the least cost-effective therapies and is related to the "revolving doors" effect that misuses the short finding available for the real evidence-based treatment of addictions. Strong family support is needed (and sometimes of danger a court order for involuntary treatment is needed) for bringing the patient to evidence-based cost-effective treatment. But these ones are also almost absent for 90% of people with active addictions needing them both in the USA and PR. Medical insurances intervention also promotes short-term stabilization and no long-term rehabilitation not paying interdisciplinary therapeutic communities. Is obvious that if you ask a person with active addiction illness if he prefers 3 paid days in a "hotel-like hospital with pool" or 3-6 months of ambulatory treatment of 3-8 hours of different therapies each week non covered by any insurance he will select the revolving door option several times. This may be in practical terms the only "escape emergency option" that the system has provided for him and his family. Is a false noncost effective option related to the confusion created in the "free will paradox". Without strong family control and motivation (or a judge order in some dangerous cases) any ambulatory treatment will have very low retention in treatment and a "revolving door effect". To retain the person in treatment (usually from 4-8 months and long-term maintenance) is necessary to obtain abstinence and to transform him into a motivated patient. This impacts positively the long-term cost-effectiveness of any evidence-based addiction treatment.
3. "Substance Substitution therapy" paradox
Most people with active addictions have no fear at all of using combinations of dangerous addictive substances but paradoxically have a strong fear of using any other medicine prescribed. They manifest a Paradox and express fears of serious side effects or of dependence on any prescription offered to them. In the case of Methadone and Buprenorphine are no exceptions. They should nod be termed a substitution because (when used as part of a complete specialized treatment) not only do not produce euphoria but also produce a reduction of craving for addictive substances. Also, express that is similar to the substitution of one drug with others and they want to get rid of all. The case is that only in the case of these two FDA-approved opioids (Methadone and or Buprenorphine) a long-term reduction of the craving and block the intoxication of other ones is achieved. There are physiological explanations that are beyond the goal of this blog to explain. The use of any other substance or even the misuse of Buprenorphine or Methadone and without the interdisciplinary treatment have shown to have a reduction in the effectiveness and retention in treatment, especially in the long-term maintenance stage. As illustrated in the graph the craving for all substances gradually increases with the use of any addictive substance. Total abstinence is an important goal for many patients (with the exception of a very severe and complex illness in some persons that needs a harm reduction approach). Contrary to what is thought the majority of persons do not have a severe complex illness but may develop them since there are no EB treatments available on PR or USA for the 90% of persons in need and the ones available are misused provoking loss of money and lack of effectiveness on the long run. In achieving total abstinence the other goals in the learning of wellness skills and the frequent use of wellness tools to prevent relapses and to improve life quality (see graph below). These skills are important to manage driving-related to long-term side effects of substances and for preventing the accumulation of triggers and managing them without relapsing in substance use.
https://www.drugabuse.gov/es/news-events/news-rele