Annie Grace is the author of This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness And Change Your Life and The Alcohol Experiment. Alcohol misuse is related to more deaths in the United States than drug overdose, and deaths related to alcohol use have increased drastically since 1999. In 2017, 2.6 percent “of roughly 2.8 million deaths in the United States involved alcohol. Nearly half of alcohol‐related deaths resulted from liver disease (30.7%; 22,245) or overdoses on alcohol alone or with other drugs (17.9%; 12,954),” according to a recent study in Alcoholism.
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After 2014, U.S. life expectancy fell for 3 straight years. This striking trend is not associated with other wealthy countries in the world and has given rise to a cottage industry of speculation on causes, with varied social, cultural, and political actors making use of the findings for preferred narratives. Some of this speculation arose after Princeton economists Anne Case and Angus Deaton coined the term “deaths of despair,” an easily misunderstood phrase. Case and Deaton used the term to refer to fatal drug overdoses, alcohol-related diseases, and suicides. “We think of all these deaths as suicides, by a very broad definition,” these economists have written,“and we attribute them to a broad deterioration in the lives of Americans without a college degree who entered adulthood after 1970.”
In late 2019, a National Institute on Aging-supported review offered a comprehensive examination of falling U.S. life expectancy. This study used data from the CDC, National Center for Health Statistics, and U.S. Mortality Database to trace life expectancy trends over a longer time frame and analyze mortality rates for particular age cohorts. It paints a complicated picture of poor U.S. mortality trends, which are not driven just by our polysubstance epidemics, and a decidedly unhappy one. The authors write, “According to one estimate, if the slow rate of increase in US life expectancy persists, it will take the United States more than a century to reach the average life expectancy that other high-income countries had achieved by 2016.”
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In May, in a reflection on her religious upbringing, societal strictures, and individual spiritual development, The New Yorker’s Jia Tolentino wrote that she first tried ecstasy, or MDMA, in college:
“We swallowed pills that had been crushed into Kleenex, and then we slipped into a sweaty black box of a music venue down the street, and I felt weightless, like I’d come back around to a truth that I had first been taught in church: that anything could happen, and a sort of grace that was both within you and outside you would pull you through."
Some individuals who have used MDMA in non-scientific settings claim that it provides them with energy and reduces social inhibitions through mind-expanding spiritual uplift. It is the substance of choice at night parties, one of the major synthesized club drugs, and linked to accidents, dehydration, overheating, and dangerous behaviors.1 Recreational use is certainly not without its risks.
But what’s the difference between the substance’s purported therapeutic function and its dangerous side? MDMA is ecstasy’s main ingredient, but individuals who use the substance recreationally are sometimes misinformed about levels of adulteration. It can also be harmful in street versions, which may mix or combine other substances with MDMA. MDMA is not perfectly unique in its effects on sociability and human connection — adages about “moderation” in use abound in part because some substances have both relaxing and stimulating properties that can make social engagements more convivial. Yet the substance is often misused, and can lead to substance use disorder (SUD). In a recent Stanford study, researchers note, “It is unknown, however, whether the mechanisms underlying [MDMA’s] prosocial therapeutic effects and abuse potential are distinct.”
Through controlled doses and experimental administration, MDMA is currently being studied for therapeutic benefits. Early reports by some researchers reviewing MDMA as one option for treating post-traumatic stress disorder (PTSD) have been most promising so far. Carefully observed and administered scientific settings dramatically reduce the likelihood of withdrawal, overdose, and diversion.2 This Stanford study tested mice to try to distinguish between MDMA’s beneficial and harmful effects.
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Experts and professionals have become increasingly aware of the health effects of trauma and stress. Trauma, sexual, physical, or emotional, can change the brain and increase risks for many psychiatric conditions and diseases. Adverse Childhood Experiences (ACEs), for example, which refer to traumatic events in the lives of people under the age of 18, can negatively affect the brain and lead to addiction, academic problems, heart disease, and depression. A recent study found that ACEs and lifetime adversity exposure were significantly associated with increased risk of substance-related hospitalization, overdose, witnessing overdose, and having a friend and family member who overdosed.1 Similar data have been reported recently for suicide.2 Discussing trauma and stress can be difficult and evoke feelings of depression or shame: they are heavily stigmatized, compounding many of these potential problems and sapping individual reserves of resilience. Science shows us that stress and adversity aren’t just generally irritating aspects of everyone’s lives. In severe forms, they’re also major threats to our health and ability to think clearly and logically.3Not all traumatic experiences cause Post-traumatic stress disorder (PTSD) or substance use disorder (SUD). Recent research findings from the Yale group suggest that trauma in the absence of a PTSD diagnosis does not lead to a stronger craving for alcohol. 4 Yet researchers know that the risk of developing mental illness rises because of psychosocial adversity. 5 “These adverse factors,” write the authors of one recent study, “include developmental psychological trauma and adult life events (situations or occurrences that bring about a negative change in personal circumstances and involve threat).” These factors can also increase the risk of developing SUD. Researchers are investigating how various therapies, including mindfulness, modify triggers and traumatic memories. 6 But experts have not clearly identified the ways in which stress and trauma dispose people to later problems. In this recent study, researchers wondered whether stress affects dopamine levels, impairing them over a longer term. They exposed participants to stress and gauged their reactions through state-of-the art PET scans.
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“Imagine if,” write the authors of a review in The New England Journal of Medicine, “the medical profession barred anyone being treated with pharmacotherapy for depression from returning to practice, insisting that only physicians who had achieved remission with cognitive behavioral therapy were fit to practice.” Why might readers imagine this? Physicians and nurses with opioid use disorder (OUD) are encouraged or required to participate in physician health programs, or PHPs, state-based treatment programs studied by experts like McLellan, Dupont, and Merlo, among others.1 These programs are often focused on abstinence and have defined 5-year outcomes, including fitness for duty and return to work. This New England Journal of Medicine article makes a case for lifting bans on medication-assisted treatment (MAT) in some PHPs and orienting the programs around structural health challenges faced by medical professionals.
It is certainly true that PHPs have a history of successful recovery, return-to-work rates, and premorbid function outcomes for physicians who are monitored and active in such programs. But all physicians are not the same. Substance Use Disorders (SUDs) are not the same, either, and physician specialties have different risks.2 Before the public heard of fentanyl, for example, it was a dangerous substance for anesthesiologists.3 And health care professionals and business executives can become political footballs in the MAT vs non-MAT dichotomy.
I like to frame this discussion around personalized medicine. We do not currently have tests or other predictors gauging which person with OUD will best recover at 5 years, and with which treatment. Some studies on PHPs suggest that health care professionals have the best 5-year return-to-work and premorbid function outcomes reported. This may be due to the generally late onset of SUDs in physicians. It could be that a given PHP works because of contingency management—follow the program and you can continue to be a physician. Contingency management is one of the most effective behavioral interventions for OUD and used much more frequently in PHPs than in non-PHP treatment settings. But few psychiatrists or addiction specialists understand the overall utility and efficacy.4
We need more research to figure this out, but physician intervention, treatment, and recovery has been a model for successful 5-year outcomes and multidisciplinary treatment.5 Some programs are strictly oriented around a non-medication approach, but others are more flexible. Some programs have mandated MAT, like those requiring naltrexone for anesthesiologists6 returning to work, but others may prohibit MAT. Merlo has reported on outcomes and on MAT utilization in this population. She found that “individuals with opioid use disorders managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without opioid substitution therapy (OST ) through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.”7