Here is the most practical, down to earth guide that we are able to put together.
Remain non-judgemental. You must do this if you are to empathise with your friend or loved one, and hence acquire and maintain their trust so that they tell you what you need to know to get them treated properly. Remember: addiction to recreational narcotics is an illness typically brought about by adverse surroundings such as excessive stress or anxiety; or by underlying trauma. Drug addicts are victims and should be treated with sympathy and care, not with scolding moral injunctions of which they will have heard many elsewhere.
Be gentle. Assisting a person with very serious drug addiction problems may be a process, not a decision. Do not dismissively remark 'it's up to them'. They are sick, potentially very sick. You would not tell a cancer patient that it is up to them whether to take the chemotherapy medications. Think about the issue in the same way. Use gradual, understanding, persuasion.
General observations
It is very hard to assist a person with a serious drug addiction problem unless you know what they are addicted to. Unless they trust you, they may feel to ashamed to tell you. But of course the most reliable means of diagnosis is the patient telling their counsellor what drugs they have been taking and in what quantities.
Serious drug addiction is in general limited to a handful of recreational narcotics that do not have the quality of decreasing effectiveness the more you consume. The principal reason it is rare to be seriously addicted to marijuana is that after you have smoked (or eaten) so much of it, it has an exponentially decreasing 'high', or effect upon your faculties of mental cognition.
Addiction specialists will tell you it is possible to become addicted to anything, and this is true. With habitual use over an extended period, anything can be addictive, from physical exercise to drinking tea to chocolates and cheesecake. Nevertheless this article is not about addiction in principle, something from which we all suffer to a degree and we would be hypocrites were we to suggest otherwise. This author is addicted to writing.
The point of this article is to highlight certain kinds of acute addiction characterised by the phenomenon that withdrawal creates a physical or mental craving for more. To anyone who has suffered from such an acute addiction, they know that it is entirely different from the 'withdrawal symptoms' that this author has when he is not given sufficient time to write. In acute addiction scenarios, the mind starts to respond irrationally to the absence of the addictive substance; or, just as bad, the body exhibits withdrawal symptoms as it has become dependant upon the presence of the addictive substance for the continuation of its ordinary operations.
Diagnosis
In no particular order, the most addictive recreational narcotics are listed below.
Heroin, a sedative, is acutely addictive by reason of the mental euphoria it provides to the user and the depression of the body's regular physical functions that, with only a short period of time, the body gets used to and struggles to revert to normality when the heroin is withdrawn. Heroin is a killer. If you continue to take it, eventually your body will become used to its physical functions not operating at all, and you will die.
Amphetamine, a synthetic stimulant known by a variety of names including 'Speed', 'Whizz' and 'crystal meth'. They are all chemically basically the same thing, although some are crystalline and others are powders. Amphetamines are both physically addictive (they get the body's metabolism working at a higher than normal rate, something the body finds it hard to readjust to upon withdrawal) and mental focus and concentration, something the mind may imagine that it thrives upon and does not want to give up. Amphetamines also appear to cause permanent damage to digestive organs and to the skin texture.
Cocaine, a white powder and principally an anaesthetic that has elatory side effects that wear off quite quickly. Cocaine is not physically addictive; excess use of anaesthesia leads to necrosis which the body will seek to fight. But by reason of the short term nature of the elation, it may become psychologically addictive because the mind wants to repeat the experience of elation.
Crack cocaine. This substance is often not understood. It is cocaine boiled up with baking powder (sodium bicarbonate or a similar cutting agent) that thereupon creates brownish crystalline blocks. It can thereafter be chopped up and snorted; or it can be smoked: if the crystals are heated, they create a narcotic vapour. Crack cocaine is significantly more dangerous than cocaine. There are two reasons for this. Firstly, the admixture with bicarbonate of soda renders the onset of symptoms of elation much more rapid than for cocaine; and the half-life of the elation is also significantly shorter than for cocaine. This means that the psychological disposition towards wanting to renew the experience is all the more intense. Secondly, crack cocaine is physically addictive in ways similar to amphetamines. The body may lurch into spasm or agony in response to withdrawal.
Alcohol. Ethanol, a depressant that nevertheless with habitual social use can serve as a short-term stimulant through the association of its consumption with enjoyable social experiences, is highly psychologically addictive (it starts to present an immediate feeling of relaxation with repeated use) and physically addictive (the digestive organs need to change their capacities to manage excess alcohol consumption, and they find it difficult to switch back to regular operation upon withdrawal). 'Withdrawal symptoms' from alcohol, including anxiety, shaking, insomnia and sweating, interestingly all subside precisely ten days after the initial act of withdrawal, provided it is upheld, irrespective of the composition of the individual or the quantity of alcohol they consumed. Nobody really understands why it is the same for every person.
Although nicotene is highly psychologically and physically addictive, and extremely harmful to the smoker and those around him, we do not include an analysis here because it is not possible to overdose in a way that causes the severe mental and physical reactions we go on to describe below.
It is easy to say 'well these are all white powders; how am I supposed to know which one the person I am caring for has been using?'. That is why it is so important to acquire and maintain the confidence and trust of the patient: so they will tell you.
As a general rule, however, expenditure patterns will reveal the likely substance addictions. Cocaine prices are remarkably stable globally, depending upon one's distance from South America where almost all of it is manufactured. Although we cannot provide a global comparative analysis of the costs of highly addictive recreational narcotics, cocaine in Europe typically costs EUR 80 per gramme. Heroin is EUR 60 per gramme. Crack cocaine is the most expensive, at EUR100 per gramme (because the process of its formation distils the psychoactive components of cocaine into a smaller substance). Amphetamines are by far the cheapest, costing as little as EUR 5 per gramme. The financial costs of alcoholism can of course be colossal over time.
Heroin is generally consumed intravenously although it can be smoked. Crack cocaine can be snorted or smoked. Cocaine and amphetamine are typically consumed per nasum, although they can also be rubbed into the gums.
Excluded substances
The following substances are excluded from these remarks on serious addiction to highly addictive substances, generally in each case because they have no physically addictive qualities and the psychoactive effects of each such substance diminishes exponentially to a plateau with increased dose; also because these substances have longer half-lives and hence withdrawal is not so rapid as to produce what some drug addicts call 'cravings'. We list them only to exclude them from this essay. Further studies could and have been and will be written about each of them.
Lysergic acid dyethilamide (LSD or 'Acid'), a research medicine developed in the 1950's to 1970's to treat various psychiatric conditions.
3,4-Methylenedioxymethamphetamine (MDMA or 'Ecstasy'), developed as a research medicine against depression in the early twentieth century.
Psylocybin, a naturally occuring component of some fungi that creates hallucinatory effects similar to those of LSD.
Ketamine, a tranquiliser with elatory effects that is also a white powder. Addiction to ketamine is rare in practice as its tranquilising properties do not appear to induce the desire for repeated use.
Marijuana, a psychoactive drug from the cannabis plant.
This is not to say that consumption in excess of any of the foregoing recreational narcotics may not be harmful; virtually anything consumed in excess can be harmful, including salt and sugar. But the foregoing substances are highly unlikely to lead to serious addiction problems of the kind this article studies.
We should also observe that the legality, and attitudes towards the social acceptability, of the various recreational narcotics listed above varies wildly. No recreational narcotic is banned in every country in the world. (In Switzerland, heroin is legal and can be prescribed by a doctor for recreational purposes.) Different age groups and professional classes in different societies may harbour glaringly different social perceptions of the use of different recreational narcotics. In London, England, cocaine consumption is widely ignored as a social problem, including by the Police. In Manchester, England, consumption of MDMA is regarded less critically than alcohol consumption, because alcohol consumption tends to lead towards incidents of violence whereas MDMA has the opposite indication. And so on and so forth.
Symptoms of severe narcotic addiction
The symptoms of all severe addiction cases follow approximately the same pattern. The following list must be studied with care by any putative helper.
Increased anxiety and paranoia. This is typically explicit: the patient starts saying that other people are thinking about them in adverse ways, for example. The paranoia or anxiety often relates to the drug in question: so the patient may be concerned that someone else is consuming their drugs, or that they have lost some of their drugs, and so on and so forth.
Psychotic hallucinations. The patient starts to see or hear things that are not there. A classic example of this is rummaging through one's pockets to look for things that are not in one's pockets, such as more drugs, or money to buy them. Inverse hallucinations are also likely: a lack of interest in or attention to anything not directly related to the consumption of drugs.
Psychotic delusions. The patient starts to believe things that are not true. Again the delusions often relate to the drug to which the patient is severely addicted. So a patient might believe that the drug is rotting their nasal septum (this is actually extremely rare; averred experiences of it are typically psychotic delusions).
Palpable physical discomfort, involuntary muscle spasms or even physical pain, resulting at their most extreme in unreasonable behaviour aimed at procuring more of the narcotic substance (such as entering into unreasonable debt obligations; undertaking sexual acts in exchange for drug financing, etcetera).
All these stages can be observed with alcoholism as well as with other highly addictive recreational narcotics.
Finally one should consider the effects of psychosis induced by sleep deprivation. These are most commonly observed in users of amphetamine and crack cocaine. (None of the other narcotics mentioned in this article will keep you awake sufficiently long.) Symptoms of sleep deprivation psychosis kick in fairly reliably after after a consecutive period of 36 to 48 hours without sleep. Principal symptoms are paranoia and psychotic delusions, that will probably but not necessarily exclusively revolve around the subject of the drug to which the patient has a severe addiction.
Even short periods of sleep (one or two hours) will mitigate against the effects of sleep deprivation psychosis. Nevertheless the correct treatment for sleep deprivation psychosis is for the patient to stop taking the drug and to go to sleep! If necessary induce sleep using a Z-drug (e.g. zoplicone).
Recommended actions
Upon observation of any of the above four categories of symptoms, the caregiver should start seriously to countenance the hypothesis of severe drug addiction.
Typically the symptoms will grow together. So the case for severe drug addiction will start to become overwhelming.
The basic treatment pattern in each case is the same: a period of enforced 'drying out'. In other words, the patient must be placed in a mandatory but preferably highly benign environment, with plenty of other stimuli, in which the substance is not available. Then a course of treatment with psychoactive medications must be begun immediately. In most cases the treatment prescribed is anxiolytics, in particular benzodiazepenes, combined if necessary with light anti-psychotics depending upon the severity of the symptoms; gradually tapered down to zero over one or two weeks. (Heroin requires a distinctive treatment in a so-called 'methadone clinic', the details of which are outside the scope of this essay.)
Patients with acute physical withdrawal symptoms (e.g. agonising pain) may need short term opioid treatment although acute physical symptoms typically subside within 48 hours of abstinence so the opioid course need only be very short. The foregoing does not apply to heroin addiction treatment, which requires a more complex regimen to address the physical addiction symptoms which subject is outside the scope of this article.
In all cases the at least daily attention of a psychiatrist skilled in the treatment of severe addiction is required, who can adjust medication levels up and down in conjunction with paramedics' observations as to withdrawal symptoms and continuing psychotic episodes.
The procedure is fairly intense for both carers and patients, but this process will be successful provided that the patient is located in a mandatory environment. Severe drug addiction can be cured in as little as a week.
Rehabilitation clinics offering this level of specialist and intensive expertise are both rare and expensive. They are seldom available courtesy of the public purse. A regular course of psychiatry or psychotherapy is insufficient. Intensive specialist expertise in a benign mandatory environment is essential. Someone will have to spend serious money. Seek donations from other friends and loved ones.
Visits of friends and loved ones may typically begin from Day 3; such visits are enormously important to boost the patient's morale and resolve. By Day 7, with a bit of luck, the patient will emerge from the clinic entirely cured of their severe drug addiction and back to the person you always knew.
How do I persuade them to go?
Psychiatric patients (which include persons suffering from severe drug addiction) need what is known as 'insight'. It is virtually impossible to treat any psychiatric patient effectively unless they acknowledge that they have a problem that needs to be treated.
Therefore the first thing to do is to get them talking about their drug use and how that slid into addiction. That is why a non-judgemental attitude is so important. You need to mitigate the sense of shame the patient will typically be suffering from, by being not just sympathetic but treating severe drug addiction as just another illness to which all humans are prone from time to time.
You need to persuade the patient to accept a course of mandatory treatment, essentially by walking them through the logic of this article. Tell them there are two categories of narcotics; they have chosen one in the wrong category; they have become sick; here is the evidence of their illness; here is how it is treated; and it won't even take very long. One week and they will be cured. They want to be cured, quickly, like all patients suffering from illness. And, provided you follow these guidelines precisely, they will be cured. Drug addiction is a wonderfully easy illness to recover from, treated correctly.
Unfortunately it is rarely treated correctly, by reason of various underlying social stigmas for which a series of historical politicians were chiefly responsible when they invented 'the war on drugs', a policy concept invented out of thin air and that was then encrusted with more rot and reinforced with more ungrounded stigma and prejudice over several decades.
If you are patient, logical and persistent, you will easily persuade your patient to undertake the course of treatment best for him or her: a one-week course of rehabilitation with psychiatric medications in a benign but mandatory environment.
Post-treatment follow up
How do we prevent post-treatment recidivism on the part of the patient?
The answer to this depends upon the underlying condition that led to severe drug addiction.
In some cases these are situational or circumstantial. The only solution is to change the situation or circumstances so as to alleviate the mental agony the patient is suffering from so as to lead them down the path to serious drug addiction. If you do not change the circumstances so torturing the patient's mental well-being, recidivism will occur.
In other cases, there is an underlying trauma or mental illness that the patient has been self-medicating with recreational narcotics. That issue needs to be properly treated by a competent psychiatrist, or the patient is liable to start self-medicating again.
One thing that does not work in recidivism cases is trying to separate the patient from the drug. They will always find a way, if they want it. Or they will cross-substitute, usually to a more detrimental habit cycle. Dubai is full of drying out cocaine addicts who just replace cocaine with alcohol abuse (cocaine is not commonly available in Dubai), which turns out to be even more expensive and even more damaging to the patient and to those around him or her. All the time, the underlying problem remains unresolved.
Encourage the patient to undertake a short course of medicine-based psychiatry, to explore the underlying issues that led to severe drug addiction.
Do not just despair of recidivist severe drug addicts. If they engage in recidivist patterns, it is because you have not yet understood their underlying mental trauma and/or situational stress that drove them to such extreme behaviour.
You must diagnose and effectively treat the underlying cause, even if that means changing the patient's entire life, or recidivism is highly likely.
Psychiatry is not particularly difficult. You just need a lot of empathy with a distressed person. Because distress is at the route of all psychiatric issues, severe drug addiction included.
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With thanks to patient A., in whose treatment this author had the privilege to assist.
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