June 11, 2009
Dependence syndromes - Cover story
The making of an addict
Experts reveal why some are more vulnerable and that an addict should be cared for like the sick and not be labelled a bad person
By June Cheong
One is the loneliest - and scariest - number to an addict.
Just one 'hit' of an addict's personal manna, be it a cigarette puff, a swig from a beer bottle, or an hour on a computer game, will invariably lead to three or even 10.
Associate Professor Munidasa Winslow, a consultant psychiatrist at Raffles Hospital, said: 'Addictions develop when use of a substance or a behaviour starts to be a compulsion, such that the behaviour is continued despite adverse consequences and when it takes up more and more of your mental energy and time.
Tolerance of the substance or behaviour comes next.
Professor Kua Ee Heok, a senior consultant in the department of psychological medicine at National University Hospital, said: 'An alcoholic may experience euphoria after drinking one glass of wine in the past but now he must drink two or three bottles to feel the same.'
An addict also shows withdrawal symptoms and his life is now controlled by whatever substance or behaviour he is dependent on.
Dr Tommy Tan, a psychiatrist at Tommy Tan Psychiatric Clinic at Novena Medical Centre, said an addict kept away from the substance or activity gets withdrawal symptoms such as dysphoria (an emotional state marked by anxiety, depression and restlessness), depression, irritability, anxiety and agitation.
Relief from such symptoms comes only when he takes the substance or performs the behaviour.
Addictions to drugs, alcohol and other substances are described as dependence syndromes while addictions to activities like gambling are called impulse control disorders.
These terms correspond to the two types: substance addiction and behavioural addiction.
People perceive addiction as something negative. Yet, Dr Kua said, many people drink beverages with caffeine, such as coffee. This is the most common addiction - or dependence syndrome.
One may be said to have developed a dependence on caffeine if more than three cups of coffee are needed a day.
Dr Tan said: 'Caffeine is one of the world's most used drugs. The stimulant is in our coffee, tea, energy drinks and various soft drinks.
'Many people start their day with a cuppa and continue to drink more through the day. If they don't, they will get irritable or be unable to concentrate and work.
'However, because caffeine is culturally accepted, most people don't see it as an addiction.'
The other common dependence syndromes involve smoking, alcohol and sleeping pills.
Dr Lee Kae Meng, an associate consultant and deputy chief of addictions at the Institute of Mental Health, said nicotine addiction (smoking) and alcohol use are the most common addictions here due to their easy availability.
The National Health Surveillance Survey 2007 revealed that nearly 14 per cent of Singapore residents aged 18 to 69 years smoked every day, compared to 13 per cent in 2004.
There are no official figures for the number of people dependent on alcohol or sleeping pills.
Asked who is most susceptible to developing dependence syndromes, psychiatrists Mind Your Body spoke to said that genetics, family history, culture, personal traits and environmental factors all play a part in the making of an addict.
For example, Indians and Chinese in Singapore are more susceptible to alcohol dependence while Malays are more susceptible to drug dependence.
In addition to socio-cultural factors, genetics may contribute to the formation of certain addictions.
Dr Winslow pointed out that a person is at four times greater risk of becoming an alcoholic if both his parents were or are alcoholics.
Impulse control disorders that are predominant here include gambling and Internet and sex addictions.
A Ministry of Community Development, Youth and Sports survey last year of 2,300 Singapore residents on gambling participation rates found that between 0.7 and 1.6 per cent of survey respondents may have a gambling addiction.
Probable pathological gamblers are more likely to fit the following profile - male, Chinese, aged between 30 and 59, with O level, ITE or VITB education, and has a monthly personal income of between $1,000 and $2,999.
While gambling addictions afflict older adults, Internet addiction is a symptom of this wired age.
A paper last year by Singapore's Academy of Medicine found that among 2,735 secondary school students surveyed, one in five admitted to being constantly online at least five hours a day, a usage the report said was 'compulsive'.
It is not known how many sex addicts there are in Singapore.
Dr Kua said families and friends of addicts should view addiction as an illness.
He said: 'If you see an addict as a sick person, you can care for him. If you see him as a bad person, you want to punish him.'
Whether the dependence is psychological or physical or a treacherous combination of both, the brain has a vital role in maintaining the cycle of addiction (see graphics on Page 14).
It is the limbic system in the brain that regulates emotional responses and reward systems.
Dr Nagaendran Kandiah, a consultant neurologist at the National Neuroscience Institute, said the neurotransmitter dopamine regulates the reward circuits in the brain. When a person takes an addictive substance like alcohol or marijuana, special neurons in the reward circuits release dopamine.
The dopamine binds to receptors in receiving neurons, providing a jolt of pleasure. Addictive substances increase dopamine's availability, deepening the feeling of pleasure.
Over time, the brain adapts to this increased dopamine by reducing the number of receptors. This results in the addict deriving less pleasure from each hit. He develops tolerance and needs stronger or more doses.
Mr Terrence Smith (not his real name), a retiree in his 60s and a recovering alcoholic, gives a graphical insight into what this neurological process does.
He said: 'I had to live within a whiskey bottle.
'As an alcoholic, you feel good for a few minutes after drinking but you drink more and more. You eventually black out, wet or soil yourself. But the obsession kicks in and you drink again.'
Asked whether it is easier to break a dependence syndrome or impulse control disorder, Dr Winslow said: 'The former are usually easier to treat as substance addicts usually know that they have a problem.
'A full blown behaviour addiction is easier to hide and the individual may fool himself into thinking he can manage or control it on his own.
'This may not be a true reflection of which is more dangerous though.'
Learning to say no - and staying motivated to say no - is key to conquering addiction.
Ms Tan Cin Yee, a certified Quit Smoking consultant and a senior pharmacist at the department of pharmacy at Tan Tock Seng Hospital, said of smokers wanting to quit: 'The smoker must have willpower and be committed to make a change in his current lifestyle and habits. He must also be personally motivated and want to kick the habit.'
While there is a range of cessation programmes, medicines and helplines available for common addictions, most people here do not knock on doctors' doors when they want to shrug off their dependencies.
A case in point: An independent street survey of 200 smokers here in 2007 found that only 15 per cent of them had sought help from medical professionals to quit lighting up.
If one is the loneliest number, then reaching out to others, be they family or the medical community, may lead to freedom from the lonely spiral of enslavement to an addictive substance or behaviour.
Slave to a whiskey bottle - Alcoholism almost killed him - not once but twice.
In 1987, Mr Terrence Smith (not his real name) nearly died of alcohol poisoning.
The 60-year-old American retiree, who has lived in Singapore since 1986, was in the United States for business but instead he spent much time on heavy drinking and even passed out once.
When he woke up in hospital, a doctor told him he had almost died.
Mr Smith then attended an outpatient clinic for three to four months and abstained from drinking.
He said: 'I didn't like to drink when I was younger because my mother was an alcoholic. A younger brother of mine died of alcoholism many years ago.
'I didn't drink very much until I was 25 and I ended up losing my business and my marriage.'
Mr Smith has since remarried - a Singaporean who is a teetotaller - and his three children, aged 15 to their late 20s, know that their father attends Alcoholics Anonymous (AA) meetings here.
He recalled that the first treatment did not stick. At his worst in the 1970s and 1980s, Mr Smith could easily knock back a few bottles of wine or a bottle of hard spirits like vodka in a day.
A year after his hospitalisation in 1988, he nearly committed suicide. He drank a litre of scotch and took a handful of Valium pills.
He said: 'I wanted to kill myself. I wanted to jump but I was afraid I would just injure myself as my apartment was not on a high floor.'
Three days later, when he had recovered from alcohol-induced illnesses like nausea and headache, he attended an AA meeting.
It was not his first time. Despite having enrolled in treatment programmes and attending AA meetings over the years, he found himself returning to the bottle six or seven times.
Mr Smith said: 'I went regularly to AA but I still slipped up. AA is not a magic wand. You may listen to the message but if you don't take it in, it doesn't help.'
He managed to stop drinking for a few years but relapsed again when he travelled for work.
He finally cleaned up his act in 1995 when he checked himself into a treatment centre in the United States for a month.
He said: 'I saw some very sick individuals there, people who were made sick by their addictions, and I finally realised that I had to admit I was a 100 per cent alcoholic.
'If I don't keep up the abstinence or if I get over confident, I can go off the rails.'
He added: 'It's an illness you can't cure with willpower. The problem with alcoholics is one drink is too many and 100 is not enough.'
Now he attends four to seven meetings and support groups for addicts every week.
He said: 'I was a slave to a whiskey bottle. At AA, we're told to find a higher power to help us overcome alcohol. We're advised to try using the group as a higher power.
'I finally accepted I had to learn from a higher power because alcohol was my higher power then.'
Mr Smith now avoids bars and sticks to non-alcoholic beverages when he is travelling, even attending local AA meetings wherever he is. The smell of alcohol no longer triggers a physical craving in him. It makes him nauseous now.
He said: 'Once you're an alcoholic, you will be one till you die. The only question is if you'll die sober.
'I'd rather die of old age than be drunk and choke on my own vomit.'
The key to recovery
Quitting is the first step for most addicts but staying off the addiction is the tougher - and more important - act.
Associate Professor Munidasa Winslow, a consultant psychiatrist at Raffles Hospital, said: 'There needs to be real behavioural change.
'That's why groups like Alcoholics Anonymous work. It's a well-structured programme with regular meetings and opportunities to cultivate new friendships.'
Ms Lim Hui Khim, the deputy head of counselling services at National Addictions Management Service in the Institute of Mental Health, said that the key to recovery is motivation and readiness to change.
Psychiatrists Mind Your Body spoke to advised those dependant on substances like alcohol or sleeping pills to commence withdrawal in a hospital.
Dr Winslow explained: 'Alcohol and sleeping pills are depressive drugs. If you've used them every day and then suddenly stop, your brain will go into overdrive.
'You may start to hallucinate and even go into epileptic fits.'
There is also medication available to treat withdrawal symptoms.
For example, nicotine replacement therapy like patches or gums and prescription medicine like buproprion and varenicline can help smokers relieve nicotine cravings and withdrawal symptoms.
Treatment should also address the social and emotional fall-out of a patient kicking his addiction.
The recovering addict's family and friends may be encouraged to learn how to cope with the addict's withdrawal symptoms and to repair emotional rifts that may have been caused or compounded by the addiction.
Meanwhile, the patient should work with psychiatric professionals to determine what brought on and perpetuated the addiction and ways to avoid these factors.
Professor Kua Ee Heok, a senior consultant at the department of psychological medicine at National University Hospital, said: 'Treatment is not just giving out medicine and counselling. You've also got to teach recovering addicts skills in coping with life and its stresses.'
Asked if the 90-day window is the optimal treatment time for addictions, DrWinslow said: 'Ninety days is the time you need to allow your brain to re-set and to deal with the withdrawal effects and behavioural change patterns.'
HELP FOR ADDICTS
For help in quitting addictions, you can contact the following groups:
All addictions: All Addiction Helpline, 6732-6837
Alcohol: Alcoholics Anonymous, 6475-0890 or e-mail email@example.com
Drugs: Singapore Anti-Narcotics Association, 1800-733-4444
Gambling: Gambling Helpline, 1800-6-668-668
Smoking: QuitLine, 1800-438-2000
Sex: We Care Community Services, 6471-5346