The Upside of Small Indiscretions

by Siegfried Othmer | March 8th, 2006

Some while ago I came across a study that blacks in this country were suffering major depression and perhaps other major mental disorders at lower rates than might be expected on the basis of known risk factors. These risk factors included obesity, smoking, and alcohol abuse, plus indices of social pathology such as social isolation and breakdown of the family.

One working hypothesis is that the very factors that may over the long-term lead to higher mortality could be playing a positive role in the short term to maintain people at a level of decent functioning, forestalling descent into major depression. If this is the case, then the person at risk would respond biologically only to these short feedback loops. The long-term implications only assert themselves through rational/intellectual feedback loops, and these don’t compete well against immediately felt biological needs.

If any of this might be valid, then policy-makers really need to take such factors into account. People at risk in our society may be adopting strategies that are beneficial for their immediate prospects. In a stress situation, the focus rightly narrows down to deal with the immediate challenges. There is beginning to be research to support these conjectures.

At the last annual meeting of the Society for Neuroscience, researchers from the University of Cincinnati Department of Psychiatry reported on rat experiments in which it was found that the rats allowed to consume sugar-sweetened drinks sustained subsequent stress tests with lower levels of glucocorticoid hormones, indicative of higher stress tolerance. Said Yvonne Ulrich-Lai, PhD, a postdoctoral fellow in the department: “These hormones help an individual survive and recover from stress, but have been linked to increased abdominal obesity and decreased immune function when produced in large amounts.”

Similarly, many find that mild doses of ethyl alcohol reduce their anxiety in the moment. Others have discovered that marijuana calms their overwhelming anxiety and may stabilize their brains against manic excursions and seizures. Many turn to cigarettes either for calming or for activation, depending on the situation. If we are witnessing here some kind of expression of the “wisdom of the body,” then we should certainly take that into account in public health policies.

These thoughts were re-stimulated by an article in the latest issue of Biological Psychiatry in which Biederman et al. address the issue of whether cigarette smoking may serve as a gateway to subsequent alcohol and other drug abuse in the ADHD population. First of all smoking is significantly associated with ADHD, with a nominally 3x greater likelihood of smoking status among adolescents with ADHD compared to controls. There is also a nominally 2.5-year earlier onset of smoking, and greater difficulty quitting smoking in later life. An association also exists with other substance use disorders (SUDs), but these tend to show a later onset. This gives rise to a gateway hypothesis in which adoption of cigarette smoking in early adolescence sets the table for alcohol and drug abuse in later adolescence. The present study was intended to evaluate the gateway hypothesis.

As it happens, most of the statistical associations of smoking with SUDs that were suspected at the outset were in fact confirmed in the study. But all that could be proved statistically was that the observed correlations are consistent with the gateway hypothesis. The data would not allow drawing any conclusions with respect to a causal relationship. Genetic and environmental factors could equally well suffice to account for the data.

That uncertainty notwithstanding, the authors reveal their preference for the gateway model by ending the paper with the injunction that “these findings have public health consequences for ADHD youth, and underscore the already pressing need to prevent smoking in ADHD children.” What then is the action item? Is it another public relations campaign along the lines of “Just say no to cigarettes,” in this case with a special focus on ADHD children?

The authors do buttress the model with the line of argument that nicotine has been shown to affect mesolimbic dopaminergic function, which in addition to reinforcing smoking may also potentiate the response to other psychoactive drugs. This effect may be larger in those populations, such as ADHD, where disregulation of the dopamine system has been identified.

Consider an alternative hypothesis that smoking in an ADHD adolescent may index a particular physiological subtype that derives some functional benefit from the experience, presumably as a result of some degree of normalization of dopaminergic function at the neurophysiological level. Call this the naturalistic model. Consider further that those who go on to abuse alcohol constitute yet another subtype, one that largely overlaps the former. We are simply postulating here that both the smoking and the drug abuse “uncover” a physiological tendency that was to a large extent pre-existing. Such pre-existing tendencies do not disregard the likelihood that drug dependency is further reinforced by the actual experience.

The evidence for such a hypothesis is sparse. But we observe that when Biederman et al carved out the conduct disordered children from the ADHD cohort the strong associations between ADHD and drug abuse moderated considerably. This in turn means that the associations with conduct disorder must be stronger than with ADHD in general. If we regard conduct disorder as a candidate subtype, we can take this as evidence for our hypothesis. Secondly, the study reveals that there is virtually no association between ADHD status and simple alcohol use. Alcohol use is so widespread among adolescents that no strong correlation with ADHD status is even possible mathematically. This means that the transition from alcohol use to the status of alcohol abuse involves another level of selection, and that may well also point to pre-existing conditions.

If the drugs of choice in these vulnerable individuals indicate some attempt by the biological system to approach a more functional state in the moment, then the strategies that focus on abstinence are not likely to work, and indeed they show all the signs of failing in our society. In prisons we see sugar cubes disappearing in great quantities in the prison cafeteria, no doubt functioning as a drug surrogate. And smoking is rampant in the prison system.

Further, the application of an inappropriate remedy may pre-empt the adoption of a proper one. For example, the proposal has been made to ban all tobacco products in the California prison system. This might be a policy little short of madness. If it is ever tried, the experiment will undoubtedly be short-lived, as prison guards will be stuck trying to manage eruptions of newly disregulated prison populations.

It may be more fruitful to regard all resort to psychoactive drugs–licit and illicit–as the signature of the need for a more appropriate remedy. Such a remedy should target the indicated neurophysiological deficit. And of course neurofeedback comes to mind as the global remedy for the “Reward Deficiency Syndrome” that seems to lie in the causal chain of nearly all addictions. The Peniston protocol has by now been adequately proved out for a variety of drugs, particularly in view of our own recently published large-scale replication. It remains to make policy makers aware of the fact that effective and proven remedies exist.

The existence of short and fast biological feedback loops that seduce us into behaviors that are not in our long-term interest may have significant implications for global health. And if that is the case, then it is a phenomenon that must urgently be better understood. Niall Ferguson reports that the decline of public health indices is a problem not only in Russia but also in the developed West. Male life expectancy in Russia is plummeting due to alcoholism and a deteriorating public health regime. But even in Scotland male life expectancy is down to 54 years! Alcohol-related death rates have climbed 350% over the last two decades. More than a third of Scottish children are overweight or clinically obese. In this regard, matters are even worse in the United States.

Ferguson rejects the simple-minded identification of poverty as the defining issue here that explains why people choose to shorten their own lives. Indeed, the Scotsmen and certainly American citizens are not poor in any absolute sense by world standards. What may well explain the trend, however, is the stress of unmanageable uncertainty that attends modern life in the West, and now in Russia as well. Moreover, this unfathomable, amorphous uncertainty ranges across most of the rungs of the economic ladder. Such individual and family stress is inevitably communicated to our children.

Under the above working hypothesis, the response to such persistent and pervasive stress may be to resort to the resources that soothe us in the moment–alcohol, tobacco, other drugs, sugar, or highly refined carbohydrates. Stress focuses us on the moment, and the short biological feedback loops take over. In the language of the economist, we “discount the future steeply” because biologically the long term does not matter in the face of an immediate threat or pervasive uncertainty. A mother kangaroo will chuck her Joey in an instant to extend her own life. A gang member makes no long-term plans. United Nations peacekeepers, finding themselves with uncertain prospects of survival in a foxhole somewhere, may engage in “emergency sex” as a palliative, the long-term consequences be damned.

Concludes Ferguson: “As the snow falls on Russia today, it is burying a society that is literally moribund. But Moscow is only the capital city of the [thick-headed] world. The disturbing thing is just how many northern European and North American towns are already headed in the same dumb, downward direction.”

A bigger problem than not recognizing these disagreeable trends would be a misdiagnosis, followed by a wrong prescription. It would be the greatest folly indeed to anticipate that mere exhortation toward better behavior would bear fruit against such ineluctable biological forces as those of addiction and the response to fear. The sociological reality is that we have unmoored a whole society and set it adrift while actively undermining traditional communal sources of cohesion and support. The biological reality is that we confront a pervasive self-regulatory deficit not only in our ADHD population but also in the society at large. The resulting pathologies are showing up most strongly in our children.

The pharmacological remedy falls short not only in the case of ADHD but in the case of the more global issues. The average length of time that ADHD children take stimulants is less than three years. On the other hand, the hazard of transition into smoking and drug dependency extends over a decade, extending roughly from the age of seven to the age of seventeen. The ground truth is that the drug remedy is failing, and mere exhortation toward improved compliance will not rescue the situation.

There must be a more comprehensive remedy for self-regulatory deficits, and neurofeedback can largely fill that need. We know this to be true, and we should have the courage to say so. Beyond that, one can only hope for a political shift that does not see the imposition of economic stresses on the population as an intrinsic and unalloyed good.

Sweet Snacks Could Be Best Medicine For Stress
Is Cigarette Smoking a Gateway to Alcohol and Illicit Drug Use Disorders? A Study of Youths with and without Attention Deficit Hyperactivity Disorder, Joseph Biederman, Michael C. Monuteaux, Eric Mick, Timothy E. Wilens, Jessie A. Fontanella, Katrina M. Poetzl, Taralee Kirk, Joshua Masse, and Stephen V. Faraone, Biol Psychiatry, 59, 258-264 (2006)
It’s a sick, Thick World, Niall Ferguson, The Los Angeles Times, January 23, 2006
Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population, William C. Scott, David Kaiser, Siegfried Othmer, and Stephen I. Sideroff, American Journal of Drug and Alcohol Abuse, 31 (3), 455-469 (2005)

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