Sunday December 11th 2016

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Does addiction run in families? – INTERVIEW with Dr. Howard Wetsman, MD

Is addiction hereditary?

One of the most frequently asked questions we get on Addiction Blog is about the link between drug addiction and family genes. What research has shown us is this: As with most other mental disorders, addiction has no one single cause and is not directly passed from one generation to another in families. But does addiction run in the family and if it does, how can families help prevent its development?

We’ve called in the expert

Dr. Howard Wetsman, MD is an addiction psychiatrist practicing in the New Orleans area. Dr. Wetsman has a long history of treating addiction within multiple paradigms. From this, he has developed a unique and effective set of techniques that he is currently refining in his treatment centers. Some of them are described in his book, “Questions and Answers on Addiction”.

Today, Dr. Howard Wetsman weighs in and shares his opinion on the connection between genetics and addiction. Plus, he shares his insight on treating family addiction and what you should work on to prevent addiction in the first place. If you still have questions concerning the relationships between family and addiction, we welcome your comments below and we will get back to you promptly. We try to respond to all questions personally.

ADDICTION BLOG: Does addiction run in the family? Why or why not?

DR. HOWARD WETSMAN, MD: It certainly does, but to understand how, we have to understand what addiction is. Most people think it is a condition of taking too much of a drug or being out of control in using a drug. This leads people to focus on addiction “to something,” like addiction to cocaine or addiction to alcohol. But the best way of thinking about addiction is as a primary brain illness that may or may not have to do with drugs. The ASAM definition is a really good view of what addiction is in nature.

The word itself was coined by Shakespeare from an older Latin legal term, addictus, which meant to be attached to someone against your will in debt slavery. I think attachment against your will is the most pithy definition of addiction I’ve ever heard, and if you understand it that way, you open up to a broader condition that usually starts before the first drug or drink. It is that condition that is largely genetic.

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As to the why, it comes from two normal brain functions. The first is dopamine tone, which allows us, simply put, to feel normal. Second, there is a dopamine spike that has a large impact on our attachment to things. In general, the lower the dopamine tone, the higher the spike, so people who are born with a genetically lowered dopamine tone have a set of symptoms that get better when they use a dopamine spiking behavior or drug and that resultant spike works to attach them to the behavior regardless of what they want their attachment to be. They are set up well to get what we call addiction.

ADDICTION BLOG: Can you explain to us some of the prevailing ideas in addiction treatment circles at the moment regarding addiction and family genetics?

DR. HOWARD WETSMAN, MD: Most addiction treatment circles are still erroneously focused on the genetics of the spike and the idea that dopamine, because drugs raise dopamine, must be bad. This is an artifact of the canard that drugs are the only things that cause addiction. So we have people discussing the epigenetic effects of drugs or the pharmacogenetics of drugs or the permeability of the blood brain barrier, all of which can be important, but not as important as the primary genetics of lowered dopamine tone.

We need to pay more attention to that primary problem, the one that exists before the first drug or drink, the primary symptoms of addiction that lead to using. Those have mostly to do with the long and complicated series of steps in the production of, release of, and sensing of dopamine in the midbrain.

ADDICTION BLOG: What about addiction and the environment? Are there any other theories or concepts that are currently trending regarding addiction and families?

DR. HOWARD WETSMAN, MD: Sure.

Dopamine tone can be thought of as a combination of three factors:

1.  Dopamine released
2.  Dopamine receptor number and function
3.  The time that the dopamine has at the receptor

Dopamine release and time are largely genetically driven. Dopamine receptors have genetic input as well, but are also greatly affected by the environment. Specifically, feeling less than or being physically isolated will quickly lower dopamine receptor density and increase addiction symptoms. We all, addicted or not, have had the experience of being spoken to in such a shaming way that the lights seemed to dim and we couldn’t imagine ever being happy again. That’s the experience of having lowered dopamine receptors.

So what if you’re raised in a shaming family? That will greatly effect your risk of lowered dopamine tone. On the other hand, it’s hard to separate when you look at the why you were raised in such a family. Was it a genetically normal (as far as dopamine is concerned) family that fell on hard times and had a bad reaction that caused shaming of children or was it a home with addicted individuals who not only passed on the shame but also the genetics. So most people I meet that have addiction have both genetic and environmental issues.

ADDICTION BLOG: In your 35+ years of experience, have you found a connection between the occurrence of substance use disorders in particular families? How often?

DR. HOWARD WETSMAN, MD: I rarely meet a person who has no family history of addiction if you define it broadly, but there are a lot of people who don’t think they do.

For instance, dad was a compulsive gambler but didn’t drink, smoke, or use drugs, but son grows up and had addiction and used cocaine. Did the son have no family history of addiction? If you limit the definition to Substance Use Disorders, you’ll miss the point, and the diagnosis.

We also see it the other way. A patient will come in with addiction using some drug and we ask, “Do you drink?” “Absolutely not,” comes the answer. “My father was a terrible alcoholic, and I’d never want to be like him. I wouldn’t touch that stuff. That’s just stupid.” Obviously, the irony is lost on them at first, but it hits eventually in treatment. If you realize it’s a single disease whether substances are involved or not, the family history aspect becomes much clearer.

The family history studies underestimate the genetic influence because they’d score the non drinking son of an alcoholic father as a strike against heritability even if he had addiction involving another drug. There are no studies of the heritability of addiction as an illness, only studies on various substance use disorders.

ADDICTION BLOG: How might siblings differ in their responses to substances? Is there a predictable variation in response?

DR. HOWARD WETSMAN, MD: There may be predictable responses if we knew more, but right now it looks random to us. Largely genetic recombination is random and so it probably will look that way until we have a deeper understanding of the genetic variables.

It’s not uncommon to meet siblings who have vastly different responses to drugs but both have addiction. I remember two brothers, both with addiction, one of whom got energy from opioids. For him, cocaine did nothing but make him shake. He never could understand why his brother would use it. The cocaine using brother on the other hand, only fell asleep when he used opioids and couldn’t understand why his brother would like the stuff. That response has to do with where in the chain of dopamine production and release the individual genetic problems were for each of them.

ADDICTION BLOG: When should families be concerned that genetic predisposition to substance abuse disorders might influence its members? What are some of the signs?

DR. HOWARD WETSMAN, MD: Low dopamine tone has several symptoms that are generally called other things in our DSM inspired diagnostic culture. I wouldn’t care normally what things are called, but unfortunately some of these diagnoses actually get treated with either medications that lower dopamine tone and make things worse in the long run or with things that spike dopamine and thereby lead to the attachment we see in addiction.

Generally, we need normal dopamine tone to attach to normally rewarding things in our environment, to enjoy the company of others, to pay attention and be able to easily refocus attention, to have motivation, to have good memory, to have normal hedonic tone. You can see how other diagnoses come to mind when looking at these.

I think I’d start wondering about them if there is a family history of addiction and you start to see signs of attachment to certain behaviors normally available to children that are known to raise dopamine, but that go beyond normal attachment. So, not a sweet tooth, but a kid who’s only happy when he’s eating; not a kid that likes video games, but one that only seems to function well when watching novel visual stimuli.

ADDICTION BLOG: Is it possible to prevent addiction in a family system when close family members struggle with addiction? What can individual members do to be more aware of their own risk?

DR. HOWARD WETSMAN, MD: The question of prevention becomes entirely different when you stop thinking about drugs causing addiction and start thinking about addiction being a primary brain illness.

If it’s caused by drugs, then the war on drugs makes perfect sense. Just keep doing it until it works. The fact that it doesn’t work tells us there’s another cause. So, what are we really wanting to prevent if we can’t prevent genetics, which we can’t? We want to prevent progression.

So, the key is early identification, early intervention, good treatment for a chronic condition if it develops and life long continuing care.

ADDICTION BLOG: What might parents (who are in addiction recovery themselves) focus on or do to help kids and teens live healthy lives and avoid the trap of substance abuse?

DR. HOWARD WETSMAN, MD: In general recovery principles, whether those of 12-step recovery, or any other long lasting, tested recovery culture will help anyone raise a child.

The best things we can do as parents is ask ourselves at every turn, “IS THIS GOOD FOR MY CHILD”? As trivial as it seems, it’s a lot to ask.

In terms of addiction and prevention, we want to do everything in our power to avoid our children from being physically isolated (unless they want privacy) and feeling less than. Parents are very powerful in that regard.

When parents make a choice to put their own wishes and conveniences of the moment ahead of the needs of their children, there will be consequences, even if we think our kids don’t notice. Now, I’m not saying to be perfect, because we can’t be, but if we can ask ourselves that once more a day than we used to…we’ll help that much more.

ADDICTION BLOG: If addiction occurs in the family, how can families support addiction recovery?

DR. HOWARD WETSMAN, MD: The most important thing, I think, is to treat addiction like an illness.

I’ve met so many people who have lost a child having been told that they needed to stop supporting their child or stop helping their child, only to see their child die of addiction. No one would tell a parent of a child with cancer or a child with diabetes the same thing.

Addiction is an illness and it responds to treatment. If it isn’t responding, by all means change the treatment or the treater, but don’t give up on your loved one because they’re ill.

ADDICTION BLOG: Is there anything else you would like to share with our readers?

DR. HOWARD WETSMAN, MD: Yes.

There’s hope for addiction, but we have to know what we’re talking about to get the intervention right. Substance abuse is the social problem of people with normal brains doing stupid things with drugs and alcohol. Addiction is a real illness and the behaviors associated with it are an expression of ill brains trying to feel normal.

These are two very different things. As long as we keep trying to call them the same thing we’ll never get this right. If we recognize them as different we can intervene differently, and for addiction we have better medical interventions than we’ve ever had before.

This is the greatest time in history to be in my field. We founded Townsend in Louisiana to be a new voice in the treatment of addiction, and I think we’ve made some good strides forward. That voice says that people deserve treatment, that they deserve to be treated like patients. We use genetics today to sequence patient’s medical treatment and we’ll be using it more and more in the future. Addiction treatment is only going to get better.

Don’t give up hope.

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