He had done things while he was on drugs, and while trying desperately to get drugs, that filled him with shame and self-loathing. To blot out these feelings, he would get high again. He had gone through rounds of detoxes, stays in halfway houses, and a rotating roster of well-intentioned helpers. And now, once again, he was back in hospital.
After a few days of stay, his mental state appeared to improve; he denied having any ongoing suicidal thoughts, became more communicative, and assured us that he would attend his follow-up appointment with our specialised addiction service. He promised his wife that he would stay at another halfway house, one that had been arranged for by his pastor.
He was assessed to be no longer at imminent risk of harm. He seemed earnest and sincere about wanting to turn over a new leaf, so we discharged him with these well-laid follow-up plans in place.
Two weeks later, he was dead. It was later established that he had taken his own life.
I was appalled. It wasn’t that, before this, I had not lost patients who died by suicide.
In my profession, there is a saying: “There are two kinds of psychiatrists – those who have had patients who died by suicide, and those who will.” And I had been in practice long enough for that to have happened a few painful times. But this was somewhat different.
Tyranny of addiction
Almost all doctors will encounter patients who are addicted to various substances (in medical parlance, we collectively refer to these conditions as substance use disorders). And what we call an addiction can be defined – in the dry precise language of a standard psychiatric textbook – as “an enduring, inordinately strong tendency to engage in some form of pleasure-producing behaviour in a pattern that is characterised by impaired control and continuation despite harmful consequences”.
The central question is not what makes these substances pleasurable for people in general, but what makes them so much more inexorable and enslaving for those who use them addictively.
There are a myriad of psychoactive substances, and it’s a growing list: from the commonplace and legal, such as alcohol and nicotine, to illicit drugs like methamphetamine, heroin, cannabis, cocaine and Ecstasy, as well as a range of other designer drugs.
This also includes the dangerous repurposing of substances such as fentanyl and ketamine, with the latest being the anaesthetic agent etomidate, which is now being laced into vaping products.
There is a medley of explanations for why people become addicted, with some leaning towards nurture, others towards nature, and some towards a combination of both.
The nature perspective views addiction as a brain disease involving neurological dysfunction.
Studies have shown that the heavy and consistent use of certain substances (stimulants like methamphetamine and opioids like fentanyl) can damage areas of the brain that regulate emotion and behaviour.
Other studies have found differences in brain chemistry between those who are addicted and those who are not.
Helplines
Mental well-being
National helpline: 1771 (24 hours) / 6669-1771 (via WhatsApp)
Samaritans of Singapore: 1-767 (24 hours) / 9151-1767 (24 hours CareText via WhatsApp)
Singapore Association for Mental Health: 1800-283-7019
Silver Ribbon Singapore: 6386-1928
Chat, Centre of Excellence for Youth Mental Health: 6493-6500/1
Women’s Helpline (Aware): 1800-777-5555 (weekdays, 10am to 6pm)
The Seniors Helpline: 1800-555-5555 (weekdays, 9am to 5pm)
Counselling
Touchline (Counselling): 1800-377-2252
Touch Care Line (for caregivers): 6804-6555
Counselling and Care Centre: 6536-6366
We Care Community Services: 3165-8017
Shan You Counselling Centre: 6741-9293
Clarity Singapore: 6757-7990
Online resources
mindline.sg/fsmh
eC2.sg
tinklefriend.sg
chat.mentalhealth.sg
carey.carecorner.org.sg (for those aged 13 to 25)
limitless.sg/talk (for those aged 12 to 25)
shanyou.org.sg
For decades, dopamine was considered central to addiction – a 1997 Time Magazine cover even called it “the master molecule of addiction”.
Addictive substances, it was believed, flood the brain’s reward system with dopamine, creating intense pleasure and reinforcing drug use.
But over time, the brain becomes less responsive to other rewards, making drug use compulsive and an insatiable craving – not to feel high but to avoid feeling low.
However, not all abused substances, such as opiates and cannabis, trigger this dopamine surge, and the dopamine-centric model has yet to yield effective treatments.
The nurture camp, by contrast, argues that addiction arises not from a broken brain but from the motivations and contexts surrounding drug use – often as an escape from intolerable conditions such as untreated mental illness, bullying, loneliness, trauma or fraught family environments.
The idea of addiction as a brain-centric disease has also not gone down well with a generally sceptical public.
Many see addiction as a defect of character or a moral failing – an inability to control desire and direct one’s own life. In this view, addiction is a capitulation of will, a surrender to a form of tyranny of one’s own making.
This sense of subjugation was captured by the 19th-century essayist and literary critic Thomas De Quincey in Confessions Of An English Opium-Eater (likely the first literary work to depict drug addiction from a personal and psychological perspective).
De Quincey agonised that what made his use of opium diabolical was not the vivid visions and dreams it induced – which were sublime, as well as surreal and terrifying – but rather the tyranny of the addiction: a malevolent force that seized control over his mind and will.
More On This Topic
Singapore’s vaping crisis lays bare the drug addiction nightmare for parents
Why the vape scourge in Singapore concerns everyone
A bitter pill
As scientists and clinicians continue to grapple with the mechanisms underlying addiction, this uncertainty that those afflicted – and their loved ones – must live with is a bitter pill to swallow.
Burnout, exhaustion, shame, disgust, rage and mistrust are common among those caring for someone constantly in search of the next hit. The same person they once loved and trusted has, through addiction, morphed into someone they may not even trust to be left alone, let alone with anything that could be stolen and sold.
Yet guilt often accompanies this bitter resentment of a parent, sibling, child or spouse who is clearly struggling with his or her own personal hell.
It is understandable, then, that many would seek to relieve themselves of such ambivalent and conflicting emotions.
This is, in part, why it can feel easier (and tempting) to view addiction in absolute terms: either as a choice or as a disease, justifying the anger in the first instance and pity in the second.
Research consistently shows that negative attitudes towards substance users among health professionals are common.
Such attitudes are associated with reduced empathy and engagement, withholding of treatment services, and poorer treatment outcomes.
This stigmatisation – marked by labelling, stereotyping and discrimination – towards people with substance use disorders often surpasses the stigma directed at patients with serious mental illnesses such as schizophrenia and bipolar disorder, which are themselves already highly stigmatised.
This was very much the case with the public as well – as we found in a study in 2023 that examined the attitudes in Singapore towards mental disorders.
“People were more likely to perceive a person who abuses alcohol as being weak, not sick, and dangerous and unpredictable as compared with (those with) other mental health conditions examined in our survey,” said Associate Professor Mythily Subramaniam of the Institute of Mental Health, who led the study.
She added: “Such biased attitudes also undermine the willingness to seek help. Those who feel stigmatised are less likely to seek help, and, if they do, they are more likely to drop out of treatment.”
More On This Topic
The new tech treatments that could improve mental health
Mental health is now on the national agenda – let’s cut to the chase
Confronting biases
When I heard that the patient had died, I felt a different kind of guilt.
I recalled that frisson of resignation and resentment while reading through his past medical records before our first encounter – thinking that it would be yet another futile effort.
I also remember feeling relieved that I could refer him to a colleague with specialist expertise in addiction. I felt that I did not quite have what it took – in terms of knowledge, experience, and inclination to manage patients with substance use disorders.
I was chastened by his suicide, and it was cold comfort to read studies showing that negative attitudes vary with the level of clinical training. Addiction specialists tend to hold more positive attitudes than general psychiatrists like myself or primary care physicians.
It suggests some sort of connection between professionals’ knowledge and skills and their attitudes, highlighting the critical role of what these papers referred to as “self-efficacy” in shaping professional behaviour.
And so, despite the wide range of evidence-based treatments available for addiction – from detoxification and transitional housing, to inpatient and outpatient rehabilitation, peer support, various forms of psychotherapy and counselling, and a number of effective medications – recent research has shown that most of these treatments remain underused.
Many people have a simplistic view of addiction. They think it happens only to dysfunctional people from dysfunctional families, or with those with “weak character” with anti-social tendencies. In reality, addiction affects people of all races, genders and segments of society. There is no single cause or single cure for addiction, and no easy, unambiguous answers to the many conundrums of addiction.
Yet there are those who have managed to turn their lives around. How they manage to do so often seems a mystery to me.
But I’ve seen that some people can change when they are faced with dire consequences – often when they hit rock bottom – but also when they have hope and support that change is possible.
As health professionals, we must provide some of that hope and support, tempered with a compassionate attitude as expected of us. More addiction training and greater clinical experience in this area would certainly help.
What may be harder, however, is learning to confront and overcome our biases, and to truly see the humanity in those struggling with addiction. If we allow those biases to persist unchecked, they will cloud our understanding and distance us from the very people who need our help.
Professor Chong Siow Ann is a senior consultant psychiatrist at the Institute of Mental Health.
No comments:
Post a Comment