The Realities of Addiction with Psychiatrist Dr. David Streem

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and today we're talking about alcohol and drug addiction. We'll cover everything from what causes people to get addicted, the treatments, and the recovery following. And for today's topic, we have with us psychiatrist, Dr. David Streem. Dr. Streem is the Medical Director of the Alcohol and Drug Recovery Center here at Cleveland Clinic. Thank you so much for being here.

Dr. David Streem: Oh, thank you so much for having me.

Nada Youssef:   Sure thing. And I'm just going to give you a few moments to introduce yourself to our viewers, in a sense.

Dr. David Streem: So, I'm a board certified psychiatrist, I'm also board certified in Addiction Medicine, and I run a treatment program. We have a hospital unit and outpatient treatment. And we use, really, all the best practices, evidence-based medical treatments in psychotherapies that we can to help people recover from substance use disorders and addiction.

Nada Youssef:   Great. Thank you. And before we begin, please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. But if you do have any questions regarding this topic, please put them in the comment section below, and we'll get it here in the second half of the broadcast.

Nada Youssef:   So the usage of alcohol or drugs interferes with family and social life, work, health, emotional stability, and even your spiritual life. Chemical dependency is a real problem. It affects individuals from all walks of life, and tragically impacts also family and friends of the dependents. So let's talk about addiction. I want to bring up that a lot of people seem to think that it's a choice. So, is it a choice? Is it considered an illness or disease? Or is it a character flaw?

Dr. David Streem: Addiction is brain disorder. We know it's a brain disorder because there are abnormalities in folks who suffer from the disorder that we can find the brain. And in animals studies, we can actually make animals like rats, and mice, and all sorts of other lab animals addicted to certain drugs of abuse, and then we find those same abnormalities in those creatures as well. It's part of a group of brain disorders that lead people to continue to do things over, and over, and over again, even though they know that it's not healthy or in their best interest, but they still can't stop.

Nada Youssef:   Okay. So let's talk about what exactly happens to a human brain when a person takes drug or alcohol. I mean, let's talk about that dopamine kick that people are getting that they keep coming back for.

Dr. David Streem: One of the interest things about habit forming drugs is that, of course, there's all kinds of medication substances drugs and they do all sorts of things, but we only abuse certain relatively small class of these substances. People don't use antibiotics abusively. There're other medicines that people generally don't abuse. And the group of substances that humans and many other mammals do abuse, they do lots of different things in the body, they make us feel lots of different ways. But there's one thing that that small group of substances all do that distinguishes them from any other substances, and that's that they cause a rather large release of a substance called dopamine into a part of the brain that's sensitized to it. And when you combine that, particularly with people with a genetic predisposition, which is about 60% of the variance in who becomes addicted and who doesn't, then that leads to changes that lead to the behavioral changes that I mentioned earlier.

Nada Youssef:   So does that mean that it's genetic?

Dr. David Streem: About 60% of the variability is based purely on genetic factors.

Nada Youssef:   Wow.

Dr. David Streem: And we also know that people who are adopted at birth away from, let's say, parents who have addiction problems, and they're adopted into families that do not have addiction history, so there's no addiction in the family, those folks have the same risks of addiction as their birth families. And when the reverse is true, again, the genetics usually predominate, and that predicts whether the kids later will have addiction problems.

Nada Youssef:   60%, that's a big number. And that's important for people that have loved ones that may think that it's a personal choice or something like that. So this information is critical, thank you. Now, we hear a lot about the drug epidemic, and we don't hear a lot about alcohol addiction, not as much as, at least, drug abuse. But what does alcohol abuse look like?

Dr. David Streem: So alcoholism and dealing with alcohol problems for our practice here is still a large percentage of our time, and it has been sort of overlooked a little bit, at least in the media, but it does occupy a lot of our time. So it's the main reason why we have that inpatient unit. We use that hospital unit to treat the medical symptoms of withdrawal, and we do a real thorough medical and psychiatric assessment to identify any coexisting problems, and again, make sure people get that best practice experience and treatment, whether they transition into a residential program or to outpatient.

Dr. David Streem: Bottom line is that when people experience an alcohol use disorder, they experience a loss of control over their use. So what that looks like is, I went to an event or some situation, and I wasn't planning on drinking and I ended up drinking, or I went to a situation and I planned on drinking this much, and I ended up drinking this much. So anytime that seems out of control and people lose control of their drinking, that's a sign that there's a problem. And then when they have consequences related to their drinking, whether they be family, health, legal, job, and they don't change their behavior based on those consequences, then that's another sign that there's a problem that's developing.

Nada Youssef:   So if you're having two drinks a day, let's say, it is not a problem, only unless you can't control yourself and the amount of drink.

Dr. David Streem: Well, I think daily drinking, depending on the amounts, and depending on the genetics and everything, can become a problem in and of itself. But a lot of times, what we deal with is people who say, "Well, I can't possibly have a drinking problem because I don't drink every day." Well, okay, so every time you drank, maybe you didn't get into trouble. But every time you did get into trouble, had you been drinking?

Nada Youssef:   Right.

Dr. David Streem: And that's, again, a way that we help people to think differently about how this condition may manifest in their lives.

Nada Youssef:   Sure. And that brings me to the next question, which is binge drinking. Can we talk about what that is and why it's a problem?

Dr. David Streem: So the National Institutes of Health defines binge drinking as basically drinking that leads a person to predictably have a blood alcohol level over 80, which is usually the legal limit for driving. In men, that looks like five standard drinks over the space of two hours. In women, that's about four standard drinks, because women absorb alcohol a little bit more efficiently. Now, these are standard drinks which are measured very precisely by the National Institutes of Health. That's 12 ounce beer, five ounce of wine, or an ounce and a half of what most people would call hard liquor. And the thing to watch out for is that wine measurement, because usually people don't measure wine.

Nada Youssef:   Yeah.

Dr. David Streem: And if you go into a restaurant and you order a glass of wine, you'll get generally a larger pour than five ounces. So it can be difficult to keep track of and think about how many drinks I'm actually consuming, and does that meet a heavy drinking or a binge drinking amount?

Nada Youssef:   Do you find that usually the restaurants are giving us more than five ounces in these nice big wine glasses?

Dr. David Streem: Yes, in the U.S., we like big wine glasses, and restaurants generally will give generous pours, and it's important to realize that it probably looks smaller than it really is.

Nada Youssef:   Sure. And then I want to talk about why identifying addiction is a complicated process because, going back to like addiction, drug addiction, there's no single face of addiction, right?

Dr. David Streem: Mm-hmm (affirmative).

Nada Youssef:   Many people think of a poor inner city teenager when they picture a heroin addict, but that's not the case, correct?

Dr. David Streem: Oh, no, no. Right now are our biggest problems, and the most common problems that we're seeing are suburban or rural people anywhere from 18 to 50 years old. And those are the highest numbers that are susceptible to overdose as well. So people come to us for all sorts of reasons. Sometimes they come to us because they're genuinely concerned about their substance intake, whether it be drugs like heroin, cocaine, stimulants, or alcohol, or other substances that have made their way into the markets, and that's a constantly changing part of this is sort of keeping track of whether the latest things that people are finding and coming in contact with. But then also people come in because they've been arrested, they have a legal problem, they are having problems with their parents, their spouse, their job, their finances, all sorts of things like that. Sometimes they're coming in because they have a new medical problem that they realize is related to their substance use, and they never had that before.

Dr. David Streem: So there's all sorts of reasons why people come to treatment, and our job is to meet people where they are, and understand, and help the patients to understand what's the real truth of, you may have thought that you were in control of this, were you really? Let's maybe test that theory a little bit and see what we come up with, and see the situation as it truly is, not how people would like to see it. Nobody wants to see themselves as ill in any way, right?

Nada Youssef:   Right.

Dr. David Streem: So no one wants to feel that they have a new medical problem, and sometimes, you know, they need a little help to understand and see it for what it is. And I think that's particularly true with addiction just because it does take so many forms that it can sometimes be difficult to see when you're right up close to it.

Nada Youssef:   Sure. And you mentioned a lot of problems that people may have before coming to you. But are there signs of addiction, whether it's drug addiction or alcohol addiction that maybe our viewers or listeners can know about?

Dr. David Streem: Well, I think the most important thing is that issue of loss of control, and that loss of control and the behavior continues despite consequences. So as the consequences rack up, we want to ask ourselves, "Okay, is this enough? Would this be enough for most people to change their behavior? Oh, boy, I should never do that again." So if people are continuing to rack up increasingly serious consequences, and yet their behavior doesn't change, more than anything else that often boils it down. But I think everyone can imagine that how that manifests in an individual person can be totally different from one person to the next.

Nada Youssef:   Sure. And just a reminder for our viewers or listeners, if you don't want to ask questions via chat on the comment section there, you can do a private message to our Cleveland Clinic Facebook Messenger, and we will make sure that it's anonymous, and we'll ask it out loud without your name being said.

Nada Youssef:   So I want to talk about addictive personalities. When someone says they have an addictive personality, they're most likely going to ... Does that really play a role in all of this?

Dr. David Streem: Well, so a lot of people use that term, and I actually don't think there is such a thing as an addictive personality. So let's think about what do people mean when they say that? And what I hear when I hear people describe that is, this is a person that if they come in contact with even a relatively small amount of a potentially habit forming substance, let's say, alcohol, that things spin out of control quickly. They tend to use more than other people use right away, and there's no moderation right away, there's no long, slow development of tolerance. These folks are drinking excessively or using excessively right away. And I actually don't think that's a personality trait. I think what we are seeing when we use that phrase, is someone with a genetic predisposition to the disease of addiction.

Dr. David Streem: We know that when folks have those specific genetic markers, they're more likely to be able to tolerate, let's say, alcohol, right out of the gate, right from the first drink better than most people, which means they end drinking more than most people. The kind of things that most people feel, feeling drowsy, feeling dizzy that cause people to say, "You know what, I think I've had enough," in folks with these genetic predispositions, they tend to continue to consume the drug, and that can create other problems. So when I hear that term, addictive personality, what I usually think is this is someone with a genetic predisposition to addiction.

Nada Youssef:   Okay. So how can you tell if someone has a genetic predisposition? Is that something that you would check for just for someone just to be careful, like as a preventive measure? Or is that kind of crazy?

Dr. David Streem: No, not at all. Look, the only way for sure to eliminate the possibility that someone could develop a problem with a particular drug, let's say alcohol, is to never drink. If you never come in contact with the substance, it's pretty impossible to develop a problem with it. There are lots of fancy tests that are in development and that are marketed for different types of genetic problems, but I find the best genetic test to do is to ask patients, "Tell me about your family. Do you have a strong family history of addiction?" And for a lot of folks who have some knowledge about what their family of origin is like, that tells me everything I need to know.

Nada Youssef:   Okay, so let me ask you this. If, let's say, my parents don't smoke, but then I end up smoking, or the opposite, parents are smoking, does that mean ... We're talking about cigarettes, because nicotine is a drug, and it's very addictive. So if your parents are smoking, does that mean, genetically, you're most likely going to end up smoking as well?

Dr. David Streem: Well, not if you never start. And so that initial exposure that triggers a lot of these genetic changes is very important. But it's also important not just to ask about parents, but grandparents, brothers and sisters, uncles, aunts and kids, because addiction, particularly alcoholism, does often skip generations, not because the genetic skip, but because people have an experience. If you grow up and your parents had alcohol problems, very often, people will decide, "You know what, I'm not going to take the risk, I'm going to never drink."

Nada Youssef:   It's like a turn off, yeah.

Dr. David Streem: And so then their children don't have the experience of the parents drinking excessively and all the problems if that occurs, and they didn't grow up maybe with grandma and grandpa in the home. So then, what happens is the grandchildren decide to try it, and then the genetics takes over.

Nada Youssef:   I see.

Dr. David Streem: Now, one of the most frightening things about the genetic drivers of this, is if you look at the animal models, you can develop animal models of mice who are addicted to all sorts of drugs of abuse. And if they're addicted, and they know the substance is in a particular spot, that's dangerous. Let's say there's the sounds of cats meowing, or the smell of cats in the room, some other predator, where every ounce of self preservation instinct of that little creature says, "Don't go in there-

Nada Youssef:   Don't do it.

Dr. David Streem: ... it's too dangerous." Their addiction will override that, okay? And they'll run into that room. That's not a character flaw. That's a very, very powerful drive that even an animal that is very interested in their own self preservation can't resist.

Nada Youssef:   Now, these drugs are changing the chemicals in your brain, correct?

Dr. David Streem: Mm-hmm (affirmative).

Nada Youssef:   And that's another big part of it.

Dr. David Streem: Yes.

Nada Youssef:   I want to talk a little bit about addiction versus dependence. Are they the same thing? Are they different?

Dr. David Streem: Well, so we've used several different terms in the field to describe what we're talking about. And dependence .... Right now, the official name of, let's say, an alcohol problem that we would diagnose would be alcohol use disorder, that replaces the term alcohol dependence. And I think using the term dependence was a very unfortunate decision. It created a lot of confusion in the public. It made a lot of people in the public think, "Well, I shouldn't be dependent on anything." Well, diabetics who need insulin, need insulin. People with emphysema or other breathing problems who need oxygen are dependent on oxygen. People who have blood pressure problems might be dependent on blood pressure medicine. So we ended up having a situation where people were a little bit overly concerned about stopping those things and struggling with the things that they needed to function every day.

Nada Youssef:   Sure.

Dr. David Streem: And of course, none of these things are addictive. So I think the change in getting away from the word dependence is a good thing, and I'm glad that they did that. Of course, we want to use language that's not stigmatizing, that's not disempowering, or shaming, but we need a diagnosis. So right now that substance use disorder, I will use the term addiction from time to time because that's also very present in the literature. But the key thing is to help people understand what has happened to me? What has happened to my brain? What has happened to my life? And how do I get things back on track?

Nada Youssef:   Sure. Okay, and before I go to my next question, I do have some live questions here, so I'm going to ask them. I have Melissa, "If someone drinks two glasses of wine at night, then a bottle each weekend nights, would they be addicted? I don't think they have ever been in trouble."

Dr. David Streem: So I think that's one of the things that we're going to look at. If we were to ask that question in an assessment is, what sort of evidence of trouble is there? Have there been any consequences? Are there changes in the liver enzymes? Is there evidence of changes in the liver? Some of that depends on the amount of time that a person's been engaging that behavior. Obviously the risks are higher if someone's been doing that for 50 years as opposed to one year. But, again, genetics play a role, too. And so we see patients who've been drinking alcoholically for maybe 10 years, and they have a big problem with liver failure. And we see other people who've been drinking alcoholically for a lot longer than that, and they have other problems related to their alcoholism, but their liver functions and everything look okay.

Dr. David Streem: And so we're always looking at that in a very individual basis. And then we're also looking at not just medical terms, but things like how's your relationship with the family? How's your relationship with your significant other, kids, parents, job? All those sorts of things. And so all of it comes through together. And then lastly, is there any evidence of loss of control? And so we're going to ask all of those questions and use a lot of ... We do like to use some scientifically validated questionnaires that patients fill out that help us to say, "Okay, based on what we know about the general population and how most people fill out this questionnaire, it's less likely that you have an alcohol problem, or it's more likely."

Nada Youssef:   Okay, great. And then I have Jen, "How can I tell if someone I know is an alcoholic or drinking too much." I talked about it a little bit earlier.

Dr. David Streem: Yeah, ultimately, it's about loss of control. And also, one of the things I would ask is, has anyone sat down with this person and said, "You know what, I'm concerned about your drinking."? And is that something that has a significant impact on their drinking behavior? They decide, "You know what, I agree with you, I think I've been drinking too much and we need to make a change." And if that change occurs, not just temporarily, but something that happens over a long period of time where they're able to be more careful and more moderate in their drinking, then that may be a good sign. Again, if they have a strong family history, that's a troubling thing, because again, the genetics is a very difficult thing to fight against.

Dr. David Streem: What we want to get away from, or at least pay attention to, is the idea of cutting down people with alcoholism problems can sometimes cut down for a little while, but then things spin out of control quickly. And the other thing to keep in mind is rules. So people who have a problem will sometimes develop quite rigid rules, I'm never drinking at home, I'm never drinking out, I'm never drinking this particular type of liquor, I'm never drinking with this particular person, all those very particular rules. People who don't have a problem, don't need to make rules to maintain control and stay mindful of how much they're drinking. So when rules like that start coming into the picture, that's another concerning thing as well because that's not normal to have to make rules about your drinking drink.

Nada Youssef:   Your drinking. Okay, great. That's a very good point. I want to talk about treatments for addiction. What treatments are essential for a successful recovery?

Dr. David Streem: So we think about four things. We think about a really solid medical and psychiatric assessment. A lot of times folks have untreated, undiagnosed, or not successfully treated psychiatric or medical problems. And we know that if we don't appropriately and effectively treat those, that's going to affect how people do, they're not going to do as well.

Nada Youssef:   Hmm, right.

Dr. David Streem: So assessment is a really important. Best practice medical treatment. And there are a number of best practice guidelines that are out there that lay out in very clear terms, what treatments are evidence based, and we definitely follow that. And then there's group therapy, there's therapy in general. Most of that therapy in our program happens in a group setting. In most programs, treatment settings, we know that people do best in the group setting, and there are a whole bunch of reasons for that. A lot of times when people are successful in the first three months or so of treatment, if they have a psychiatric condition that would benefit from individual therapy, we'll move them from the group to individual therapy at that time. And then lastly, self-help, which usually, especially in Northeast Ohio, means Alcoholics Anonymous, or some other 12-step-based program. Akron is a 20-minute drive from here, and it's the epicenter and the place where AA founded.

Dr. David Streem: So we have a tremendous 12-step tradition in Northeast Ohio, and the patients who come to treatment here really get the benefit of a very rich history, and great community engagement, and acceptance of 12-step-based program. So we definitely want patients to have an experience in 12-step work. If they decide that some other type of mutual help or self-help organization is right for them, after they're done with our primary treatment program, and they've had good exposure initially, hey, beyond that, whatever works, right?

Nada Youssef:   Right. Exactly.

Dr. David Streem: But a lot of folks do get a lot of benefit, and there's a lot of research actually that says that people who engage in true 12-step recovery work and become part of the fellowship, do well.

Nada Youssef:   Excellent. Now, I want to ask you, if someone is struggling with addiction, should they go to rehab if their surroundings contribute to their addiction, if their willpower is a big factor in recovery, just like you said, family members, maybe they're around it a lot? Are those the patients you would say, you should go to rehab? Or what do you think?

Dr. David Streem: Well, environment is a very important consideration. So in our outpatient programs, people are generally going home, to a home environment of some sort. And if that environment does not support their health, then that's going to really undermine our efforts in treatment. So sometimes we will talk about changing that environment to really give people the best chance of doing well. Sometimes that means going out of town, or going away from home in some way, shape or form. And that's all part of the consideration of how do we address all of this person's needs? And environmental can be one of the challenges that we identify. And then, what do we need to do to set them up for success rather than setting them up for failure? Probably the best example of that, that most people can understand, is if you have a couple that lives in a home together and they both smoke, and one person tries to quit smoking, the success rate of that is really not good. It's really hard. It's not impossible, but it's really hard.

Dr. David Streem: So you can imagine changing environment would really help that person who wants to try to quit smoking. Things are going to go a lot better if there are no ashtrays around, no cigarettes around, the smell of cigarettes is not in all the textiles and the clothing and everything. And we want our patients to succeed.

Nada Youssef:   Sure, great. All right, well, let's go to some more live questions. I have Christophe, "Can you explain how to get off opioids?"

Dr. David Streem: So there are some very excellent treatment guidelines, which is what we follow. The essence of opiate use disorder treatment is a combination of all the things that we mentioned. And the number one thing in that list that seems to have one of the most profound, if not the most profound impact on outcomes, is medication assisted treatment. So there are three types of medication assisted treatment that are available, that's buprenorphine, methadone, and naltrexone. And we know that overall from start to finish, methadone and buprenorphine do the best. Depending on the situation, if patients can get through the first two to four weeks on naltrexone, they do really well after that. So it's important to us to offer best practice treatment that yields the best effects.

Dr. David Streem: In Northeast Ohio, we had almost 800 people die of opiate overdoses last year, we're going to have a little less this year, maybe 5% less, which is better than last year, but it's still worse than the year before. So we still have a major problem with opiate use disorder and opiate overdose, and we know that abstinence based treatment is the outcomes, and the success rates of that are, again, it's not impossible, but it's a really tough road to go.

Nada Youssef:   Sure. And then I have Mitchell, "What can be done if past attempts at alcohol rehab treatments have not worked?"

Dr. David Streem: Measuring treatment success is so important, and it's a tough subject. First of all, I do see a lot of patients who have been through treatment before. The average person has been through treatment five to six times before they establish more than a couple years of sobriety. This is a chronic relapsing-remitting disease, relapse is part of the condition. However, I'm always looking for, are there things that we could do that could be better? Is this someone that maybe went to five meetings a week, got their coexisting panic attacks treated, but they never got medication assisted treatment for their alcoholism? And so adding that might help improve how they do and their outcomes down the road. So a lot of times there are things that have been missed that could be better and that can improve people's chances of success.

Dr. David Streem: The other thing to remember is that, again, that people learn things in treatment. So when we say we went through treatment and treatment failed, what do we mean by that? A lot of times, people do learn a lot in treatment, and they might think at the end of their treatment program that they know enough to be, and they have all the skills and the tools to be sober for the rest of their lives. And then when they leave treatment, they find out, well, I learned some things, but I didn't learn everything that I needed to know. I know a gentleman who's been sober 35 years. He went through treatment five times. And he will tell you that he learned something in treatment every time, and all five times were important. But if you only look at his drug use as the metric to decide whether the treatment was a success or a failure, you would say he had four failed treatments and one successful one. And he would say, that's a complete mischaracterization of all of his treatments. They were all important.

Dr. David Streem: One of the things that I find interesting in my work is trying to figure out, how do we measure, how do we say for sure, how do we demonstrate, what did he learn in those first four treatments? What was accomplished and how do we identify that, so we don't just call those treatments failures?

Nada Youssef:   Sure.

Dr. David Streem: Because I can see why people would think that, but it's really more nuanced than that.

Nada Youssef:   And just like you mentioned, he's learned something from every single time he's been there.

Dr. David Streem: Yes.

Nada Youssef:   Yeah.

Dr. David Streem: And of course, he spent about 20 of those years running his own treatment program, which is a testament to how well he has learned a lot of these skills.

Nada Youssef:   That's fascinating. All right, and I have Samia, "Are all drugs addictive? What makes them addictive?"

Dr. David Streem: That's a great question. What is common about drugs of abuse? Drugs of abuse do all kinds of things. Some of them raise blood pressure, some of them lower blood pressure. Some of them raise heart rate, some of them lower rate. Some of them will make us feel more alert, some of them will make us feel drowsy. So what do they all have in common? They all cause this huge release of dopamine into this part of the brain that deals with what is relevant, what is important in our surrounding. Some people would call it the reward center. It's a little bit more than just a reward center, but let me take a moment to explain what I mean.

Dr. David Streem: So when people might see a beautiful sunrise, or they might go home at the end of a busy day and see their baby daughter, let's say, so they see this beautiful thing, this thing that's relevant and important for them. What happens from that is there is a recognition in the brain that this is something important in their lives and in their environment. And a little bit of dopamine gets released into this reward center of the brain that says, "This is an important thing in my life."

Dr. David Streem: Drugs of abuse cause releases of dopamine, hundreds, thousands, tens of thousands sometimes of times as potent. So the amounts of dopamine that get released are huge. And this reward center of the brain can't handle that. It's not designed to deal with that much dopamine, and it has two choices: one to suffer damage, or the other, to become insensitive to dopamine. So it reduces its sensitivity level. And what that means is the next time you go home and you see your baby daughter, it doesn't mean as much, it's not as reinforcing, because that little release a dopamine, the reward center of the brain isn't as sensitive to that.

Dr. David Streem: So over time, what happens is that reward center of the brain becomes less and less sensitive, and the only thing that's capable of stimulating it becomes the drug. And so what that means in the person's world is now the baby, the job well done, the beautiful sunrise, the great workout, all the things that used to be very reinforcing, and important, and give us pleasure, now, none of those things are important anymore. The only thing that's important in the person's surroundings is how do I get the drug, consume the drug, and recover from the effects so that I can get the drug again?

Nada Youssef:   And then you end up taking more of the drug.

Dr. David Streem: Mm-hmm.

Nada Youssef:   Yeah. All right. "Why do only some people get addicted to drugs?"

Dr. David Streem: So a lot of this is based on genetics, and there's been a tremendous amount of work on genetics all over the world, particularly in the U.S., the National Institute on Drug Abuse has identified a whole bunch of genetic factors. Some of this has to do with, again, the genetics that determine the sensitivity of that reward center of the brain. So if you start out with the reward center of the brain being extremely sensitive, even a use of a small amount of a drug is very overwhelming and not pleasurable, and it directs people away from using again. When the addiction center of the brain, when this reward center is less sensitive to start out with, sometimes people find particular drugs of abuse more pleasurable, and a lot of this has to do with the particular genes that people inherit.

Dr. David Streem: Particularly now with the opiate epidemic, it is interesting to me to hear from people who maybe don't have a strong family history of addiction, don't have a personal history of addiction, and they come in contact with oxycodone, or some other prescription opiate that they get for some injury, and they find it very not pleasurable. They get nauseated, they get drowsy, they get dizzy, and I'm never taken that again. And other people, they might have a tooth taken out or something, and they'll get a few oxycodone, or Vicodin, or something, and they will tell you, "I was addicted from the first pill."

Dr. David Streem: The other thing that we've seen a fair amount lately is traumatic brain injuries. So when people either have their own experiences in physical traumas, or perhaps they start using drugs and alcohol, and they have an experience where they sustain a head injury either from car accident or a fall, that can affect their brain ... I mean, both of them can affect their brain function. And if we don't diagnose and try to address those problems, we're not going to have success in our addiction treatment. So it's not a universal thing by any means, but it is very common. And that's why we screen people for trauma with every single admission.

Nada Youssef:   It's good to know. And before I go to her follow up question, I want to ask you, how about like anxiety and depression? A lot of people I could see masking their feelings with alcohol or drugs. Is that also a big factor?

Dr. David Streem: Yes, that's a very common coexisting, co-occurring disorders. And a lot of times, by the time people have come into treatment with us, they've had at least one or two tries at treatment for those underlying problems. Maybe those treatments didn't work because they just weren't right for that individual patient, or maybe because the person was continuing to consume alcohol or drugs, the medication or therapy never had a chance really to work. So we're going to look at that situation and look at the different symptoms that the person has, try to make a good diagnosis again, and provide them with best practice treatment for those conditions.

Nada Youssef:   Okay, great. And then, okay, so we have a followup from Eva, "Can addiction grow out of peer pressure at parties where drugs and alcohol are used for recreational purposes and the purpose of fitting in? In other words, is it a result of bad habits? Can partying and drinking become habitual?"

Dr. David Streem: Well, I think many people struggle with bad habits, and most bad habits don't turn into an addiction problem. Again, addiction is the product of the substance, the genes, and a bunch of other problems. But peer pressure can lead to exposure to substances, and that's where a lot of the genes takeover and the other things takeover. That can be a difficult thing to talk about, particularly with young people. And I meet with a lot of parents who have addiction problems themselves, or maybe they have parents of theirs that have addiction problems, and they come to me and they say, "How do I talk to my child, my teenage child about addiction and our experiences in our family?"

Dr. David Streem: What I say is, "Well, you got to start out with, everybody's different, everybody has their own genetic risk factors. And other people may be able to drink in a controlled way, or use drugs in a controlled way, but we, in our family, generally can't. Things spin out of control quickly. And look at all the experiences your grandfather had, or your grandmother, or your parents, or your aunt and uncle. That's why we don't drink, and we expect you to not drink or use drugs as well. When you see friends or other peers doing those things, you got to remind yourself, you don't know what their family's like, you don't know what their family history is. They might be able to control it. You have different sets of risk factors, and it's important to respect those because they're really powerful."

Nada Youssef:   Sure. And you don't know what you're taking, drugs or alcohol at a party, and that's-

Dr. David Streem: Absolutely.

Nada Youssef:   ... that's probably not a good idea.

Dr. David Streem: That's a particular problem now, pills and powders, boy, there could be anything in them. And even plant material that's smoked, there's a lot of evidence of chemicals being sprayed on that that people find out later it wasn't what they thought it was.

Nada Youssef:   Yeah. Well, we are running out of time. Is there anything else that you want to tell our viewers or listeners? Or I mean, we pretty much covered everything?

Dr. David Streem: Well, recovery is a journey and it can have some bumps in the road, but it doesn't have to. We have a lot of people in our program, many of our volunteers who have been sober a lot of years, and our wonderful beacons of hope for the rest of the people who are starting on that journey. A lot of those volunteers and the folks who've been in recovery a long time are some of the best people I know, and they are tremendous assets to their communities, and we are very lucky to have them. We don't have a person to waste in this world. So it's important that when people have problems like this, that we get them the help they need, best practice, evidence-based, science-based help, so that they can have an opportunity to fulfill their potential. And that's what we do.

Nada Youssef:   Thank you so much for your time and bringing awareness to our audience. It's very important. And to make an appointment with the Alcohol and Drug Recovery Center here at Cleveland Clinic, please call 216-363-2120, and for more information, visit clevelandclinic.org/adrc. And for more health information, make sure you're following us on Facebook, Twitter, Instagram, and Snapchat at ClevelandClinic, just one word. Thank you. We'll see you again next time.

Nada Youssef:   This concludes this Cleveland Clinic Health Essentials podcast. Thank you for listening. Join us again soon.