10/31/17

Mistaken Beliefs About Addiction Relapse

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The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, “Terry Gorski’s Blog”, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

10/27/17

Ability to Choose … Within Limits

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It’s not too difficult to discover where Sam Harris stands on whether or not humans have free will. We unequivocally don’t. “Free will is an illusion.” In a lecture Harris gave for Skeptic Magazine that was based on his book, Free Will, he added that if the scientific community were to publically declare free will to be an illusion, “it would precipitate a culture war.” Science has revealed that we are “biochemical puppets” and “The universe is pulling your strings.”

Free will is an illusion. Our wills are simple not of our own making. Thoughts and intentions emerge from background causes of which we are unaware and over which we exert no conscious control. We do not have the freedom we think we have.

This illusion of free will is based on two false assumptions, according to Harris. The first is that we can behave differently than we did in the past. But since we live in a world of cause and effect, our wills are determined by a long chain of prior causes, “and we’re not responsible for them.” Alternately, what we perceive as free will is the product of chance; and again, we’re not responsible. Or there could be some combination of chance and cause and effect, but still no personal agency. Whichever way we conceive it, free will is an illusion in a world ruled by chance and cause and effect.

The second false assumption is that we are the conscious source of our thoughts and actions. “We presume an authorship over our own thoughts and actions that is illusory.” There is no self, no ego, no soul to generate thoughts and actions, according to Harris. They just emerge in our consciousness. And if we cannot control our thoughts, if we don’t know what our next thought will be until it consciously emerges, where is our free will?

How can we be free as conscious agents, if everything we consciously intend was caused by events in our brain, which we did not intend, and over which we had no control?

Sam Harris is an author, philosopher and neuroscientist who has written several popular books in addition to Free Will. Along with Richard Dawkins, Daniel Dennett and Christopher Hitchens, he has been referred to as one of the “Four Horsemen of New Atheism.” The reference draws on the title of a 2-hour unmoderated discussion between the four that is available here on the website for the Richard Dawkins Foundation for Reason and Science. They discussed the public reaction to some of their books critical of religion, and some common misrepresentations of them and their beliefs.

Harris’s position on free will assumes the universe is a closed system of cause and effect. Since there are no creator gods, everything that now exists is the result of what has come from “a long chain of prior causes.” The theologian Francis Schaeffer referred to the understanding of science that comes from this view of the universe as modern, modern science—science rooted in naturalistic philosophy. The uniformity of natural causes, which is an essential starting point for scientific investigation, must be understood as occurring entirely within the natural order of the universe. Nature is closed to any causal intervention from outside.

There is no Creator; no First Cause. There is only chance or cause and effect. Not only physics, but psychology, social science and human nature must be explained within the confines of this closed system. The biologist and neuroscientist Robert Sapolsky believes that every bit of human behavior has multiple layers of causality. He said what we call “free will” is simply biology that hasn’t been discovered yet. “It’s just another way of stating that we’re biological organisms determined by the physical laws of the universe.” See “Ruling Over Our Genes” for more on Sapolsky.

In Escape From Reason, Schaeffer concluded this materialist unity of all things leaves us afloat on a deterministic sea with no shore. The only way this unity can be achieved is by ruling out freedom. “The result of seeking for a unity on the basis of the uniformity of natural causes in a closed system is that freedom does not exist.” Free will is therefore an illusory cognitive construct.  The nonmaterial mind or soul is also an illusion.

However, Harris and Sapolsky aren’t the only neuroscientists to ever consider the possibility of free will. Harvey McMahon is a staff scientist and group leader at the Medical Research Council Laboratory of Molecular Biology in Cambridge. He is also a member of The Royal Society, the world’s oldest independent scientific academy. Past members of the Society have included Isaac Newton, Albert Einstein and Charles Darwin. Current members include Richard Dawkins and Stephen Hawking.

McMahon discussed free will in: “How Free Is Our Free-Will?” He opened his essay by noting science has provided evidence that free-will may be an illusion. Yet free-will was fundamental to our sense of wellbeing, and underwrote our sense of morality, our judicial system, and our Judeo-Christian faith. “We may not be as free as we would like to think, but within boundaries shaped by our individual histories, our genetics, and our environment we can make decisions that determine our character, relationships and future.”

He noted the paradoxical nature of freedom. For example, if we marry we limit the relationships we will have with others, while at the same time opening up new avenues of freedom from being settled in our choice of partner. This principle, McMahon said, applies to all our choices. We change our future possibilities by the choices we make today. “Thus freedom is not unconstrained choice, for with each choice we limit our freedom, and in so doing shape our environment and ourselves.”

These constraints are from our culture, our relationships, our jobs and our families, and other influences. Added to these is the subconscious working of our brain, processing cues of which we are not aware. “Thus the brain may even be making decisions for us.” Do we really have a choice? Here McMahon acknowledged Harris’ above noted argument (and book), that free-will was an illusion. But rather than an illusion, he thought it better to say it was constrained by many factors.

Free-will, McMahon thought, “is a cognitive concept, involving the mind.” It is the ability to choose deliberately between options. “It cannot be regarded as the opposite of determinism, where events have cause and effect outside human control.” He illustrated what he meant with the following diagram. Free-will only applied to cognitive processes where we use our minds to make choices—in between the two extremes. Although not stated by McMahon, I’d say completely free choice is only possible within the mind of God.

Human free-will is then not completely determined, nor is it completely free. McMahon suggested free-will occurred within the boundaries of predetermined factors, where there was little or no freedom to choose. These factors could be biological or genetic. They could also be family, culture, or environmental factors. See the diagram below.

Within an outer sphere of predetermined boundaries, lies a continuum of interaction between prior free-will and proximal free-will. Prior free-will is where an immediate decision is constrained by past decisions and history. Going to work on a given day is more the result of a past decision than one made when you woke up that day. You can re-assess the decision and not go to work for some reason, “yet the choice does not have to be constantly re-evaluated.” In-the-moment or proximal decisions can be inconsequential, like choosing between tea or coffee, or involve active cognition, as when we weigh our options. “Both of these give a strong sense of free-will in the moment.”

Plasticity refers to the fact that our brains are moldable. “We are constantly learning new information, meeting new people and acquiring new skills, which all require that our brains are ‘plastic’.” New synapses can be formed or existing synapses can be modified or lost. “At a molecular level there can be changes in the expression of various proteins which in turn influence the excitability of a given synapse or circuit.”

The choices we make influence the behavior patterns we develop, which are laid down as neuronal pathways. In turn, these pathways influence other choices. “So in this sense we are masters of our own destiny… all because we have a ‘plastic’ brain (i.e. not completely preprogrammed).” Although there is difficulty in the process, we can change. If we make certain choices repetitively, they lay down neuronal pathways and turn into learned behaviors.

Plasticity is thus key to the possibility of free-will [see the above diagram]. While memories of past experiences may not be completely eradicated, they can be scaled back by the new experiences that occupy our minds as we choose to dwell on other things.

Jeffery Schwartz and Rebecca Gladding coauthored You Are Not Your Brain, a self-help book that applies the principles of neuroplasticity discussed above. Like McMahon, Schwartz and Gladding affirm the reality of the human mind and the existence of free-will. Dr. Schwartz is one of the world’s leading experts in neuroplasticity. You can read more about him and his books on his web page here.

McMahon said the relationship between this conception of free-will and intentionality is complex. To the extent we willfully choose and can foresee certain outcomes, ”we can be held responsible for the outcome.” However, if we could not foresee the potential consequences of decisions, to what extent can we say their outcome was intentional? Furthermore, what about when reason has been suppressed for some reason, or if it has been erroneously applied (if we haven’t reasonably weighed our potential thoughts or actions), and non-intended consequences result.

Despite the caveats, in general each of us is responsible today for what we did yesterday because these were acts of free-will, or actions resulting from an absence of self-control. The responsibility for evil can be lessened by considering our circumstances but it never excuses us because at some point in the past we have actively participated in shaping who we are today.

McMahon goes on to describe how he believes our brains and free-will interact with each other. He suggested that while individual neurons do not have free-will, “it is an emergent property of neuronal networks.” He suggested free-will sits upon a tripod of past memories, present inputs (combined with the ability to compute and learn) and future predictions and aspirations within the plasticity of the brain.

There is more to read and think about in his article. McMahon also shares his thoughts on how God constrains us and yet frees us. He wrestles with the question of whether free-will is compatible with divine sovereignty. Read more on how he applies the above discussion to this theological dilemma. His conclusions are worth repeating here.

With the above in mind the following definition of free-will can be offered: Free-will is the ability to choose intentionally within limits placed by a sovereign God, with resulting human responsibility. Free-will is not the opposite of determinism: one can have free-will within the limits set by determinism. Indeed our relationships and our decisions are not absolutely predetermined, and this is a reflection of the freedom given to us by being made in the image of God. So, we have the best of both worlds, where we have freedom to make decisions and yet our personal future and that of the world are secure.

The above understanding of free-will indicates we are less free than we may like to think we are at any given moment, because of prior decisions and predetermined factors. And while neuroscience hasn’t extinguished free-will, it does help us see why we do the things we do. So we are not biochemical puppets, but biology constrains us. “We are not determined by our past, but certainly influenced by it.”

10/20/17

Beginning of the End?

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According to David Meade, September 23, 2017 was a momentous day—the day that the prophecies written in chapter 12 of the book of Revelation will be evident. He said the world itself was not ending then, but the world as we know it will end. There was to be a series of catastrophic events over the course of weeks afterwards. “A major part of the world will not be the same the beginning of October.” … Still waiting … Anything happening yet?

As The Washington Post noted, the pregnant woman described in the twelfth chapter of Revelation was to appear in the sky on September 23rd. On her head will be a crown of twelve stars. She’ll be clothed with the sun; the moon will be under her feet. The woman represents the constellation Virgo, which will be “clothed in sunlight” and positioned over the moon and under nine stars and three planets. The planet Jupiter will emerge from Virgo, “as though she is giving birth.”

But then Meade revised his prediction, saying that while there were major signs in the skies on September 23rd, but the most important date of the millennium was October 15th, 2017—which would be the beginning of the world’s destruction, the beginning of a seven-year period of tribulation. On his website, Meade wrote: “Hold on and watch — wait until the middle of October and I don’t believe you’ll be disappointed.” You could buy and read his book, but he warned, “You don’t have long to read it.”

Before Meade there was Harold Camping, who predicted the end of the world twice. The first time was supposed to happen between September 15th and 27th, 1994. The second prediction by Camping said it was supposed to happen in 2011. On May 21, 2011, at 6 pm local time, the Rapture and Judgment Day was to take place. Then on October 21, 2011 would be the end of the world. He would later write that while his statements were incorrect and sinful, they allowed God to get the attention of a great many people who otherwise would not have paid attention. “Even as God used sinful Balaam to accomplish His purposes, so He used our sin to accomplish His purpose of making the whole world acquainted with the Bible.”

Meade and Camping are examples of a repeated mistake made by Christians when they fail to read and interpret the visionary texts of the Bible correctly. They often confuse or misinterpret two related visionary genres, prophecy and apocalypse. In How to Read the Bible as Literature, Leland Ryken described visionary literature as picturing setting, characters and events in an imaginary context as opposed to ordinary, empirical reality. This, however, does not mean that the visionary literature of the Bible is pure fantasy.

Visionary literature pictures settings, characters, and events that differ from ordinary reality. This is not to say that the things described in visionary literature did not happen in past history or will not happen in future history. But it does mean that the things as pictured by the writer exist in the imagination, not in empirical reality.

Neither prophecy nor apocalypse is entirely visionary; nor are they necessarily futuristic in their orientation. But they will transform the known world or the present state of things into an imagined reality. “In one way or another, visionary literature takes us to a strange world where ordinary rules of reality no longer prevail.” Ryken said the simplest form of this kind of transformation is to give a futuristic picture of the changed fortunes of a person or group or nation. The motifs of transformation and reversal in visionary literature mean that when interpreting it, the reader needs to be “ready for the reversal of ordinary reality.”

There are several elements or themes within Biblical visionary literature that form its otherness that must be cautiously read and interpreted. There is the portrayal of a transcendental or supernatural world, usually of heaven. This transcendence primarily takes the reader beyond the visible, spatial world and not forward in time. The scope of Biblical visionary literature is cosmic rather than localized. There are supernatural, fantastic agents and creatures. Inanimate objects and forces of nature become actors in the visionary drama.

In the strange and frequently surrealistic world of visionary literature, virtually any aspect of creation can become a participant in the ongoing drama of God’s judgments and redemption. It is a world where a river can overflow a nation (Isaiah 8:5-8), where a branch can build a temple (Zechariah 6:12) and a ram ‘s horn can grow to the sky and knock stars to the ground (Daniel 8:9-10).

The strangeness of such writing leads to a related rule for reading it: visionary literature is a form of fantasy literature in which readers use their imaginations to picture unfamiliar scenes and agents. And the reader must remember that the vision is an imagined reality—different than ordinary, empirical reality. “The best introduction to such visionary literature in the bible is other fantasy literature, such as the Narnia stories of C. S. Lewis.”

The purpose of visionary literature is to break through our normal way of thinking and shock us into seeing that things are not as they appear. The world may not continue on as it is now; there is something wrong with the status quo; or reality cannot be confined to what we can see with our senses. This element of the unexpected extends even into the structure of visionary literature. It has brief, shifting units. There is a range of diverse literary material in the Biblical visionary texts. There can be visual descriptions, dialogues, monologues, brief narrative segments, letters, prayers, hymns, or parables. Visionary elements may be mixed with realistic scenes and events. “Instead of looking for the smooth flow of narrative, be prepared for a disjointed series of diverse, self-contained units.”

There is more that could be said, but this gives us a sense of what constitutes visionary literature in the Bible. Now back to Meade and his prophesied end of the world. He is taking an explicitly apocalyptic text, Revelation 12, and treating it as if it were a prophetic text.  There are specific features of apocalypse that distinguishes it from its literary cousin, prophecy. The Biblical scholar Leon Morris summarized the features found in apocalyptic literature as follows:

  • The vision or revelation is of the secret things of God, inaccessible to normal human knowledge. There are secrets of nature, of heaven, of history of the end.
  • Pseudonymy
  • History is rewritten as prophecy
  • There is a determinism in history ending in cosmic cataclysm, which will establish God’s rule.
  • Dualism (good and evil).
  • Pessimism about God’s saving rule in the present.
  • Bizarre and wild symbols denote historical movements or events.

Apocalyptic is a rather loose category, meaning that texts designated as such won’t always share all the same features. Revelation, for example is not pseudonymous. And the book of Revelation often modifies the apocalyptic features it does have. The golden age for apocalyptic literature was roughly between 200 BC and 400 AD. It is primarily found in Jewish and early Christian texts. Some examples include: Assumption of Moses, 1-2-3 Enoch, 2-3 Baruch, 4 Ezra, Apocalypse of Peter, Apocalypse of Paul, Apocalypse of Thomas, and Ascension of Isaiah. Within the Bible, the following show some features of apocalyptic literature: Numbers 23-24 (Balaam’s oracles), Daniel, Ezekiel, Isaiah 24-27, 1 Thessalonians 4-5, 2 Thessalonians 1-2, the Olivet Discourse (Matt. 24; Mark 13; Luke 21), Revelation. Some scholars would also add parts of Zechariah. With these particular in mind, here is how another Biblical scholar, J. J. Collins, defined apocalypse:

A genre of revelatory literature with a narrative framework, in which a revelation is mediated by an otherworldly being to a human recipient, disclosing a transcendent reality which is both temporal, insofar as it envisages eschatological salvation, and spatial insofar as it involves another, supernatural world.

Now let’s turn to the text of Revelation 12 used by Meade in his prediction that October 15th, 2017 would initiate a seven-year period of tribulation, resulting in the destruction of the world. Here is a four-minute YouTube video by Unsealed that illustrates how Meade and other Christians believe September 23rd represents a spiritual sign of the ending of the “Church Age.” On his website, Meade said: “We’re all watching for the September 23 Sign because we know it means the end of the ‘Church Age.’  That is a spiritual sign only.  But it is huge.” Now compare the video to the following verses in Revelation 12 that it interprets.

And a great sign appeared in heaven: a woman clothed with the sun, with the moon under her feet, and on her head a crown of twelve stars. She was pregnant and was crying out in birth pains and the agony of giving birth. And another sign appeared in heaven: behold, a great red dragon, with seven heads and ten horns, and on his heads seven diadems. His tail swept down a third of the stars of heaven and cast them to the earth. And the dragon stood before the woman who was about to give birth, so that when she bore her child he might devour it. She gave birth to a male child, one who is to rule all the nations with a rod of iron, but her child was caught up to God and to his throne. (Revelation 12:1-5)

This passage in chapter 12 of Revelation is one visionary unit in a series of visions give to John by an angel (Revelation 1:1). After the letters to the seven churches, which represent the Church universal, John looked up and saw a door open in heaven (Revelation 4:1). Then came a series of visions including the throne room in heaven. The scroll and the Lamb, the seven seals, the 144,000 of Israel, the seven trumpets, the angel and the little scroll, the two witnesses, and more. At the sound of the seventh trumpet, the twenty-four elders worshiped God. Then God’s temple in heaven opened to reveal “the ark of his covenant.”

The context of Revelation has many of the characteristics of apocalyptic literature. There is a vision framed within a narrative. It’s mediated by an angel to John, and discloses a series of scenes of what is happening in heaven. Chapter 12 describes the conflict between good and evil; the pregnant woman and the dragon. There was the symbolic representation of the encounter of the woman and the dragon; and what happened afterwards.

Revelation 12:1-5 is a condensed retelling of the story of the gospel using apocalyptic. There will be enmity between the seed of the woman and the serpent. In pain she will bring forth children (Genesis 3:15-16). Jesus is that seed, and the verse in Genesis 3 has been traditionally identified as the protoevangelium—the first gospel. Satan intended to “devour” him, but failed. Jesus was caught up—by God—to his throne at his ascension (Acts 1:9-11). A final clue that the passage is not a prophetic foretelling of a future time to John, namely the September 23, 2017 initiation of the end of the church age, is the parallel here to the Greek myth about the birth of Apollo. Gordon Fee, in his commentary on Revelation related the following.

It is important for the modern reader to know that the whole scene is a common one in ancient mythology as well; thus the first readers of this book, mostly Gentile converts in the province of Asia, could hardly have missed here an echo of the well-known myth from their own history. In that myth about the birth of Apollo to Leto, wife of Zeus, the dragon Python hoped to slay the child (Apollo) but he was protected by Poseidon. When grown Apollo then slew the dragon. But whatever the coincidences that may exist between that myth and the essential Christian story, John’s imagery has effected its total transformation into the basic (historical) story of Christ, who through his cross and resurrection thus defeated the dragon. At the same time, the astute biblical reader will see something of a replay, but in a radically new way, of the scene in the Garden of Eden in Genesis 3; but now the woman withstands the snake, and her child is rescued by God, who also protects the woman in “the wilderness.”

The interpretation of Biblical apocalyptic literature is fraught the dangers of misunderstanding and misinterpretation, as Harold Camping discovered and hopefully David Meade will himself acknowledge. In his own apocalyptic narrative in the Olivet Discourse of Matthew 24, Jesus said: no one knows the time of his return and the end of the age; not even the angels in heaven, nor the Son, but the Father only (Matthew 24:36). Not even David Meade knows.

10/17/17

Tell It Like It Is

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Recently I saw one of the ubiquitous “ask your doctor if … is right for you” commercials for Rexulti. The slick 90-second ad tells you that when Rexulti is added to your antidepressant, it has been shown to reduce symptoms of depression. The smiley faces used by the actors illustrate how: “Even when you’re taking an antidepressant, you may still be struggling with depression.” You learn that 2 out of 3 people taking an antidepressant may experience unresolved symptoms of depression; and that antidepressants can cause unusual changes in behavior, worsening depression and thought of suicide, especially in those 24 and younger. But you never learn that Rexulti is not an antidepressant.

The commercial never claims Rexulti is an antidepressant, but it clearly leads its viewers in that direction. Counter intuitively, in order to make the case for using Rexulti, it not-so-subtly tells you that antidepressants alone aren’t always effective, since 67% of people taking them have “unresolved symptoms” of depression. But then you learn Rexulti has been shown to reduce symptoms of depression when it is added to an antidepressant. The message is that Rexulti is effective relieving symptoms of depression. But let’s deconstruct what the commercial is telling you even further.

In the mix of the marketing rhetoric, you hear a litany of possible adverse medication side effects. The initial side effects are found with antidepressants: there could be unusual changes in behavior, worsening depression, even thoughts of suicide. “Antidepressants can increase these in those 24 and younger.” This information is legitimately about the side effects from antidepressant medications. See “Antidepressant Misuse Disorder” and “Antidepressants: Their Ineffectiveness and Risks” on this website.

Actually, Rexulti is an atypical antipsychotic or neuroleptic; in the same drug class as Abilify, Zyprexa, Seroquel and Risperdal. The other described side effects and warnings in the commercial are commonly found with atypical antipsychotics. See “Adverse Effects of Antipsychotic Medications” by Muench and Hamer for further information.

Looking further, the commercial said: “Elderly dementia patients taking Rexulti have an increased risk of death or stroke.” Antipsychotics were being used to control behavior problems in elderly patients with dementia. Then research demonstrated there was an increased risk of death in the elderly patients given antipsychotics. So the FDA issued a black box warning to that effect. There was also evidence that antidepressants increased the risk of stroke with elderly patients, thus the Rexulti warning. See “Seniors and Antipsychotics” and “Stroke Risk in Elderly Treated with Antipsychotics” for more information on this.

“Uncontrollable muscle movements” in the commercial is likely referring to tardive dyskinesia, a serious and potentially permanent neurological side effect from antipsychotics. The risks for developing metabolic syndrome (high blood pressure, high blood sugar, excess body fat at the waist, and abnormal cholesterol levels) are mentioned as well. Tardive dyskinesia and metabolic syndrome are widely acknowledged as potential adverse effects from antipsychotics, but not antidepressants. Try “Blind Spots with Antipsychotics,” Part 1 and Part 2 for a discussion on metabolic syndrome and other side effects from antipsychotics. Stiff muscles, confusion, and high fever are symptoms of “a possible life threatening condition” known as Neuroleptic Malignant Syndrome (See “Neuroleptic Malignant Syndrome”).

So you wouldn’t know Rexulti was an atypical antipsychotic or neuroleptic drug from listening to the commercial unless you knew the above were typical side effects with that class of drug. And you may not even discover this from reading the required Medication Guide, unless you knew what to look for. The FDA’s highlights of prescribing information for Rexulti, all 38 pages worth, does have a more complete discussion of the warnings and precautions as well as the adverse reactions. And Rexulti is referred to there as an atypical antipsychotic. However, in the shorter, two page medication guide, that is made available to individuals filling a prescription for Rexulti, there is no explicit reference to it being an atypical antipsychotic or neuroleptic.

The Rexulti Medication Guide does describe tardive dyskinesia, “problems with your metabolism” and Neuroleptic Malignant Syndrome as possible side effects, which are all potential side effects from antipsychotic or neuroleptic medications. But the only place in the medication guide that the word “antipsychotics” is used is in the section “What should I tell my healthcare provider before taking Rexulti?” There, the medication guide advised that if you become pregnant while taking Rexulti, you should “talk to your healthcare provider” about registering with the National Pregnancy Registry for Atypical Antipsychotics. The only place in the Rexulti medication guide the word “neuroleptic” in mentioned is when it notes how Neuroleptic Malignant Syndrome is a possible side effect.

This rhetorical sleight-of-hand is also present in the medication guides for three other antipsychotics approved by the FDA as adjunct medications for depression. Aripiprazole (Abilify), Olanzapine (Zyprexa) and Quetiapine (Seroquel) all use the same descriptive technique of avoiding reference to the drugs as antipsychotics or neuroleptics in their medication guides. And several have an extended discussion of information on antidepressants. Again, someone not familiar with the medications might think they are taking an antidepressant rather than an antipsychotic medication.

The rational for this would appear to be because the initial market for antipsychotics, treating schizophrenia, is limited. Atypical antipsychotics are now the largest-selling class of drugs in the U.S. with more than $14.6 billion in annual sales for 2014. They also are the class of psychiatric drugs with the most side effects. See “Wolves in Sheep’s Clothing” and “Abilify in Denial” for more on these observations.

Another piece of information about Rexulti in contrast to the other antipsychotics approved as adjunct medications for depression is that it is the only one still on patent. Rexulti patents don’t expire until February of 2027 Abilify, Zyprexa, and Seroquel have all been approved as generics.  So Otsuka Pharmaceutical Company Ltd. has the potential for much greater profits from Resulti over the next ten years than the generic pharmaceutical companies have for the off-patent atypical antipsychotics.

There seems to be a general trend when discussing psychiatric medications to avoid any reference to them as atypical antipsychotics or neuroleptics. You can even see this in the FDA press release for the approval of Rexulti in July of 2015. This means a consumer looking for information on the potential adverse effects from an atypical antipsychotic may have some difficulty finding and then understanding what the risk is for them to take the drug.

For clarity’s sake, I think the FDA should require all consumer medication guides to clearly identify the drug class for approved psychiatric medications. They should also direct a patient to where they can find a more complete discussion of the potential adverse effects of the medication than what is contained within the brief summary of the medication guide. Confusing discussions of depression, its symptoms and the side effects from antidepressants included in antipsychotic medication guides should be clarified or removed entirely by the FDA. Additionally, there should be a truth in advertising requirement that tells it like it is for all psychiatric drug advertisements. An antipsychotic by any other name is still an antipsychotic and the commercials should say so.

10/10/17

Rejecting God in Addiction

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The Bible affirms that every human being has a sense of what is right or wrong. There are moral absolutes which God has clearly revealed, and which we know, regardless of whether or not we live our lives in obedience to his will. There are no circumstances in which a person can ultimately say, “I didn’t know that was wrong.” We all have a moral compass. It is with this moral compass that the alcoholic does his “searching and fearless” moral inventory in Step Four. We are without excuse and cannot deny culpability for our actions before God. Even in our rebellion, God has seen fit for us to know His will. God’s judgment was to give Adam and Eve what they wanted: knowledge of right and wrong independent of God’s revelation.

In The Abolition of Man, C. S. Lewis affirmed the reality of the doctrine of objective value, which is the belief that certain attitudes towards the universe and ourselves are really true, and others really false. Lewis referred to this conception of objective truth in all of its forms, as the Tao; a term he borrowed from Chinese thought. Other conceptions of what he calls the Tao in Western thought are: Natural Law, Traditional Morality, and the First Principles of Practical Reason. This doctrine of objective truth is also found in nonWestern thinking.

In Hindu thought, conformity to Rta (righteousness, correctness, and order found in nature) is human conduct that can be called good. The Chinese of course speak of the Tao, which is the greatest thing; the Way in which the universe goes on; the Way in which every person should walk in imitation of the cosmic order, conforming all activity to that great exemplar. The Navajo spiritual/religious concept of hózhó seems to be their conception of the Tao as a spiritually based, balanced lifestyle. Hózhó means to live in beauty; to observe the Navajo philosophy or religion of living and interacting with the world around you so that your life has beauty, balance, calm, and stability. To be out of hózhó is to be “sinful” to a traditional Navajo.

This Tao is not just one among a series of possible systems of value. “It is the sole source of all value judgments.” If rejected, all value is rejected. Lewis said that in the history of the world, there never has been—nor will there be—a radically new judgment of value. The logic here is that if the pursuit of scientific knowledge is a real objective value that proceeds from God’s general revelation, then conjugal fidelity, self control in sobriety and other “objective values” are points on God’s moral compass in his special revelation, the Bible. This sense of a moral compass lies at the heart of the downward spiral of sinful, unmanageable behavior specified in the following passage from Romans:

And since they did not see fit to acknowledge God, God gave them up to a debased mind to do what ought not to be done. They were filled with all manner of unrighteousness, evil, covetousness, malice. They are full of envy, murder, strife, deceit, maliciousness. They are gossips, slanderers, haters of God, insolent, haughty, boastful, inventors of evil, disobedient to parents, foolish, faithless, heartless, ruthless. Though they know God’s decree that those who practice such things deserve to die, they not only do them but give approval to those who practice them. (Romans 1:28-32)

Once again in Romans 1:28 Paul said: “God gave them up”, using the same Greek verb tense to communicate past completed action as he did in verses 24 and 26. First note the intensification of the repeated judgment by God. Then notice that “impurity, dishonoring their bodies among themselves, dishonorable passions and doing what ought not to be done” are all consequences of failing to acknowledge God (Romans 1:21).

v. 24 God gave them up (in the lusts of their hearts) to impurity, to the dishonoring of their bodies among themselves.v. 26 God gave them up to dishonorable passions.v. 28 God gave them up (to a debased mind) to do what ought not to be done.

The passage reiterates the “root and fruit” association of heart (or mind) and behavior evident in verse 24. Out of the overflow of the heart, the mouth speaks. Or in this case, they did what ought not to be done. As a result of failing to acknowledge God, and being given over to a debased mind, they were filled with all types of sinful desire. As Robert Mounce said in his commentary on Romans, “When people turn from God, the path leads inevitably downward into degeneracy.”

There is a subtle change in the Greek grammar of the passage that helps to distinguish the wrath of God in giving them up to a debased mind from the sin that came as a result of their debased mind. In essence, the verses say that God gave them up to a debased mind, filling them with unrighteousness, evil, covetousness and malice. As a result, they did what ought not to be done: envy, murder, strife, deceit, and maliciousness. This downward spiral of sin has a root and fruit, heart and behavior pattern: sinful behavior is inescapably influenced by a debased heart and mind.

The unrestrained nature of this downward spiral of sin is illustrated with a further litany of sins from gossiping to ruthlessness. For the most part, they are rarely used terms in Biblical Greek, again intensifying the sense in which it seems that sinful behavior gushes out from a debased heart. The summary here reads like a checklist of character defects for individuals preparing to complete their “searching and fearless moral inventory” in the Fourth Step.

Perhaps the most damning assessment of unrighteous is saved for last. Despite the whirlwind of sin that comes from God giving them up to a debased mind, they still know that these vices are worthy of God’s judgment; they are still capable of recognizing right from wrong. Even in the depths of their depravity, they know their sin and its consequences. What can be known about God is still plain to them (verse 1:19). Yet they encourage others to engage in the same cycle of sin and judgment. They know that by their actions they suppress the truth of God to their eternal damnation; and yet they still encourage others to do the same.

We are not only bent on damning ourselves, but we recruit others to follow in our footsteps.  As John Murray said in his commentary on Romans: “Iniquity is most aggravated when it meets with no inhibition from the disapproval of others and where there is collective, undissenting approbation [endorsement].” So the gathering of heavy drinkers to watch a football game and get drunk; the licentiousness of an out-of-control bachelor party; and an opioid addict shooting up a friend for the first time all find their condemnation here.

I’m struck by the strong parallels in this passage of Scripture to the heart attitudes and unmanageable behavior of active addiction. Beginning with verse 18, the wrath of God is revealed against the ungodliness and unrighteousness of people who deny (suppress) the truth by their unrighteous behavior. The order of the terms ungodliness and unrighteousness has some significance here, as moral decay (in alcoholism and addiction) follows from the rejection (denial) of God. In the chapter “We Agnostics” of the book Alcoholics Anonymous, Bill W. wrote: “When we became alcoholics, crushed by a self-imposed crisis we could not postpone or evade, we had to fearlessly face the proposition that either God is everything or else He is nothing. God either is, or He isn’t. . . . Do I now believe, or am I even willing to believe, that there is a Power greater than myself?”

God has revealed His divinity in creation. Unrighteous (addictive) behavior suppresses this truth and seeks to be like God. Ernest Kurtz wrote that “the fundamental and first message of Alcoholics Anonymous to its members is that they are not infinite, not absolute, not God.” Every alcoholic’s problem begins with wanting God-like powers, especially the ability to control their drinking. But an alcoholic cannot control their drinking. At some point in their addictive career, they experience a loss of control over thoughts, feelings and behavior when they drink. Eventually they lose control over the act of drinking itself and will deny or minimize their inability to control it.

Craig Nakken, in The Addictive Personality, suggested that much of an addict’s mental obsession resulted from refusing to recognize the loss of control they experience. Denial, suppressing the truth of the addict’s inability to control their drug or alcohol use, is thus a fundamental part of addiction. Alcoholics Anonymous saw denial as the fundamental symptom and deep core of alcoholism. It is the initial issue addressed by the First Step: “We admitted that we were powerless over alcohol [addiction]-that our lives had become unmanageable.”

Recognizing this denial is then an essential part of recovery; failure to do so means that the addict becomes futile in their belief that they can control their drug use. Their foolish hearts are darkened to the reality of addiction. Alcohol or drugs become their God. The basic text of N.A., Narcotics Anonymous, simply says: “Isolation and denial of our addiction kept us moving along this downhill path. Any hope of getting better disappeared.”

God gives him what he wants; He gives the addict up to the lust of his heart and to a debased mind; to do what ought not to be done; to pursue the false god of his addiction. He is filled with all manner of unrighteousness, evil, covetousness and malice. He is and does everything noted in verses 1:29-31. This litany of consequences provides a summary of the unmanageability present in the life of the addict and alcoholic. He becomes hopeless and helpless as a result of his rejection of God (ungodliness) and the addictive behavior that results. His only hope is in the God he rejected from the beginning.

If you’re interested, more articles from this series can be found under the link for “The Romans Road of Recovery.” “A Common Spiritual Path” (01) and “The Romans Road of Recovery” (02) will introduce this series of articles. If you began by reading one that came from the middle or the end of the series, try reading them before reading others. Follow the numerical listing of the articles (i.e., 01, 02, etc.), if you want to read them in the order they were originally written. This article is “05,” the fifth one in the series. Enjoy.

10/6/17

Is Ketamine Really Safe & Non-Toxic?

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An article in The Morning Call, a newspaper for Allentown and the Lehigh Valley area of Pennsylvania, announced that a local company, the Lehigh Center for Clinical Research, would be conducting clinical trials for two pharmaceutical companies to gain FDA approval for modified versions of ketamine as a treatment for depression. The psychiatrist running the trials said the drugs could hit the market in the next few years. He said: “It’s exciting and promising but I think we have to wait to see it used in the widespread population to know whether it’ll be safe and non-toxic.” I thought the safety and toxicity of a new drug was supposed to be assessed BEFORE the FDA approved its release into the wider population.

There have been waves of excitement and concern over the past few years about the development and use of ketamine and ketamine-like drugs to treat depression. Ketamine has been an FDA approved medication since 1970, where it was used as an anesthetic in the Vietnam War. It is classified as a Schedule III Controlled Substance by the DEA, meaning it has a potential for moderate to low dependence or high psychological dependence. Ketamine is also a recreational drug known as Special K because of its dissociative properties. “Due to the detached, dreamlike state it creates, where the user finds it difficult to move, ketamine has been used as a ‘date-rape’ drug.” See: “Falling Down the K-Hole” and “Family Likeness in Depression Drugs?”

The excitement over ketamine, as a treatment for depression, centers on its rapid relief of depressive symptoms; sometimes within hours of it being administered. But the effects fade rapidly and require frequent, repeated treatments. Currently ketamine is administered intravenously, similar to its use as an anesthetic. There is an intranasal spray version (Esketamine) in the works. See: “Psychedelic Depression,” Ketamine to the Rescue?,” and Ketamine Desperation.”

The clinical trails being done by the Lehigh Center for Clinical Research would appear to be for Esketamine, by Janssen Research and Development, and Rapastinel, by Allergan. While Esketamine is a nasal spray, Rapastinel is administered by weekly IV injections. Both are currently in Phase 3 clinical trials. This involves randomized, double blind testing in several hundred to several thousand patients. Upon successful completion of their Phase 3 trials, a pharmaceutical company can request FDA approval for marketing their drug. Somewhere around 70 to 80 percent of drugs that make it to Phase 3 are eventually approved.

Although Esketamine and Rapastinel are similar to ketamine in several ways, they are still distinct NMEs (new molecular entities), patented by their respective pharmaceutical companies. Ketamine was first developed in the 1960s and has been off patent for decades, meaning there is no profit in Pharma companies pursuing ketamine-based treatment for depression. But since ketamine is an FDA approved drug, it can be used off label to treat depression. And there are a growing number of ketamine treatment facilities around the U.S. and Canada that do just that.

Earlier in 2017 All Things Considered on NPR featured a story on the off-label use of ketamine to treat depression, “Ketamine for Severe Depression.” Psychiatrist Gerard Sanacora said over 3,000 patients have treated at dozens of clinics with ketamine for depression. He has personally treated hundreds of people with low dose ketamine. Sanacora said when he is asked how he can offer it to people on the limited amount of available information and without knowing the potential long-term risk, he responds “How do you not offer this treatment” to individuals likely to injure or kill themselves, who have unsuccessfully tried the standard treatments?

Sanacora and others authored “A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders” that was published in JAMA Psychiatry in April of 2017. They noted how several smaller studies have demonstrated the ability for ketamine “to produce rapid and robust antidepressants effects in patients with mood and anxiety disorders that were previously resistant to treatment.” It also cautioned that while ketamine may be beneficial to some patients, “it is important to consider the limitations of the available data and the potential risk associated with the drug when considering the treatment option.”

Zorumski and Conway published “Use of Ketamine in Clinical Practice” in the May 2017 issue of JAMA Psychiatry. They also noted the increasing evidence from small studies that ketamine has rapid antidepressant effects in patients with treatment-resistant depression. They commented how ketamine is having a major effect on psychiatry. “If clinical studies continue to support the antidepressant efficacy of ketamine, psychiatry could enter an era in which drug infusions and deliveries with more rapid responses become common.” They indicated the cautions of Sanacora et al. were noteworthy and should be emphasized.

Because of the limited data to guide clinical practice, these limitations extend to almost every recommendation in the consensus statement, including, perhaps most importantly, patient selection. The bulk of the literature describes the effects of ketamine in patients with treatment-refractory major depression. The definition of treatment-refractory major depression and where treatments such as ketamine fall in the algorithm for managing treatment-refractory depression remain poorly understood. . . . It is unclear whether patients with depression that is not treatment-refractory or patients with other psychiatric illnesses are appropriate candidates for ketamine treatment, and extreme caution must be exercised in patients with psychotic or substance use disorders.

So then comes the Short et al. study in the journal Lancet Psychiatry in July 2017, “Side Effects Associated with Ketamine Use in Depression.” It was the first systematic review of the safety of ketamine in the treatment of depression. After searching MEDLINE, PubMed, PsycINFO, and Cochrane Databases, they identified 60 out of 288 articles that met their inclusion criteria. “Our findings suggest a selective reporting bias with limited assessment of long-term use and safety and after repeated dosing, despite these being reported in other patient groups exposed to ketamine (eg, those with chronic pain) and in recreational users.”

Science Daily reported that the lead author for the study said there were major gaps in the research literature that should be addressed before ketamine was widely used as a clinical treatment for depression. “Despite growing interest in ketamine as an antidepressant, and some preliminary findings suggesting its rapid-acting efficacy, to date this has not been effectively explored over the long term and after repeated dosing.” Given that ketamine will likely involve multiple, repeated doses over an extended time period, “it is crucial to determine whether the potential side effects outweigh the benefits to ensure it is safe for this purpose.”

Commenting on the Short et el. Study for Mad in America, Peter Simons also noted the expressed concern with the selective reporting bias and a limited assessment of long-tem use and safety after repeated dosing. Researchers are generally careful to report safety and side effect data on studies of ketamine used recreationally or for chronic pain. However, depression research tended to ignore the safety and side effect concerns with ketamine, often not reporting such issues at all.  “Most people receiving ketamine had acute side effects.” Studies that did report adverse events said that after acute dosing, patients in ketamine treatment reported more frequent side effects.

Common side effects led a number of patients to withdraw from the study. Suicidal thoughts were common and there was one suicide attempt reported. Previously reported potential long-term adverse effects from ketamine include: urinary tract problems, liver toxicity, ulcerative cystitis, neurocognitive deficits and memory problems, and dependence or addiction. Some of the many additional side effects that were reported included:

 

  • Worsening mood
  • Anxiety
  • Emotional blunting
  • Psychosis
  • Thought disorders
  • Dissociation
  • Depersonalization
  • Hallucinations
  • Increased blood pressure
  • Increased heart rate
  • Decreased blood pressure
  • Decreased heart rate
  • Heart palpitations/arrhythmia
  • Chest pain
  • Headaches
  • Dizziness
  • Unsteadiness
  • Confusion
  • Memory loss
  • Cognitive impairment
  • Blurred vision
  • Insomnia
  • Nausea
  • Fatigue
  • Crying/tearfulness

Because of the extensive list of potential adverse effects, as well as the unknown possibility for harm from long-term use, the authors of Short et al. recommended large-scale clinical trials with multiple doses of ketamine. Long-term follow up to assess the safety of long-term regular use was also recommended. “As it stands, the safety of ketamine treatment for depression is unknown—and that is largely due to inadequate and biased reporting of safety issues.”

I hope that these concerns are seriously considered and factored into the FDA’s assessment process for approving Esketamine and Rapastinel. Otherwise, the real safety and toxicity assessment of these drugs will be done on the first wave of depression sufferers prescribed the new drugs for treatment-resistant depression. Given the short length of clinical trials, the long-term effectiveness and impact on a patient’s quality of life, including potential misuse of the drugs, will not be clear  for either Esketamine or Repastinel until Phase 4 Post Marketing Surveillance Trials are completed … after the drugs are on the market. Will they live up to their therapeutic promise or become another example of the Pharma patent medicine show?