IamA I'm Dr. David Sack an addiction psychiatrist. AMA about substance-abuse on campus! AMA!

Ever have a really weird (not odd) case, and did your research help you where you are now or not?

People present with a lot of issues that are not clear when you first meet them. Psychiatry still relies on the clinical history more than anything else to make a diagnosis. We don't have specific reliable tests we can use to tell what's causing a problem. If you continue to work with someone a lot of these issues become clearer over time.

What motivated you to become an addiction psychiatrist, and then focus on addiction?

Like many who go into psychiatry, there is a family story. Depression in my grandmother and severe anxiety in mother made me more aware of other people's emotions. That, and I like talking to people and seeing them change.

How would you suggest someone approach abstinence from marijuana for a couple months? I have a medical card from my state, which allows me to legally purchase and consume marijuana for medical purposes (in my case: anxiety and depression)?

My company was recently bought and we need to pass a drug test as a result of our new employers. They don't give a flying fuck that I benefit from weed. Instead, I'll be chewing on (prescribed) Klonopin like they're candies.

We live in interesting time when a drug is simultaneously illegal at a federal level and an accepted treatment under state statutes. There are many better treatments for chronic anxiety that the Klonopin you are chewing down. The best way for someone like yourself to manage their anxiety and depression without using marijuana is to work closely with a psychiatrist who specializes in treating these conditions.

What are the biggest obstacles to overcome in keeping these nationwide network of addiction and mental health treatment centers running?

Most centers operate independently and many are run by people whose primary experience was overcoming their own addiction. This makes it challenging to implement new treatments and ideas since operators and owners may not be aligned with the research and academic communities. At Elements we have worked hard to embrace and values of our employees, our clients and their families while striving to continuously innovate and improve treatment.

What does the research suggest about the link (if any) between alcohol binging behaviors on college and alcoholism later in life?

Not everyone who binges becomes an alcoholic, but heavy social drinkers are more likely to develop alcoholism down the road and binging itself causes a number of problems. Binging episodes have been linked to memory impairment. This is thought to occur because brain glutamate levels become elevated during the binge (to counteract the effects of alcohol) and are toxic as the alcohol wears off. Most cases of alcohol poisoning occur in college age adults who are not regular drinkers and therefore have not built up tolerance to the effects of alcohol. Safety related activities - driving and machinery - are clearly affected by binge activity.

Do you have an opinion on addiction to things that are NOT actually substances? It looks like you primarily treat drug addictions, but I hear all the time about addictions to gambling, pornography, shopping, etc. Are these actual addictions, and how do they differ/coincide with substance addictions? Thank you!

This is an area of debate but I agree with the American Society of Addiction Medicine definition of addiction that says that it is a disorder of the brain's reward circuitry and related areas. Drugs are just one way in which these centers are overstimulated. Gambling, pornography and shopping all are associated with increased dopamine activity in the nucleus accumbens, reward central in the brain.

Work has really been stressing me out, to the point where I have made myself physically sick to my stomach. There doesn’t seem to be any way to unload any work on anyone else. I have tried therapy as well as anti depressants. What should I do?

Your problem is all too common. I would start with have a heart to heart conversation with your supervisor. It is their responsibility to help manage/balance your work load. Bringing temp help, paying others to work overtime are ways they could lighten the load.

If that doesn't work you may need to speak with you physician about putting you out on disability until you can get your stress under control. Of course, this is only a temporary solution if you have to go back to the same job and nothing has changed there.

I think at that point therapy to help you set your priorities and figure out whether you need to find another job may be helpful.

What are the trends in drug use on campus? Is it going up or down? And which drugs are most popular these days?

Drug use in nearly all categories is going up on campuses and this appears to be part of a long term trend. Marijuana (perhaps due to legalization and medical usage), alcohol and opiates are leading the charge. Adderall (amphetamine/dexamphetamine) continues to be popular because it is used as both a club drug as well as to pull all nighters.

How hard is it to smoke a cigarette just to try, and never do it again?

Only about 1 in 7 people who try smoking become addicted to nicotine. A family history of cigarette smoking contributes. A great deal of this is genetic but some of it is behavior modeling. Depression and other serious psychiatric disorders also increase the risk of becoming nicotine dependent but we don't fully understand why. Young women sometimes start to smoke to control their weight, while both men and women may start smoking cigarettes to gain social acceptance.

What is your view generally on the use and dangers of marijuana?

Marijuana has been used by many cultures over long periods of time but because it is a schedule I drug, it hasn't been as well researched as many other drugs.The endocannabinoids (the neuropeptides that we make in our brain which marijuana mimics) are involved in regulating many other neurotransmitters that control sleep, appetite, energy, mood, memory and sensory experiences. There is good reason to be concerned that there is much left to be learned about the effects of the many cannabinoids in pot. Research research shows that marijuana can be addicting and that regular users sometimes experience withdrawal when they quit. People who start using marijuana when they are young teens are at greater risk to develop schizophrenia but we don't know what underlies this association.

Are there any new trends in addiction treatment that you find particularly interesting or promising? What are your thoughts on the use of technology to support or improve the delivery of substance use disorder treatment?

We've learned a lot over the last quarter century about how drugs of abuse affect the nervous system but it has been difficult to translate that knowledge into effective treatments. Some of the most promising work today has to do with vaccines for drug addiction that would prevent specific drugs from reaching the brain and causing a relapse. Vaccines are being tested for cocaine, heroin and nicotine but they are not close to being approved by the FDA.

In your opinion, what are the main causes for substance abuse on college campuses, and what can be done by colleges, and law makers to cut down on it's prevalence?

Drug experimentation peaks between adolescence and young adulthood and substance use on college campuses reflect that trend. The stress of separating from home and finding one's own identity plays a role. Needing to assert freedom from parental oversight, leads to more drug use. Then, there is the notion of the 'outlaw', the young adult who defies cultural norms in a quest for a superior lifestyle or enlightenment. Drugs somehow get entwined and romanticized in that 'quest'. There are lots of other reasons, disinhibition of sex, social anxiety, and peer acceptance to name a few.

One more question: My friends at the school I'm going to really like to get wasted. I've just never been attracted to the stuff -- drugs or alcohol. They love that I can be the designated driver, but I worry that I'm just helping them have problems and get themselves in trouble. Whenever I say anything, they laugh me off. But I'm pretty sure at least a couple of them are alcoholics. And I've seen all of them do things they really regret later. How can I actually get through to them about the risks they are taking in a way they might actually listen to? Or should I just shut up and let them make their mistakes and learn the hard way.

People change their drug use when they see it as being more of a problem than a help. When people use a lot they often wind up in situations they regret or where they are injured. You can help your friends by trying to have a conversation with them (when they are sober) about the things they like and don't like about what happens to them when they get high.

Are study drugs safe or not? More important, do they actually work?

I am not sure what you mean by study drugs but I will assume that you mean drugs that are being investigated for clinical use in research trials sanctioned by the FDA. In general we know much less about the safety of these medications in humans that meds that have been in long term use (>5 years). This is because only a limited amount of safety testing has to be done before a drug can enter the clinical stage of investigation. Some infrequent side effects can take years to come to light. We will always know more about the safety of older drugs than newer drugs, but we will always need new drugs since there are many people who don't respond to the treatments we have.

I was referring to drugs that people use/abuse to help them study longer, such as adderall.

Stimulants like the amphetamine salts in Adderall improve short term cognitive performance - concentration, attention, memory. Over time people develop tolerance to these effects and the benefits are limited. This benefit is limited to lower doses, with higher doses often have an opposite effect, causing restlessness and distractibility. There is always a price to pay in terms of insomnia, weight loss, irritability and rebound poor concentration when amphetamines or other stimulants are used regularly.

I heard the drugs Prince died from were counterfeit prescription pills. If you buy prescription pills off the street, is there a way to tell if they’re fake?

The only way to know if a medication is a fake is to send them off for testing. Most over the counter kits will not generally detect synthetic drugs like Fentanyl well. Even if you send it off and it is the real drug, the next batch from the same dealer might be something completely different. We see this with spice where people have hallucinations and convulsions, and OD deaths with Oxycontin and Heroin that's been tainted with fentanyl.

Are you familiar with the Ashton Withdrawal Schedule for Benzodiazepine Use?

I am asking, because I had 2 Withdrawals from Lorazepam. One within 4 Weeks, starting at 10 (sic!) mg, one Ashton style Withdrawal, same starting point but took 1/2 year. I can not express the hell, which the first withdrawal was and how much a lark the Ashton Style Tapering down was. Do you have an opinion on how to best taper down Benzodiazepines?

Slow tapers are generally more successful most clinicians would put 4 weeks into that category. Many clients can have their benzodiazepines reduced but experience more withdrawal again when they try to stop them entirely. Late withdrawal reactions are much more common with benzodiazpines that with alcohol. The taper schedule should not be based on a formula but on what withdrawal symptoms an individual experiences at the dose is decreased.

I am not familiar with her scale but have read much of what is posted on her website. It is well reasoned and clinical sound. Benzodiazepines should not be used for long periods of time but that safely withdrawing from them requires medical supervision.

I don't want to debate the devastating impact of drug use, but f I look around on campus, the most abused substance seems to be the smartphone: whatsapp, facebook, instagram, reddit, pokemon. It alters the everyday behaviours and mannerisms of a whole generation and impacts not just the quality of their work as students, but their future contribution to society. Their concentration span, reading ability, social skills, and mental maturity seem to suffer from this (though they themselves are probably not really to blame for it).

Could you convince me that this is an alarmist view?

Technology tends to change the ways in which people relate each other but that is not always a bad thing. Thomas Jefferson invented a machine with two pens so he could keep a copy of correspondences, but isn't it much easier to search a 'sent' folder? I believe that part of what we are seeing is that people love to communicate and prefer to communicate with people they know more than the people who are right in front of them. Hence, the popularity of facebook. Is that a good thing or bad thing. Does it make it easier to meet new people or harder.

We don't know enough about how social skills are formed to accurately predict what will happen next but I think we know that life will continue to change just as it did after the telephone became widespread and the news was instantly available on television.

are any of the forms of adaptation to these technological advances in human behaviour in any way similar to habits and behaviour you see in drug addicts?

Some of these behaviors have the compulsive quality of addictions. Video games often seem that way. Online shopping does too but we need to be careful not to assume that similar behaviors have the same underlying mechanism. Avoidance and anxiety can be big factors in some online compulsive behaviors and also contribute to why some people become addicted to drugs or alcohol.

As an alcoholic, I'm having a hard time taking sleeping pills that effects the GABA. Are there any other medicines that works great with people who have sleeping disorders but without triggering the depressants in my head?

I have had tremendous luck with Melatonin. Long term studies show no real tolerance build with prolonged use. I take 3mg an hour before bed and it seems to do the trick. Because it's a natural hormone, side effects are minimal.

If you are asking if this is safe, it is for the most part. Melatonin is the body's chemical signal for night and is involved in the regulation of hormones. Menstrual irregularities have been noted with melatonin and the synthetic melatonin agonist.

Most sleeping medications lose their effectiveness over time and are not that helpful for chronic insomnia. If you have been struggling with this for a long time, it may be worth discussing a sleep polysomnogram (PSG) with you doctor as there may be treatable causes for your insomnia that are people overlooked. Insomnia is a contributing factor when alcoholics relapse so you want to some work into solving this. There are non-addicting medications that do not work directly on GABA that are used with recovering alcoholics. A couple of medications that are often used are the sedating antidepressants like trazadone and doxepin, and the atypical antipsychotic medications in low doses like quitiapine. You should consult with a psychiatrist or addiction specialist about this.

What’s the difference between Molly and ecstasy? Or is there a difference?

Molly is a slang term for methylenedioxymethamphetamine, also known as MDMA or ecstasy. Sometimes other synthetic euphorigenic hallucinogens like bath salts are substituted for MDMA so you don't necessarily get what you paid for.