The Science of Recovery

David Condos: Hey guys, welcome to another episode of Recovery Unscripted, a podcast powered by Foundations Recovery Network. I’m David Condos, and my guest today is Dr. Cardwell Nuckols, an internationally recognized authority in the areas of behavioral medicine and addiction treatment. He sat down with me at the Innovations in Behavioral Healthcare conference in Nashville to share some of his expertise about the science of addiction and the role that brain chemistry has played in the current opioid crisis. Also stick around to the end for more trivia from this week in recovery history. Today’s question highlights the 12 traditions of Alcoholics Anonymous, officially adopted in which year: 1940, 1945 or 1950? Find out after the interview. I’m here with Dr. Cardwell Nuckols. Thank you for being with us today.

Cardwell Nuckols: Hey, my pleasure. You’ve got a great company.

David: [laughs] Thank you. First, let’s have you tell us a little bit about your personal story and how you got started doing what you’re doing in behavioral health care.

Cardwell: Well, it started out for me back in almost mid 70s, I was at Medical College of Virginia and got busted on a drug charge, got kicked out of school and thrown in prison for about nine months and then I found AA. That was 42 years ago. I’ve been in the field for about 40 years and background is more in the medical area and medical research, a pharmacology and a doctorate in psychology and neurobiology. In both area of life, I just bounced around and it all seemed to work out okay.

David: All right, then like you were saying before we started recording you have your own training and consulting company, what led to you starting that?

Cardwell: Well, I worked with a few companies for a while, and I realized that I love to teach and it was something that I really found I had a passion for and I’d been involved over the years in a lot of different treatment programs and some consulting in terms of helping trouble programs or building clinical teams or making a new program. I remember if you remember the mid-80s when we started to have the cocaine problems and actually started in the late 70s, early 80s, and that’s really what got me out into the marketplace because I had a pretty good idea of what to do with cocaine addicts and everybody else was hung up on alcoholics. That allowed me to write some books and speak at a lot of conferences, develop a few programs and from there it just took on this life of its own, I’m just very grateful to God who has been good to me.

David: Was cocaine the drug that you were involved with when you went to jail?

Cardwell: Well, I loved all of them, I tended to like opiates and cocaine a lot and marijuana was a staple back then. It was the late 60s, early 70s, and I was a product of that generation.

David: You had some personal experience with it when you went into the healing side?

Cardwell: Oh sure yes. That probably was where I started with, I understood it, I understood what the drug was all about and what it did to people, then all of a sudden crack yet and everyone was in a panic about that but it was good for me professionally, it was horrible for the country.

David: Now a lot of people to help.

Cardwell: Yes, I hope so.

David: I know one thing you want to talk about was the opioid epidemic. It just seems like it’s on everybody’s mind right now. Could you start by giving us some history and in your view how did the opioid crisis get started?

Cardwell: Well, we’ve always had opioid problems. We’ve always had heroin problems. It’s been there since — well at Civil War we had more opioid addicts than any other time in our country including the Vietnam era but what’s happened in this last 10 to 15 years is we started to see a lot of problems an issue where it’s a pill mill, unscrupulous distribution of large amounts of painkillers to people with no pain problems. What happened is we started to see the overdose deaths rise and about that same time we started to see heroin come back in the market. States really crack down on the prescription stuff and in most states, if you go to a doctors’ office they’ve got all the scheduled drugs that you’ve been given for the last six months.

It’s harder to get them, they were much more expensive out on the street, what happened is that people started to use heroin because it was cheap, it was very high quality and we saw with that the influx of fentanyl and fentanyl analogs, a lot of that were coming in from China and through Mexico, for example, there’s an analog called carfentanyl which is only for veterinary use for large animals. Two milligrams would knock out an elephant. What they started doing was lacing some of the heroin or actually making pills that look like hydrocodone or oxycontin by putting fentanyl and fentanyl analogs in it. Fentanyl is extremely strong drug when compared to heroin, and carfentanyl is 100 times stronger than fentanyl, also some of these drugs are like 10,000 times stronger than morphine if you can conceptualize that, so what we started to see was a rash of overdose deaths.

This is where we are today, even the Center for Disease Control has stated that it’s not the prescription, medication that’s driving the epidemic it’s here on analogues of fentanyl although most people seem to still believe in the news seems to still be pushing the fact that it’s unscrupulous doctors and pain clinics and things like that, that still goes on but it’s no longer the principal driving force behind what we’re seeing out there now.

David: The unscrupulous doctors like you are saying, so that may have contributed to where we are now but it’s moved past that and almost snowballed?

Cardwell: Yes, I think very much so. I was showing at the lunch talk today a vial of heroin and it had a little bit in the bottom, this is about how much it might take to kill you. Then I put a fentanyl only a few grains in the bottle and if you look at carfentanyl, it will be like a piece of salt-

David: You can barely see it?

Cardwell: Yes, it’s that potent, it’s really a disaster.

David: Why are some of these drugs being laced with such strong carfentanyl like you’re saying? Like I guess just to keep making things stronger and stronger, is that just the natural progression of that drug production then?

Cardwell: Well, money drives it, I don’t like to place a lot of blame on anyone one person or country but we’re seeing an awful lot of this stuff coming in through Mexico and to our ports, it’s coming from China. They actually busted a delivery into Canada of a pill press and then you make your own pills. It’s big business but if you’re lacing the heroin with something stronger giving it a little bit more pop, that’s a weird thing about addicts. If someone says there are three people overdosed on the other side of town, then their mind immediately goes, “Well, that must be some really good stuff, I’ve got to get some of that.” It is a weird economy.

David: It’s a sad thing but if the demand is there then that void will be filled.

Cardwell: Sure.

David: You were saying before we started that Canada even has a more significant per capita opioid crisis than we do, is that right?

Cardwell: Yes, back two years ago for the first time Canada surpassed the United States in terms of per capita pain pill consumption and when you look at the Asian population in the Vancouver area and the west coast of Canada what they’re getting is the same heroin when it was that the Vietnam soldiers guys coming in from Afghanistan and other places and whereas in the west coast, Southwest we’re getting black tar from Mexico and then on the East Coast it’s coming up from South America.

The same routes have been used to smuggle cocaine and other things for years and years. There’s a whole lot of different ways we’re seeing it but regardless it’s only these days pretty inexpensive and very powerful, it’s not like the 70s. The Vietnam veterans coming home after deployment couldn’t hardly get high on the heroin on the street is under 4% something like that. But now we’re seeing some very potent stuff on the street and it’s often laced with other things, the consumer just doesn’t know what they’re getting.

David: That’s part of why it can be so dangerous.

Cardwell: Yes. Well, I talk to heroin addicts and a lot of them will say well we’re trying to know the dealer, we don’t want fentanyl, we don’t want to see other stuff we’re just one heroin but it’s the quality control on the street is just not there.

David: With the dire situation that you just described, in your view, what can we do to stem this tide?

Cardwell: Well, that’s always the question. Of course, there’s interdiction trying to keep it out of the country, but that’s never going to be really successful. I think we’ve got to learn to treat it much more effectively than we have. One of the things that I notice with the opiate addicts is that a good half of them or more have really life developmental trauma, they come from non-enriched environments. If you think about something like heroin or any opiate, one of the things it does, it causes disassociation. I don’t experience fear, anger, negative emotions. I don’t feel anxious. It stimulates endorphins in the body and that’s the same chemical that makes a little child feel warm and cared for and fed.

It gets you away from negative feelings. You feel warm and fed and in control. At the same time, it doesn’t screw you up too bad cognitively, so if you do work, you can function fairly well on it unless you take too much. On top of that, I think you get the dopamaine and the reward center of the brain and you get high. There’s a whole lot of things that happen.

David: Especially if you’ve experienced a lot of trauma, that sounds pretty good.

Cardwell: Yes, that sounds great, that’s one of the problems.

David: Another thing I wanted to get into is the presentation that you just gave at the conference about the science of recovery. What do some of these latest neurobiological research items say about how addiction progresses?

Cardwell: Well, we talked about a couple of things in particular. One is genetic risk. There are certain genes that are atypical genes that for example, produce too few dopamine receptors in the reward center. With people who have those types of problems, they often don’t feel as happy as others around them. They may have attention problems, they just don’t feel like they fit in, kind of irritable and discontent. What we’re finding interestingly enough is that if they really get involved in groups and actively participate in groups, we’re seeing that that can form an epigenetic perspective, environmental perspective, solve a lot of those genetic problems. It can actually be helpful to them.

We were talking about a neurotransmitter called glutamate. When a person reaches that point in their addiction where things start to go wrong, the losses build up, maybe late, middle, early chronic stage. Glutamate becomes a driving force. We always knew dopamine was but glutamate is drug seeking. Even if you’re not getting off on the drug very well, when drug seeking kicks in, you run from your mid brain, your sensory brain and all you have to do is just be around people, places and things and you’re gone. You don’t have that top down ability to regulate, to say no, to deal with urges and impulses, to balance the positives and the negatives, which is a lot of what that area behind our eyes allows us to do.

There are things that we’re noticing and things we’re trying to do to changing our educational processes, trying to stimulate pre-frontal growth. I think that a lot of things that we’ve actually taken for granted, like therapeutic relationships, physical exercise, mindfulness, these things can be very helpful in recovery. The opiate problem has been the toughest one we’ve had so far. We just don’t seem to be as successful with them.

But I think there’s ways we can be, I really do. I think we can get a lot better at it. One of the things that has always been there is this issue of treating trauma and early recovery and starting to look at what we can do to be helpful to people who come from those sorts of environments, because a lot of it is they tend to have early life non-enriched environmental problems.

David: Back to the glutamate you were talking about, could you describe a little bit more about how that works, how that drives the impulses or the urges of drug seeking?

Cardwell: Let’s think of it this way. What we said was that as your disease progresses, dopamine and reinforcement and pleasure and all of that, endorphins to some degree driving all of that. Then you’ve reached the late middle stage, maybe we start to see glutamate become a key player. What that does is it knocks the pre-frontal cortex offline. Even if you had a well developed one, like Bill Wilson, he could swear to his wife by family Bible, he was going to change his ways but when he went down in Manhattan and got around the people he drank with and he was drinking whole, he had no top down ability to say no.

What we’re noticing is that some of the effects of glutamate tend to affect the ability of patients in early recovery, especially those first weeks, to be able to learn. They can take the information in but they can’t convert it into, what does that mean in terms of making recovery oriented changes. So we’re trying to do certain things to speed that process up if we can.

Again, there’s people who’ve been looking at medicinal ways of doing that, use of Inositol Cysteine and some other amino acids but I think truly the challenge in the brain and trying to bring it back and the relationships that they have, trying to keep them in some sort of recovery environment for a year or so, to let that brain develop, let it come back.

A lot of people get out of treatment, they’re afraid to go home. If you give them that opportunity to become productive within the environment they got straight in and the support to do it, then you’d grow your own recovery. You got sponsors, you’ve got something, you got an energy, you got a good energy.

David: Just a little bit back about the neurochemistry you were talking about, how does some of the research and the new information that you’re seeing, how does that inform how we might better treat patients, specifically with regard to the opioid crisis right now?

Cardwell: If you look at why people fail, that pretty much tells you what you need to work on. They fail because of non-enriched environments. They fail because of early life trauma. They fail because they have a high degree of neuroticism. For example, in their pain clinics, what we’re seeing is the pain clinic participants who tend to abuse their medicine often, score very high on neuroticism. They have more of a depressed or anxious personality. Being able to treat those sorts of things and just creating the opportunities, it’s people and it’s the environment. Really an enriched environment will make dopamine go up on its own but a very poor environment dopamine goes down, cortisol goes up.

I don’t think it’s rocket science so much as trying to create the systems that allow it. Because you take someone and put them in for 30 days but then send them right back to the environment they come from, that’s not working for a lot of these people. I think that we almost have to create recovering communities. It’s that culture, it’s that environment, that support, that opportunity to grow, maybe find a job, meet some like-minded people. I think as much as anything else, that’s what it is.

I think that one of the things that this younger population, 18, 25, 30 and there, the fit that they have in the adult treatment program, sometimes what we find, the issues are so different. They’ve not held jobs and had families necessarily and other things. Sometimes that brain just isn’t that developed. Some of them come across as 10, 12-year-olds almost, still concrete thinkers. I think that being able to adapt our systems a bit to be able to meet those needs — I’m starting to see people do that around the country now. That might be a very good avenue.

David: These are patients who are legally adults but not developmentally. They don’t fit with the developmental needs of other adult patients.

Cardwell: Yes, they see the world different. As our brains develop, especially in the dorsal lateral pre-frontal cortex, we develop executive functioning ability to plan, to map out that plan, to follow through on that plan, to delay a little gratification. Without those skills sets, without that level of development, it’s like magical thinking. Why am I just not there instead of here? It says a whole bunch about what they need. They need to grow up a little bit and take more responsibility and develop the skills. They need to hope to have a good life.

David: Yes. You’ve served in this industry for a long time, you said since the late ’70s, right?

Cardwell: Yes, about mid-’70s.

David: Mid ’70s? Why would you say that helping people find recovery is important to you?

Cardwell: As an addict, I was a taker. I’d take everything I could get. I was brazen enough to ask you for more. But the 12 Steps — I do a lot of spiritual teaching, I’ve written spiritual books. To me, the discovery that giving it away is the greatest joy there is and to see people who didn’t look like they had much of a chance and you run into them two years later and you see the smile on their face, there something about that that does my heart a lot of good.

David: All right.

Cardwell: I appreciate it, thanks and you folks put a great conference and you really know what you’re doing. I appreciate it. It’s been an honor to be a part of it.

David: All right. Well, thank you for being with us today.

Cardwell: Thank you. You take care now.

David: Thanks again to Dr. Cardwell for joining us today and thank you for staying for another installment of our trivia segment called, This Week in Recovery History. Each time, I’ll share a question that features a different pivotal event from this week in history that has helped shape our current world related to addiction and mental health recovery. Today’s question highlights the 12 traditions of Alcoholics Anonymous which were officially adopted at AA’s first international convention in the year 1950.

As the number of AA group grew throughout the ’40s, so did the number of questions that members were sending to AAs headquarters in New York. Questions about handling disputes, managing finances and defining membership roles. In response to these questions, AA co-founder Bill Wilson formulated the basic ideas that he would then use to write the 12 traditions over the next few years.

In short, the 12 traditions provide guidelines for relationships between 12-Step groups, members, and society at large. Some examples include number three, which says, “The only requirement for AA membership is a desire to stop drinking.” And number 10, which states that AA has no opinion on outside issues hence, the AA name ought never be drawn into public controversy. That’s the 12 traditions of AA, adopted this week in the year 1950.

Stay tuned for more trivia from Recovery History in future episodes. This has been the Recovery Unscripted podcast. Today, we’ve heard from Cardwell Nuckols, author and leading expert on addiction. For more about his work, visit CNuckols.com. And thank you for listening today. If you’ve enjoyed this episode, please pass it along to someone else who might enjoy it as well. We’d love to have your help spreading the word. See you next time.