Inside the brain of a drug user

Psychiatrists say the effect of drugs on the brain could be so damaging as to cause paranoia even months after a person has already stopped using the substance

Jee Y. Geronimo

2:31:51am August 19, 2016

5:18:41am August 19, 2016

READ: Part 1: War on drugs: Rehabilitation must be more than a knee-jerk reaction

MANILA, Philippines – The nightly news nowadays is replete with images of lifeless bodies sprawled on the cold, hard ground, many of them drug suspects killed in police operations.

Police officers have defended the deaths of drug suspects with one word: "nanlaban" (resisted arrest and fought back). 

To date, at least 612 drug suspects have been killed in police operations since the Duterte administration's crackdown on drugs began months ago. 

But according to psychiatrists, the effect of drugs on the brain could be so damaging, it causes paranoia even months after a person has already stopped using the substance. 

"Ngayon, sa practice ko bilang private psychiatrist, ang nakikita ko ngayon is kine-claim ng mga pasyente is mga 2 to 3 months na silang tumigil, pero ang lumalabas ngayon 'yung consequence ng sequelae nung paggamit, so karamihan sa kanila napa-paranoid," Fareda Fatima Flores, president of the Philippine Psychiatric Association (PPA), said in a recent roundtable discussion on the issue.

(Right now, in my practice as a private psychiatrist, what I see now is that patients claim they have already stopped using drugs for 2 to 3 months, but what shows now is the consequences, the sequelae of drug use, so many of them are paranoid.)

"Karamihan sa kanila, ang theme ng paranoia, nandyan na si Duterte and whatsoever, when in fact, pag-test namin, mukhang totoo na 'di na gumagamit," Flores added.

(For most of them, the theme of their paranoia is, Duterte is already there and whatsoever, when in fact when we conduct tests, it's true that they've long stopped using drugs.)

With paranoia, it is "highly possible" for these drug suspects to fight back, according to psychiatrist Benita Sta. Ana-Ponio, a member of the Department of Health and the World Health Organization's task force on drug rehabilitation.

"Even if they have not used a substance for some time, even months, they're still paranoid, and they can act [in a certain way] if they believe they are at risk. It's like defending themselves," Ponio said, agreeing with Flores.

There is no shortage of threats in the President's campaign against drugs, which has so far seen the surrender of at least 576,176 drug suspects. (READ: Rising number of users seeking drug rehab is a 'happy problem' but...)

For instance, in Cebu City 5 days before his inauguration, President Rodrigo Duterte claimed rehabilitation is no longer a viable option for people who are already addicted to shabu.

"If I couldn't convince you to stop, I'll have you killed... if you're into drugs, I'm very sorry. I'll have to apologize to your family because you'll surely get killed," he said back then.

Health Spokersperson Eric Tayag said the President knows what shabu can do.

"I think everybody was surprised….He knows that even if you get into [rehabilitation], many actually will show signs later of the permanent brain damage," he told Rappler in an interview.

Tayag explained: "Unfortunately for shabu, there are no medications that act like an antidote, unlike for heroin and other classes of drugs. This involves counseling, spiritual [development], [and] family support."

But counseling and other behavioral therapies, according to the health department, are critical components of effective treatment for addiction.

What drugs do

Latest statistics from the Dangerous Drugs Board showed that the duration of drug-taking among abusers currently in residential and out-patient facilities is more than 6 years, with many of them poly drug users or abusers of more than one drug.

The drugs or substances of abuse are methamphetamine hydrochloride, cannabis, and inhalants.

Ponio, also the executive director of private psychiatric care and rehabilitation center Metro Psych Facility-Roads and Bridges to Recovery, explained the biological aspect of addiction.

"Mayroong mga binabagong chemical sa utak natin ang drugs, especially if you're going to talk about methamphetamine and cannabis. Iniiba po niya 'yung dami ng tinatawag na neurotransmitters na dopamine sa utak mo. Kung masyado ka nang maraming dopamine, maganda pakiramdam dahil sa drugs, pero 'pag naubos 'yun, hahanapin mo 'yung drugs," she explained.

(Drugs change certain chemicals in our brain, especially if you're going to talk about methamphetamine and cannabis. It changes the amount of dopamine – a neurotransmitter – in your brain. If you have too many dopamine, you feel good because of drugs, but when it runs out, you will start craving it.)

She added: "Mayroon pang ibang chemicals like 'yung glutamate sa brain na nagbibigay ng magandang memorya – ‘Ay ang sarap!'. 'Yung glutamate na 'yun ang magpapaalala sa 'yo nang paulit-ulit na ang sarap at ang ganda ng pakiramdam 'pag nakapag-drugs, so now if it is good, it feels good, and your memory is telling you it is good for you, then nothing else matters."

(There are other chemicals like glutamate in the brain that provide good memory – 'Ah, it feels good!'. That glutamate is what will repeatedly remind you that drugs feel good, so now if it is good, it feels good, and your memory is telling you it is good for you, then nothing else matters.)

These effects on the brain cause those who use drugs to "take all the risks just to get the next hit," Ponio explained.

She also observed that among patients in their clinics, when the addiction starts at a young age of 12 to 14 years old, it worsens once the person reaches his 20s and 30s.

"It is more difficult when that happens because when our brains develop, what develops first is the satiety center, where pleasure and happiness are. If you're exposed to drugs at a young age, and that's the only part of your brain that's well developed, poor you!" Ponio explained in a mix of English and Filipino.

SURRENDER. A Filipino suspected drug user takes his oath taking after voluntarily surrendering in Manila, Philippines, July 15, 2016. File photo by Mark R. Cristino/EPA

SURRENDER. A Filipino suspected drug user takes his oath taking after voluntarily surrendering in Manila, Philippines, July 15, 2016. File photo by Mark R. Cristino/EPA

"Because your logic center, which is the prefrontal area of the brain, is not yet developed, so there's no logic, so by that time that you grow into adulthood, and the brain starts developing the logic, that pleasure has already been incorporated, so it's a difficult problem."

Drugs and mental health

Since drug addiction works that way, Ponio said the country needs a mental health law so that government can prioritize "everything about this problem".

At Roads and Bridges to Recovery, for instance, it is estimated that 80% of the patients in the private drug rehabilitation center are dually diagnosed.

"When I say dually diagnosed, they have both a mental illness – so that's either a mood disorder, a psychotic disorder, or an anxiety disorder – plus the substance use problem. So one or the other aggravates it, that's why usually they are the more difficult ones, they have a lot of behavior consequences, [it's] harder for them to recover," Myra Dee Lopez-Roces, an in-house psychiatrist at the center said.

The health department's Dangerous Drug Abuse Prevention and Treatment Program actually recommends that a drug-abusing individual with co-existing mental disorders should be treated for both disorders "in an integrated way".

The program at Roads and Bridges to Recovery follows the therapeutic community model wherein patients or "trainees" go through 3 phases:

Intensive phase – Patients are restricted from seeing their families. Focus of treatment is on behavior change, so it involves a lot of processes, from mirroring, group therapy, to introspective activities.

Partial reintegration – Patients can go on days off for a certain number of hours per week.

Community reintegration – Patients are expected to function within structures outside the center – whether at school or at a workplace. They only stay at the center twice a week.

On average, it takes 12 months before a patient of Roads and Bridges to Recovery is discharged.

This is also the maximum number of months mandated by Republic Act 9165 or the Comprehensive Dangerous Drugs Act of 2002 for the confinement, treatment, and rehabilitation of a drug dependent in a center.

But the treatment does not stop once the patient leaves a drug rehabilitation center. The health department's aftercare program, which is given for at least 18 months, helps "recovering drug dependents" adapt to everyday community life.

"Aftercare means we will complete what is needed so that there will be good assimilation in the community, providing them work, education. These may be the underlying conditions why they use illicit drugs," Tayag said in a mix of English and Filipino.

Relapse, and the role of community

But much like any other medical condition, relapse is part of substance use disorders. Tayag said the relapse rate in drug rehabilitation centers is at least 20%.

"We don't believe that [killing drug suspects will solve the problem] because we are in the helping profession….We need to help them."

COMMUNITY ACTIVITIES. Drug users in Mandaluyong City attend to their required weekly Zumba class for rehabilitation in Barangay Mabini-J Rizal covered court on July 10, 2016. File photo by Alecs Ongcal/Rappler

At Roads and Bridges to Recovery, Roces said only 47% of patients complete the program, and from that, 32% go through a relapse.

"[Relapse] can happen even several years after [recovery]. And common with them is they don't attend aftercare, there's less family support, or difficulty in adjustment, or maybe just not being able to cope with cravings," Roces explained.

She said it's especially hard for dually-diagnosed patients who have already stopped taking their medications or seeing their doctor.

"So sometimes they deal with depression or anxiety, and then they think [of] drugs as a quick fix, instead of remembering that there are other medications that they can take to relieve those symptoms."

But for Ponio, the relapse won't be "as bad as the previous one" if a drug dependent is given the right intervention at a drug rehabilitation center.

Both family and community have roles to play to help recovering drug dependents. After all, health experts agree that this is not just a criminality problem nor a health problem, but also a societal one.

"Family is very important because it provides emotional, psychological, and well, financial support. A lot of our trainees are dependent on their families. So when taken out of the equation, [patients] feel like they're paralyzed," said Myra Dee Lopez-Roces, in-house psychiatrist of Roads and Bridges to Recovery.

Tayag, meanwhile, highlighted the importance of the government's crackdown on drugs.

"They will get back to their old habit if the clampdown of the [Philippine National Police] will not be serious enough…. It's like this: They went through rehabilitation, but they will only go back to an environment where they can access illicit drugs? That would result in relapse," he said in a mix of English and Filipino.

But for Flores, the fight against drugs doesn't have to be deadly.

"We don't believe that [killing drug suspects will solve the problem] because we are in the helping profession….We need to help them," she said in a mix of English and Filipino.

Still, the threats against drug users seem to be working. Flores recounted that some families now ask rehabilitation centers for a certificate that will prove a patient is undergoing treatment.

"Takot na takot ang mga pamilya ngayon na ilabas ang kanilang mga pasyente. Sabi namin hindi puwede, kasi ang program dictates na kailangan na namin silang subukang [ilabas]."

(The families are very afraid now to bring out their patients. We tell them the patients can't stay in the center because the program dictates that we have to try reintegration into their communities.)

According to the health department, recovery from drug addiction can be a long-term process that may require multiple episodes of treatment.

It is these intricacies and nuances in drug rehabilitation that the police and even the President himself need to consider as they promise to double or triple the efforts against illegal drugs. – Rappler.com

For inquiries on drug rehabilitation, call DOH's Dangerous Drug Abuse Prevention and Treatment Program at 711-0781.