The Difference Between Substance Abuse and Addiction

---

Transcript

Chrissy Billau:

Welcome to Prescribed Listening from the University of Toledo Medical Center. On this podcast, we interview our experts to get the answers you need and can trust. I'm your host, Chrissy Billau.

So many people have been touched or tortured by alcohol or drug abuse, some cases spiraling to addiction. So whether you're the one with the problem or you're a loved one seeing your family become fractured, this episode explores the pain. Substance abuse cases over the course of the pandemic were high, so how do you know if you were a loved one has reached a point to where they're abusing drugs or alcohol, and how can you manage pain without the use of addictive drugs? We are talking with UTMC psychiatrist Dr. Tanvir Singh, about what you should look for in yourself or a loved one and what substance abuse looks like for the person going through it. Dr. Singh, thank you for joining us today.

Dr. Tanvir Singh:

Well, thanks for having me here.

Chrissy Billau:

So right off the bat, how do you define substance abuse?

Dr. Tanvir Singh:

So substance abuse, so it's tricky area because substance abuse is different than addiction. That's where most of the people, they get confused. Addiction is a lack of control over your use. So you could be a substance user but might not have addiction. Actually, 85% of the users, they have not reached a point of addiction. Addiction, you only know when you try to stop using the substance. It's not about using. It's about you don't want to use but still have to use. So it's a lack of control. So like I said, 85 of the people, they have not reached a point of addiction. So that's a window where you can avoid going into the addiction, and that's something which many people they don't really understand.

Chrissy Billau:

So you're using more than you should, say if it's prescription drugs, it's more than you're prescribed, but you're not hooked on it yet. It doesn't control your life.

Dr. Tanvir Singh:

Yeah, it's not just about the control, it's about the choice. So I'll give you an example. So if there is a cocaine user, so he's cutting into cocaine, he's having some problem with it, but then he decides to quit. So you can quit much more likely if that happens early, part of the use. It takes around somewhere close to a year for a cocaine user to lose that control, where there is a difference between the intent and what you're doing.

So say after a year that person wants to quit and really wants to quit. He's losing everything, he's developed health issues, he's lost a job, he's having problem with the. So he's so desperate to quit. But the brain makes it harder for them to quit at that time because persistent use makes changes in the brain. And then it's not just about the intent anymore, and that's what defines addiction. But there is a long window between the use and the addiction, and that's where you can change things. That's where prevention in substance use disorder is the key, because once you reach a point of addiction, then it's a very long, long road to recovery.

Chrissy Billau:

For substance abuse, when it comes to alcohol, it seems a little hazier sometimes. Is it substance abuse if you have a glass of two or wine at night or a few beers at night or a glass of whiskey to wind down?

Dr. Tanvir Singh:

There are a lot of individual variables with alcohol use and even with other substance use. For some people, even two or three drinks could be a lot. And for some, it might not be a lot. But it's again the persistent use, which is the key part. The persistent use, which is reasonably heavy enough, which leads you to go into this free fall. And then it's not even about your choice.

Chrissy Billau:

Over the course of the pandemic, cases were up for substance abuse. Why do you think that was?

Dr. Tanvir Singh:

Okay, so it all comes down to what changes would happen with the pandemic. So the first thing is the social isolation. So your social lines are cut off because socialization become more of a hazard than something which we need, which means the stress levels are going to be high for everyone. And the vulnerable population, who anyway struggle with dealing with stress or have a high baseline stress. Their stress levels obviously going to go off the roof. And whenever our stress levels go off the roof or they're higher, we are more likely to make mistakes. More impulsive tendencies, more lack of judgment, which in way mean more high risk behaviors. So that's the time when people are more vulnerable to go into high risky ways, which could be one trying to cope with the stress. And substance abuse is one of the examples, and that's exactly what we saw with the pandemic.

Chrissy Billau:

Have cases leveled all out or are they still high?

Dr. Tanvir Singh:

They are still high because the stress levels, which were still with pandemic, they haven't really reduced as much because the fabric of the whole society, the way relationships are and everything got messed up during the pandemic. And we are still trying to balance that part. The financial situations of people changed and then we were hit with inflation after the pandemic, which is huge stress levels. Again, especially with a more vulnerable population, people who have struggle in so many ways and then you add more stress. So no, we are still dealing with that pandemic elevation.

Chrissy Billau:

How can you recognize the signs, the symptoms of substance abuse and a family member, for both drugs and alcohol? If it's someone you love, a family member or a friend?

Dr. Tanvir Singh:

So this is such a good question, which again people don't really understand. So I was talking about substance use and addiction. Addiction happens much later. And once you are in the addiction, the structural changes in the brain, when I say addiction, when the intent is not the issue anymore, the behavior has gained so much of strength that it assumes a compulsive and impulsive burden. So you're going to be using it even if you do not want to use it. So that happens after a really long time. And when people are in addiction, they run into the healthcare system. So who sees it when there is only substance use going on and not addiction? That's going to be the people around those people, like family or close friends.

So those are the ones who can play such a huge role in the prevention, which is a key part of trying to reduce the substance use complications. So what happens, the preoccupation. So that's the key thing with substance use. And as it progresses, there is more and more preoccupation. The person is more focused on the use, and then they will start making compromises with other areas of ... Whether it is social part, job part, relationship part, so the preoccupation, when that becomes priority. And it is progressive. So you see that happening. You see that happening, but the family's going to see much more before we are going to see it.

Chrissy Billau:

Do you mean not showing up for work or being distracted at work or if you're at home, someone's pulling away from you?

Dr. Tanvir Singh:

Exactly. And there is a pattern of such behaviors. Excuses, and again excuses. So it's a pattern of behavior which is progressive in nature and family and loved ones are going to see it much, much before these people go into the healthcare system. And even when they go to healthcare system, it's such a difficult road because the addiction has already set in or is close to setting.

Chrissy Billau:

But when you're in the substance abuse area, if you're lucky enough to have a loved one around you who can ... You're in the 85% window that you cannot go off this cliff, we can help you here.

Dr. Tanvir Singh:

Exactly.

Chrissy Billau:

There's a lot of reasons people pull away from things or don't show up. So short of finding the pill bottle or the bottles of whatever liquor, is there anything that's a sign?

Dr. Tanvir Singh:

That's a difficult one. What usually works is engagement. Try to still stay engaged with them, even though you are seeing all those signs and you're seeing those signs just keep on happening. But try to not disengage or not try to use "Got you" approach, but try to still keep that engagement going. Try to keep that conversation going, try to keep that time with that person going.

Chrissy Billau:

So if you don't do the threat of, "If you don't stop doing this, I'm leaving"?

Dr. Tanvir Singh:

It usually does not work. And even if it works, it doesn't work for too long. But there is a denial and distortion at that time. They can have control over their use as far as the function of the brain goes, but they're not ready at that time. And usually, it is ready to something positive they feel they're getting. There are two things, positive reinforcement, which is the relaxing, euphoric kind of effect. And then there's negative reinforcement, especially with people who struggle with other areas like trauma, mental health. They don't feel anxious anymore, they don't feel depressed anymore or they don't get flashbacks anymore. So they're reluctant to make that decision at that time, but that window of opportunity slowly goes away from you. So engagement, I'll give you an example. I'll give you an example with me.

I had a friend who used to drink and drink heavily, but he never thought that it is an issue anymore. So we had this very casual conversation. And what we decided is that he's just going to hold on to his bottles of liquid. He's not going to dispose them off. He's just going to collect it for a month to see how much he's drinking. And he did that. He collected and he had so many bottles that he could hardly find space for it, which made him understand himself that, "Oh my god, so my use has gone so much." And at that time, his brain was still there enough that he could control the use.

Chrissy Billau:

So help them get a little perspective on what you're seeing?

Dr. Tanvir Singh:

It's trying to have them decide on their own, not make it a ego issue or somebody compelling it. Like I said, if you compel them, they'll do it. But they won't do it for too long or they'll just hide it in a more effective way.

Chrissy Billau:

Okay. So if you've identified what looks like abuse in a loved one, there are ways to help with engagement and trying to help them. Are there some right things to say or completely wrong things to say in this moment that might you think it's right, but you're going to hurt them and make them step away?

Dr. Tanvir Singh:

You can talk about their use without being judgmental about it. Alcohol is an example because it's legal. So people are more willing to talk and most of the people, they do drink. But the person who it seems that is having a drinking issue, just having a conversation about the drinking pattern more as a narrative coming from their side, let them talk about it without you making a judgment call, which force people to think about it again. When they're with you, they might not think about it. But once they're alone, they are going to think about it. But if it comes from them, they're more likely to pay more attention and not let it be a control or a ego issue. So we say this, identify this population, which is bulk of the people who might end up having more serious issues, at-risk population. So at-risk population, they can quit and they are capable of quitting. But they'll quit when they have more insight about what's going on. So if you make ego an issue, they're more resistant actually to change.

Chrissy Billau:

Is it an okay thing to say, "Hey, maybe instead of whatever your drink is at night, go for a run", or am I a jerk?

Dr. Tanvir Singh:

No. It's an excellent idea, but the approach which is more likely to work is, "Okay, let's go for a run. Yeah, let's just go for a run." Because when you replace or when you introduce a healthy habit or healthy activity, it is likely to replace the unhealthy one because that's another challenge. Another thing which people need to understand is substance use is very emotional experience. There are emotions associated with it. When you drink or use a substance, it does cause very high emotions. And many people, they think of those emotions as very positive emotions too. So it's like a companion. And then that's the reason the substance use causes more and more preoccupation because you develop this friend, which you create when you use. And even people's socialization, many people who drink more as a social, so actually they're drinking and their companion is alcohol, not the other person.

They hardly even know that person after some time because they're associating through drinking. We call it the relationship of intoxication, because actually the companion is more alcohol rather than the other person. So the question is when you take that companion away. It's going to cause a lot of emptiness, a lot of loneliness, and this is ... Vulnerable people, who they got into this thing because of that vulnerability too. So it's a harder one. But if you introduce, like we was giving an example let's go for a run. So if you introduce a healthy activity, it's much easier to give up that companionship you have with the substance.

Chrissy Billau:

Getting back to real life, after you're on a recovery journey trying to stay sober, in whether it's alcohol or drugs, are there any tips of working back to real life? I'm not talking about addiction. I'm talking about substance abuse at this point.

Dr. Tanvir Singh:

So the focus initially obviously is trying to get away from that pattern of use. But after that, you got to raise your quality of life, raise it even more than an average person has. Because given an example, it's a very emotional experience and the euphoric effect or the relaxing effect, people would look at as a positive emotional experience too. So you got to compete with that experience with a better healthy experience. It's like you have to invest in something which you don't want to lose. So if you raise that quality of experiences, then you don't want to go back to that substance use. It's like you put money in the bank and then you are invested in it. So you don't want to mess it up, which helps you to motivate yourself during difficult times. Because when you are making a change, there is a magnet, especially initially or during your stressful time, is try to pull you back to where you are. So what helps you resist is that money in the bank, which is when you're invested in something much more healthier.

Chrissy Billau:

If someone reaches out for help, can they get in trouble with police at the same time? And where I'm coming from this is when we're talking about drugs, cocaine, any kind of illicit drug or prescription drugs that you've now started going to a dealer to get. If you say, "I have a problem and I need help", are you also going to get in trouble with the police at the same time?

Dr. Tanvir Singh:

No, if you're seeking treatment, you don't get into any legal trouble. There is an extra HIPAA confidentiality codes served with addiction treatment, which are also very protective. So no.

Chrissy Billau:

Can you get addicted if you just try something once?

Dr. Tanvir Singh:

There is a population which is more vulnerable to persistent substance use, even addiction later on. There're genetic reasons in family history or there're individual reasons. So when more and more people are exposed to these substances which have an addiction potential, more likely they're going to hit the more vulnerable one, which might have harder time stopping themselves. So there is a point if more population is exposed, more likely people are going to progress to persistent use or even addiction. So one time use is not going to do anything, but that's not a very healthy choice to make because you could be one of those vulnerable one.

Chrissy Billau:

Is pot addictive?

Dr. Tanvir Singh:

Yeah, pot can be addictive because anything which has an emotional experience attached to it and the persistent use, you can end up losing control over it and it can be addictive. Yeah.

Chrissy Billau:

Is it a gateway drug?

Dr. Tanvir Singh:

Yeah. Pot is considered one of the gateway drugs, [inaudible 00:18:35] smoking, alcohol. And the concept of gateway drug is more applicable with a younger population, the teenage population. And we are seeing more exposure to cannabis because it is used as medical marijuana. So though it's still illegal for the miners, but still it is more available now. So they are more exposed to it. And the gateway drug idea, the concept is that this population is more vulnerable to more hard drug use later on. Even to attaining that addiction model in the brain much sooner. It's like your brain, even your DNAs, they just make you more prone to those structural changes in the brain, which we're talking about those 15% addiction where intent is no longer the issue. So these populations are more likely to go there.

Chrissy Billau:

Well, I'm asking about pot because the state line's just a few miles away from UTMC and the University of Toledo, and it's legal in Michigan. So a lot of shops in Michigan target Ohio consumers on the billboards. Has there been an impact locally on that?

Dr. Tanvir Singh:

Yeah, the cannabis use has increased. I'm a child, adolescent psychiatrist too. So cannabis, many kids who are using cannabis, they are more prone to more major psychiatric complications, even psychosis. So we many times see kids with first episode of psychosis after exposure to cannabis. And the other thing is the cannabis complications, they vary a lot based on the concentration of cannabis. And now we have this edible cannabis, and it does have very, very high concentration of THC there, which makes people much more prone to complications, like health complications, medical complications, and even more addiction potential.

Chrissy Billau:

So even an edible a day could constitute substance abuse, put you on that path?

Dr. Tanvir Singh:

Yeah, especially in selective cases. Like I said, the genetic makeup, your individual vulnerability, anybody could be. And that person might not be fully aware of how vulnerable they are. And more and more people are exposed, more and more are going to end up in that dangerous road.

Chrissy Billau:

According to the Ohio Department of Health, fentanyl was involved in 81% of overdose deaths in 2020, often in combination with another drug, but that percentage was up from 76% in 2019. Does that seem to line up with what we see in northwest Ohio and UTMC?

Dr. Tanvir Singh:

Yeah, it's a very unfortunate, but it's a very scary situation. And if one addict who has addiction at his structural brain level, caused such a havoc around all those people associated with him, the complications are just unimaginable. So if somebody who's in active addiction for a family, the only thing they can do for that person is enable their use because it's so difficult. So difficult to make a positive difference. Inactive addiction.

Chrissy Billau:

Well, it's hard to even give somebody money like to go get gas or maybe some cigarettes or something that you think you're helping improve their quality of life, but that money's not going to what you thought it was going to.

Dr. Tanvir Singh:

Exactly. So the people who care the most, they end up enabling that person rather than trying to help that person, because they're just so helpless. So the havoc it creates is humongous. The complications it creates is so humongous.

Chrissy Billau:

Naloxone, commonly known as Narcan, over-the-counter drug used to revive a person believed to be suffering from an overdose by blocking the effects of opioids in the brain. Where do you get it and how can you learn to use it if it's needed?

Dr. Tanvir Singh:

So it's pretty readily available. You can get it from any of the pharmacies. People who are prescribed opiods, they are offered naloxone too. And the awareness has been better. People do carry the naloxone and the people who have struggled with addiction. Even if they're in sobriety or trying to be in sobriety, they are more aware now. And the other thing is there are much more people who are trained in the use of naloxone. Even University Toledo has done many training sessions. There's so many students who are trained.

Chrissy Billau:

Well, you put it up your nose? Somebody's nose?

Dr. Tanvir Singh:

Yeah, there is an naloxone kit available and it is the most easiest thing to administer. You put it through the nose and yeah. And you should still try to get the patient to the emergency because many of them, they can slip back into respiratory depression, even if they respond to that nasal spray, even if they respond. Because sometimes, what they use is so longer acting that they can slip back. So you should still get them medical attention. But it is lifesaving.

Chrissy Billau:

UTMC operates Toledo's only hospital-based adult inpatient medical detox program. It's been in operation for five years now. And tell me why this is such a special resource for our community.

Dr. Tanvir Singh:

So many people with addiction and significant substance use, they have dealt with lot of medical health issues too, because there's obviously not much self-care and the use itself carry so many complications. The needle use, put you more risk for hepatitis, HIV, even the heart conditions like endocarditis. So with alcohol population, they're more prone to seizures, even going in delirious state, liver failures. A lot of health issues. So being in a hospital, it really does help these patients because they can get the medical attention too, while they get help for their addiction. So that's a unique facility to be available in northwest Ohio.

Chrissy Billau:

I want to talk about addiction medications that can be prescribed. The ones I'm familiar with are ... Was it methadone to wean off of it? And I know the other one is Suboxone to stop the cravings or prevent symptoms, to stay sober and stop a relapse. Sometimes you think it sounds counterproductive to stop using drugs by giving another drug, but can you explain how these can successfully work?

Dr. Tanvir Singh:

Yeah. So medication assist treatment is highly successful if patients can stay compliant on it, they can take the way it is prescribed. It's highly, highly successful, especially for that patient population who have gone too far in their use. But all this intervention, medication assist treatment, they're approved when they're used with counseling. The counseling is such a key part because you are trying to rebuild your mental state, the way you cope. So that piece is so, so important, because addiction is a very psychological dependence too. So all this intervention, they're more effective if you use it with counseling.

Chrissy Billau:

For someone who's avoiding drugs and alcohol altogether, but maybe they were in a car accident or they have some kind of chronic pain as they age, what are some alternatives for pain management?

Dr. Tanvir Singh:

So in the University Toledo Medical Center, we do have a clinic which is focused on looking at physical therapy to deal with the pain management. They even help patients to go off opiates and their success rates have been pretty high, because pain again is a feeling. It is an emotion and it's all about how you cope with that feeling.

Chrissy Billau:

The clinic you were talking about, is that UTMC'S Functional Wellness program?

Dr. Tanvir Singh:

Yeah, it's part of the Functional Wellness program. It is run by the PMR and they work with the physical therapists.

Chrissy Billau:

My understanding, it's a seven-week program and you have physical therapy and mental health counseling, to manage chronic pain without drugs?

Dr. Tanvir Singh:

That's an excellent resource. And they do have a very high success rate too. And it's a tough road. Patients who go through it, they feel miserable because like I said, there is a lot of [inaudible 00:27:43] emotions at that time and when they feel pain. So when you take something away, when the pain medications don't let you feel the distress, when you don't use something, you lose it. So you develop what we say distress intolerance. So when they are exposed to pain, again, initially it is tough for them because they haven't used that. But you can always develop with time those skills, which were gone because of the pain meds. So it's a difficult period on a temporary basis, but gives you a much higher quality of life later on.

Chrissy Billau:

If we can talk big picture here, I know we talked a little bit about society right now. But we've seen celebrities through the decades suffer from addiction. But I have a question about how society talks about them and what that does to someone's ability to talk about it themselves in their own personal life. So after a celebrity dies, yes, you'll see some people saying, "Oh, it's so sad, it's so tragic, such talent gone. Why?" But when someone's in the throes of that addiction and they're having issues and they're acting irrationally, there's a tendency to laugh at them and make them a punchline. You've heard the line, "Crack his whack." But look at Whitney Houston, Amy Winehouse. You have Robert Downey Jr. who he was able to turn it around. But why do people turn something like this into a punchline? And what is the impact on regular folks who may be battling their own demons?

Dr. Tanvir Singh:

The way we have to look at it is that we all humans are equally vulnerable or can be equally vulnerable. So that's the way I look at it, that as humans, we all are vulnerable and we all can go on the wrong road, which just leads to misery. And we all are vulnerable to bad situations, which can even lead to premature deaths as we have seen so many times with the celebrities. Sometimes, being a celebrity means just more high stress levels. And like we talked about, the stress levels earlier too, they're more likely, they're more prone to more impulsive decisions, lacking judgments. And when you are famous, there are lesser people who can tell you that you are making a mess of your life. So those people, they're actually more vulnerable.

Chrissy Billau:

So switching gears, we have experts on here all the time. And I'm going to ask you the questions that I ask them too. Just we have a baseline of questions. Dr. Singh, some elements of your practice. What have you been working on lately that you'd like to talk about?

Dr. Tanvir Singh:

So I'm a psychiatrist. I'm a child psychiatrist too. I have actually three boards. So I have boards in adult psychiatry, child psychiatry, and addiction medicine. So I started doing more addiction during the peak of the opioid epidemic. My focus right now is really the youth programs. I think that's where you can play much bigger role, like I said, with addiction treatment. What I have realized with my own experience for last 20 years is the key prevention, prevention and prevention. We need to stay focused on the treatment of the ones who unfortunately have gone too far and keep on working and trying to improve our success rates there too. But prevention, especially with the at-risk population, that's the key area and that's where I'm focused on and that's where University Toledo is focused on too.

Chrissy Billau:

What's the most common question you get from your patients and what is your answer?

Dr. Tanvir Singh:

The most common question you get is regarding the self-doubt, which is patients are not sure if they can pull this thing. And the answer is always yes, you can pull this thing through. But we always tell them that, "Okay, so you're trying to do something difficult." The word difficult means there is always chances that they're going to be setbacks. And then the persistence is the key. It's like if you're trying to solve a very difficult puzzle. It's likely going to take you a bit longer and sometimes it would feel that you can never figure this puzzle out. So anything which is difficult, the persistence is the key.

Chrissy Billau:

How can someone who's listening to you and thinking, "I really want to talk with them", how can someone schedule an appointment with you?

Dr. Tanvir Singh:

Yeah, they can reach out through their department of psychiatry and they have the recovery services, both inpatient and outpatient. Yeah, they can even call through the 419-383, 4,000 through the operator. Yeah, the addiction unit number is 419-383-3441.

Chrissy Billau:

Okay, well thank you Dr. Singh for taking the time for this critical conversation about drug abuse, alcohol abuse, and addiction. And that's all for this episode of Prescribed Listening. Tune in next time and subscribe for more on Apple Podcasts and Spotify.