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What the addict in your life needs from you
With water temperatures around 44F, Charles Chucky Rosa, of Seabrook, N.H. submerges himself in the Atlantic Ocean on Monday, April 24, 2017. Regardless of weather, Rosa takes the plunge nearly every day as a way to remember his sons, Vincent and Domenic. A father of six, Rosa lost his two sons to separate drug overdoses when they were in their early 20s. Their ashes were spread in the ocean. Today, Rosas trips to the water outwardly serve to raise awareness for substance abuse while also serving as reminder and a way to recharge. In addition to taking plunges in the ocean and encouraging others to join, he runs the non-profit Chuckys Fight that focuses on teaching younger generations about drug and alcohol abuse. - photo by Jennifer Graham
Picking up trash with a recovering drug addict on a New Hampshire beach, Charles Chuck Rosa knows what some passers-by are thinking about his companion.

Degenerate. Thug. Sinner.

He knows, too, that some people would have thought the same of the two sons he buried more than a decade ago.

But losing one-third of his children to drug overdoses gave Rosa a terrible gift: a compassion that some people find hard to summon when faced with the ugly consequences of drug and alcohol addiction, such as last year's viral photograph of a 4-year-old in the backseat of a car, with two adults passed out in the front.

The photograph sparked anger at the Ohio police department that posted the image on Facebook, but people were equally enraged at the adults (one, the child's grandfather) who had overdosed on heroin. In the comments on Facebook, they were called scum, druggies, carcasses and trash by people who dismissed the current thinking of medical experts, who say that addiction is a disease and should be treated as such.

"Leprosy is a disease; drugs are a choice made by weak people who only care about themselves," one commenter wrote.

While those comments were made by strangers, even family members and friends may struggle to feel empathy for an addict who might steal, endanger children, lose a job and generally stop functioning in every way but for the pursuit of drugs and alcohol.

"Addicts seem to have fewer visitors and support systems. Often it's because they have alienated many of those close to them," said Dr. Danielle Ofri, a New York internist and author of the book "What Patients Say, What Doctors Hear."

"It's very sad because they need so much support but are often very much alone," Ofri said.

To help an addict recover from the brain damage caused by drug abuse, some friends and family members may have some tough work of their own to do, getting to the emotional place where they can love the addict and withhold judgment, since supportive relationships are a factor in breaking an addiction that impairs the ability to make a rationale choice, health experts say. They also have to navigate the fine line between being empathetic and enabling.

Seeing the teddy bear, not the 'thug'

Everybody thinks hes a thug. And he looks like a thug, but hes a teddy bear, Chucky Rosa is saying about the latest recovering addict he vouched for in court.

Rosa and his wife, Mary, are Roman Catholics, as evidenced by the crosses Rosa wears around his neck, as well as their large family. The couple, who live in Seabrook, New Hampshire, had six children. Four are alive today. Twenty-year-old Vincent died of a fentanyl overdose two days before Halloween in 2003. Thirteen months later, his older brother, Domenic, died of a heroin overdose at age 23.

The young men were caught up in an epidemic that has swept the country over the past quarter-century, with fatal drug overdoses rising more than 500 percent since 1990.

In 2015, 52,401 Americans died from drug overdoses, more than the number killed by guns or car accidents. In Salt Lake County in 2015, overdoses were responsible for 27 percent of deaths between ages 15 and 44. In Washington County, the rate was 31 percent, the highest in Utah.

The percentages are even higher in some parts of Pennsylvania, Ohio and West Virginia, and in New England, where the Rosas live.

In the years after his sons died, Rosa faced down his grief by becoming a one-man crusade against addiction. Now operating as a nonprofit called Chuckys Fight, Rosa talks to school groups, provides scholarships for impoverished drug users to go to sober-living homes, and helps recovering addicts do community service, such as beach cleanups, or, for women, doing manicures for residents of nursing homes.

Such activities can be game-changers for those in recovery. The work transforms them from someone whom strangers will disparage to someone whom strangers will thank.

People want to talk about therapy; they say its all about talking. Im not saying you dont need to talk, but the bottom line is you really need to get out and do stuff with them," Rosa said.

"How many people want to do a beach cleanup with them, pick up trash? They need to do things that make them feel good. They need replacement activities thats a fancy word for hobby, he said.

In helping recovering addicts perform community service, Rosa extends friendship to a vulnerable group of people, something he's able to do because he learned the nature of addiction from the loss of his sons. "They tried to manage something that will eventually manage you," he said.

The most common misconception about addiction is that addicts have a choice in their behavior, said Constance Scharff, director of addiction research at Cliffside Malibu, an evidence-based addiction treatment center in Los Angeles.

In the brain, the decision-making process has been compromised; what the addict actually loses is choice. These neural pathways get stronger every time someone bathes their brain in whatever substance they're using," said Scharff, who overcame an alcohol addiction nearly 20 years ago. "You build, essentially, a hamster wheel so that all you do is drug-seeking behavior. It doesnt matter if your daughters wedding is today, youre going to get loaded.

The brain of an addict

Previous generations dealt harshly with addicts and were proud of it recall the "Toughlove" movement of the 1970s and 80s, which encouraged parents of addicted children to kick them out of the house if they didn't get help.

But the founders of Toughlove are now deceased, and the philosophy is widely shunned today, as the number of people addicted to opioids and other substances soar. Spurred by research on how drugs alter neural pathways in the brain, most recovery experts now say that addicts need understanding and compassion to help them recover.

Addiction begins in the nucleus accumbens, the part of the brain where dopamine is released in anticipation of pleasure, whether it's from music, food, touch, alcohol or heroin.

While food can be addictive, too, more people become dangerously hooked on opioids than, say, blueberry pie, because some types of drugs cause a greater release of dopamine, up to 10 times more than food or sex, according to the National Institute on Drug Abuse.

But not everyone who takes opioids or drinks alcohol becomes addicted, only those who are vulnerable because of genetic and environmental factors, said Dr. Edwin A. Salsitz, an addiction medicine specialist and assistant professor at the Icahn School of Medicine at Mount Sinai in New York City.

People become addicted when they have an exaggerated response to the dopamine released, often because they are "unhappy and miserable for a variety of reasons."

"The more misery (a substance) is taking away, the more likely a person will go back to it, sooner, in larger quantities," Salsitz said.

When people return repeatedly to a substance in order to soothe themselves or feel euphoric, the brain adapts to the demand by reducing the number of dopamine receptors. This makes it harder for the addict to get the sensation he or she seeks, causing more use (and ultimately, abuse) of the substance. Ultimately, the person's capacity for experiencing any type of pleasure is muted, and chronic substance abuse can cause long-term changes in the brain that make relapses not just possible, but likely, the National Institute on Drug Abuse says.

That's one reason why people even doctors often lack empathy for drug users, according to Ofri, the New York City internist.

"Addicts are frustrating patients because they don't get 'better' easily. Medical caregivers definitely want to help their patients improve, and working with addicts can often feel like hitting a brick wall. A sense of nihilism can unfortunately set in."

But people need to keep in mind that addicts don't continue with self-destructive behavior because they want to, Salsitz said.

"Most people think addicted people are sitting in parks, getting high, having a great time. They're not. They're miserable. Why are they using heroin or alcohol or Percocet? Because they're trying to stay out of withdrawal. They can't tolerate being in withdrawal because it's a very uncomfortable state to be in," he said.

"Nobody chooses to be addicted. Why would they? It would be insane."

'The genesis of true empathy'

Addiction, of course, doesn't just happen to people who use drugs recreationally. Sometimes people who were prescribed drugs for pain wind up addicted; professional football players, for example, have four times the rate of opioid abuse as the general population.

There are conflicting opinions about whether people taking opioids for severe pain can experience euphoria from the drug, Salsitz said. But about three-quarters of Americans addicted to opioids didn't have their own prescriptions for pain; they were obtaining the pills from someone else, according to the National Survey on Drug Use and Health. And there is a difference albeit a slight one between someone who is physically dependent on pills and someone who is addicted, Salsitz said.

"All addicted people are physically dependent, but not all physically dependent people are addicted," he said. The addicted person generally likes taking the substance, and is causing harm to himself and others, while a person who is simply physically dependent is not.

As for people who become addicted without a history of pain, there are as many theories of addiction as there are types of addiction. Some people believe that addicts sooth themselves with drugs or alcohol to cope with buried traumas of childhood or some people posit traumas of previous generations that linger in our familys DNA.

Regardless, the family and friends of an addict may never know the cause, nor do they need to know it to behave compassionately and to say the words that Scharff says every addicted person needs to hear often: I love you and I want to support you in getting help."

It also helps to ask meaningful questions to learn more about the person and get them to think about how they got to this place, Ofri said.

In her 2013 book What Doctors Feel, Ofri described how respectfully asking one question and really listening to the answer changed her perspective, and thus the treatment, of a drug addict who had been admitted to New York Citys Bellevue Hospital 57 times.

The question was this: Might you be able to tell us the precise moment when you knew that you were addicted?

The patient knew, and answered thoughtfully and movingly, and the exchange changed the dynamic of how the staff interacted with him, and how he interacted with the staff.

The change in the team was palpable, Ofri wrote. For the first time, we had some insight even if slight into what Mr. Carellos life was like. It was the genesis of true empathy.

Salsitz said that people should also watch how they talk about addiction.

I even hate the word addict.' I say addicted patient or patient with the disease of addiction. We should be using medical terminology, not street language. That's another way to change attitudes, by not using derogatory language. For me, that softened the language, and enabled me to have a better attitude," he said.

Another way to show empathy requires no words, but is an action that may save someones life, Scharff said. Everyone in that persons life needs to have naloxone, and know how to use it. It needs to be on the mantel or another shelf so everyone knows where it is. Everyone who spends any time in your home needs to know how to use it," she said.

Naloxone, sold under the name Narcan, Evzio and others, is an antidote for opioid overdoses that can be administered through injection or spray. Although officially only sold by prescription, people can usually get a prescription by telling their doctor they have a loved one at risk, and drugstores in some states, including Utah, will sell it without a prescription. (On the website of the group Utah naloxone, you can find a list of pharmacies that stock "naloxone rescue kits.")

Habitual sin or disease?

During the 2016 presidential campaign, Hillary Clinton tweeted, Addiction is a disease, not a moral failing. We should support those who are struggling with it.

The tweet disturbed the Rev. Heath Lambert, director of the Association of Certified Biblical Counselors, who has written that he believes addiction is a moral problem, not a disease. But that doesnt mean that addicts dont need and deserve help, he says.

When the secretary says that, We should support those who are struggling with it, she assumes that declaring addiction to be sin will be at odds with genuine support and care for addicts. Nothing could be further from the truth, he wrote.

Rosa doesn't wade into that debate, but most every day, you will find him trying to keep teens from using drugs and alcohol. In classrooms where he speaks, he gives away dogtags to anyone who promises to stay clean and sober. He figures he's given away 50,000 so far. They listened to me, probably because Im a little rough around the edges. I dont candy-coat anything.

Sometimes, one or more of those teens will join him on the New Hampshire beach where he dives into the ocean every day regardless of weather to briefly commune with his boys, whose ashes were scattered in the Atlantic. He asks Vincent and Domenic to help him have the strength to have a good day.

Rosa himself has done battle with alcohol, and sometimes he needs their help to walk past the New Hampshire state liquor stores, something that seems easier to do when youve plunged into the Atlantic bare-chested and in shorts in the middle of a blizzard.

Im not doing cartwheels when its 20 below zero, but its something I make myself do, he said.

I dont have really deep pockets. I do a lot of it out of guilt that I could have saved my own sons, so I try to do what I can do here. We get some decent results. But Im like a small speck of sand on the beach.