Nurse Jackie Takes Us to Hell and Back–And Back Again: Was This Relapse Necessary?

nurse jackie(Caution:  Spoilers ahead)
Well, the production crew on Nurse Jackie isn’t taking any prisoners this season, that’s for sure. This is as realistic (and thus harrowing) a depiction  of the familial ravages of addiction as I have seen portrayed in the popular media, at least since the release of When A Man Loves a Woman.  This week  Jackie underwent a  grueling  home detox effort facilitated by her sponsor, her boyfriend and a pharmacist colleague from the hospital where she works.  During the worst of it, she  had a feverish and  nightmarish vision of the destructive impact her many lies and betrayals have perpetrated upon her eldest daughter, Grace. The vision concluded with Grace directly accusing Jackie of failing her, saying, “You should have fought harder!”
 I have been a fan of this show since its inception and willingly suspended all disbelief as I watched Jackie struggle with her addiction to pain meds. I devoutly wanted to believe (as I’m sure many others did) that this moment would prove to be Jackie’s rock bottom. And I thought the deal might be sealed when,  in TV reality, Grace, who has been so angry with and so alienated from Jackie, had a hurtful encounter with the mean girls at her school  and came home and threw her arms around her mother and sobbed, “Mommy, I’ve had a really bad day!”  Yes! The universe  was dealing Jackie a second (or actually a 9th or 10th) chance with her severely wounded child. Surely, surely she would seize it and hold on for dear life.
Sadly art  closely imitated real life in this case.  And it felt like a very real and very  hard punch to the gut when,  within the cinematic half-hour, Jackie snorted opiates yet again. Yeah, I was sucker-punched,  even though I’ve witnessed this kind  of heart-breaking lapse hundreds of times over the course of my career, and even though I explain these falls, on a regular basis to devastated, outraged family members.  So I’ll review the bidding again, for myself, for other members of Jackie’s fanworld, and for family members who are feeling similarly sucker-punched in their own lives.  Then, let’s take a look at how things might have gone differently.
Here  is what I tell addicts and their friends and family, as a way of helping them to understand the disease they are up against, and as a way of cautioning them  against surrendering disbelief too easily.
Addiction is a brain disease capable of disrupting functioning in all dimensions of an addict’s life.  Depending on severity, chronicity and individual susceptibility, it can compromise health, distort perception, undermine judgment,  dysregulate emotion. produce highly pathological (including criminal) behavior and destroy relationships and careers. These terrible things happen because drug abuse and addiction  produce  profound changes occur in the reward centers and executive control regions of the  brain.  Again, depending on individual vulnerabilities, this can happen pretty rapidly.
The short version of brain remodeling that occurs as the result of drug and alcohol abuse  is that the brain changes itself to defend against the pleasurable flood of  dopamine it receives every time an addict imbibes, ingests, injects or absorbs psychoactive substances. Very importantly, it begins to produce less dopamine on its own and it becomes less sensitive to  its presence as well.  As addicts develop this “tolerance” to their drug or activity of choice, they need more and more of it to achieve the pleasure they’re used to getting from their habit. Moreover, the brain’s reluctance to produce dopamine on its own means that addicts  also feel less and less pleasure from doing the things and being with people that used to make them happy (and whom, in their right minds, they dearly love). This is  a critical  thing to understand. Sooner or later, drug rewards become more important to addicts than anything else.
Moreover, as I explained in a previous post,  drug abuse and addiction also  weaken  executive control mechanisms in the pre-frontal cortex.  This is the  part of the brain that  helps people to regulate emotions and impulsive behavior.  Heavy drinking (including intermittent binge drinking)  and other drug use undermine the very functions that are needed to make healthy decisions about future use.  This includes the ability to make accurate  calculations about the impact of using on the self and others. These dramatic changes in brain structure and function mean that addicts can transiently, and sometimes for sustained periods, lose any useful awareness of the destruction they are wreaking on themselves and others. As Robin Williams once observed, ” As an alcoholic, you will violate your standards quicker than you can lower them. You will do shit that even the Devil would go… ‘Dude!’
I was right there with the Devil after Jackie’s latest lapse.  Though it’s probably not accurate to call it a lapse.  Jackie had no sobriety, or even abstinence to lapse from in this case.  Despite the “detox”, she was still a complete wreck.  This is something very important that  the show has an opportunity to teach its audience. The brain takes an extended period to heal after someone abstains from alcohol and other drug use. Two or three days of detox, and even 30 days of residential rehabilitation aren’t nearly enough.  A recent study of current and former cocaine users for example,  found that even after 4 years of abstinencethere were abnormalities in some brain regions involved with reward processing.
Actress Julie White, who portrays Jackie’s 12-step  sponsor this season, said in an interview that by the end of her stint on the show, she felt like, “… man, I am the worst sponsor ever!” And in fact, home detox was a terrible choice for someone whose addiction is as severe and chronic as Jackie’s.  It’s probably always a terrible choice unless there’s  an extremely strong social , medical and educational structure in place to support ongoing recovery.  Such a structure would  include 90/90 (90 12-step meetings in 90 days), addiction-informed individual and/or group therapy, anti-craving medications, treatment for any co-occurring disorders, and regular, random drug-testing.  Most of this would be aimed at specific brain dysfunctions that stem from drug and alcohol abuse.  The 90/90 guidance, addiction-informed therapy and even the drug testing are all ways of  enhancing the recovering individual’s awareness of information flowing from the more rational, logical centers of the brain about the potentially disastrous consequences of further use.  Intensive 12 step meetings and psychotherapy are also about gradually re-orienting addicts, whose lives have become organized around the pursuit and use of drugs, to the comfort and rewards that are available in constructive and emotionally intimate relationships.
I am grateful to the cast and crew of Nurse Jackie for delivering the news about the “cunning, baffling and powerful” disease of addiction in a manner that is not only technically, but also emotionally accurate. I hope that they stay in this groove for as long as the show continues, in order to convey to their audience what it really takes to establish stable sobriety…which is…everything you’ve got.

By the way, you might be interested in this recent article from The Washington Post:  Does “Nurse Jackie” Work in a Hospital Near You? It points out that physicians in recovery “are typically mandated to 90 days of residential treatment, followed by five years of monitoring with random drug tests. As a result, rates of recovery exceed 80 percent, even five years after treatment.”  Good to know.  I wonder if nurses receive  a similar quality of treatment and follow-up?

Read more about addiction and the family in Dr. Wood’s books: Children of Alcoholism: The Struggle for Self and Intimacy in Adult Life and Raising Healthy Children in an Alcoholic Home

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