Author: Marc

Hi all,

This morning I finally had a chance to listen to our debate in Amsterdam from 9th January. And I find that we are not that far apart on some points, though we remain in opposite corners on others. When I posted the slides from my talk and described the evening’s dialogue, my impression was that I was taking on the disease model as a sort of David fighting Goliath (a handy form of grandiosity when you’re the weakling). And while we did and do clash swords at times, maybe that’s only half the story.

One of Nora Volkow’s slides

What does it signify that Nora Volkow talked explicitly about the power of the social environment, the role of stress in triggering relapse, the risk created by growing up poor, with inadequate parental monitoring? What about her emphasis on the value of positive social relationships and support? Her clear (and to my ears novel) discussion of recovery, of the fact that many one-time addicts get over it — for good — which seems a far cry from NIDA’s characterization of addiction as a chronic disease? In fact Nora showed a slide depicting how social subordination (at least in monkeys) greatly increases vulnerability to addiction — and the brain mechanics that might underlie this relationship. It was a slide I might have used myself, as it identifies addiction as a response to low self-esteem, isolation, and/or frustration — a point that Carl Hart or Johann Hari or I might just as easily have made.

What I think it shows is that Nora Volkow is talking about addiction in a broader light than ever before, paying homage to the social, psychological, and even societal forces that get people to take drugs. And maybe it shows that Nora Volkow can lead NIDA and similar organizations into a more evolved understanding of addiction, rather than serve as an anchor that holds the disease model in place. In fact — and this is purely speculation — maybe Nora finds herself between a rock and a hard place, trying to balance the pathology-oriented brain data (and the research program that spawns it) against insights that are sensitive, humanistic, and true to the actual experience and context of addiction in our society. And/or maybe Stanton Peele, Bruce Alexander, Maia Szalavitz, Carl Hart and others (like me) have been nipping at her heels to some effect.

She and I still have our differences of course. I can’t stand her slides showing big red or yellow splotches on the brain scans comparing cocaine addicts to “normals”. She and her colleagues certainly know that cocaine and other psychostimulants compile dopamine in the synapses, unlike the many other addictive drugs that do no such thing, which could easily explain a temporary blunting of dopamine metabolism as a compensation. Yet she points to those slides and says: see, look how different their brains are. Not fair! And she still talks about addiction as destroying will power, which still seems to me entirely wrong-headed (though that’s sometimes how it seems). And then I wonder, is that her talking, or is that the NIDA party line? And if it’s the latter, then maybe she really is walking a kind of professional tightrope or perhaps struggling with her own intuitions while trying to be a good scientist. I know that feeling myself.

I quite like this woman. Her very expressive face (sometimes pleasant, sometimes fierce) is currently looking up at me from the cover of LEF magazine, a Dutch publication for addicts and those who live or work with them. I admire her energy and her devotion to data, not to mention the heap of accomplishments she’s contributed as an active neuroscientist — regardless of or despite her role as the head of NIDA. So I’ll end with a paragraph from an email I just sent her.

Hi Nora,
I finally had a chance to listen to the recording made that evening in Amsterdam. I want to say that I have now really listened to your words, and I see that our perspectives are getting more and more convergent. Your emphasis on environmental factors, on the importance of social support in recovery, your discussion of diversity in outcomes…so many things we actually agree on. And of course we also agree (and I acknowledged) how important it is to stop blaming and start helping. I feel a bit guilty, partly because you were so tired that night — I thought it was heroic that you spoke so energetically and clearly after three days of meetings and talks..and jet lag — but also because my main points were critical of the traditional disease model, and maybe I didn’t acknowledge how much your thinking seems to be increasingly comprehensive, and how much common ground we can find.

Two posts ago I promised to follow up on “what is addiction?” by supplying the missing piece. Anyone who has experienced addiction or  studied it knows that compulsion is that piece — the elephant in the living room.

Here’s a quick review:

A key aspect of addiction, as we experience it, is the urge to complete the act, scratch the itch, etc. You’ve probably heard a dozen phrases that try to capture that feeling, that moment. We know we’re not going to feel any better, maybe worse, or if we are going to feel better it won’t last long. We’ve gone through all the arguments and counterarguments as to why we should not, cannot, do it one last time. We have done all we can to steer a path home that avoids the liquor store, to wait until our dealer is out, to provide a context that makes it unattractive or even impossible, like going to a meeting even. And then we lunge for it. The behavioural switch has been switched on — so it seems. And the alternatives and obstacles fade into the background. Just do it. Get it over with. There’s still 15 minutes before the liquor store closes. We can still find our dealer if we try.

This compulsive aspect of addiction arises over time. It’s not there for the first few weeks, or months, or maybe even years. And then it’s the main act. It’s the Achilles’ heal that resists every effort at mindful self-control.  So it seems. And resisting the urge just wears us down — as per my descriptions of ego fatigue, in my book and other writings. The anxiety that mushrooms as we continue to resist becomes agonizing.

We can trace this psychological and behavioural sequence in ourselves or others. Both at the minute-by-minute scale — the way it builds over the course of an afternoon — and the month-by-month scale, the way it gets stronger the longer we continue using. But what’s going on  with the brain in parallel?

The launching of an action (toward a goal) is governed by the striatum (or basal ganglia), a large structure with connections both “downward” to the amygdala and other parts important for emotion and “upward” to the prefrontal cortex, where expectations, plans and choices are activated. The striatum has a ventral (“southern”) terminal, which we often refer to as the nucleus accumbens. That’s considered the hot spot for addictive cravings. But it’s also got a dorsal (“northern”) region. While the ventral striatum evokes anticipation, longing, and zeroing in on potential rewards (e.g., drugs, booze, porn), the dorsal striatum seems to be involved in automatic behaviours — what psychologists call Pavlovian conditioning, or stimulus-response (S-R) events.

I’ve written about all this stuff previously, so I won’t get into more detail here. The main point is that only the ventral striatum (southern region: nucleus accumbens) becomes activated (bright yellow spots on the MRI) in early addiction — e.g., the first few months. But in later-stage addiction, activation increases in the dorsal striatum. For a while addiction neuroscientists thought that the addictive trigger got passed along, so to speak, from the ventral to the dorsal striatum. That could explain how addiction seems to evolve from being an active desire, motivated by an expected good feeling, to a habit, beyond conscious control and motivated by nothing at all — purely automatic. In fact, the disease model of addiction — the idea that drugs hijack the brain and destroy the will — got a lot of traction from this kind of neural model. See, folks, addiction means no more choice — it’s simply a compulsive act that can’t be stopped.

That turns out to be inaccurate. Recent studies, both with addicts and with those suffering from OCD (which has lots in common with addiction), show that the ventral hot spot, the nucleus accumbens, remains part of the flow of activity that moves us from a stimulus (a rumbling in the gut, a vodka ad, a phone call from a buddy) to a response. The response. The data suggest that the ventral and dorsal striatum both get involved in the kind of compulsive actions that characterize addiction. But they seem to take up different phases of the moment-to-moment sequence, with the dorsal striatum staying active longer, holding the action “at ready” until it’s executed, and the ventral striatum contributing to the earlier phase, the blush of wanting and seeking.

So the habitual nature of addiction is nothing like the habit of wiping your hands on a napkin or brushing your teeth. It’s not automatic in the same way. Addictive urges are far more complex. Even after years of addiction, those compulsive moments are packaged together with an emotional surge, a bouquet of emotions that are probably both positive and negative, a conscious sense of moving toward an expected reward, AND, finally, a more automatic sense of “must.”

What’s the point?

If the compulsive aspect of addiction remains part of a conscious stream of anticipation and preparation, then we have far more choice than we might have thought. Choice and will don’t just disappear with years of use.

Certainly the compulsive “just do it” urge increases over time, both over months and years and over minutes and hours. But the compulsion never replaces the impulse, the wish, the want, the conscious anticipation that we associate with the nucleus accumbens. Rather, the compulsion might be the final springboard to action, coming at the tail end of a series of thoughts and feelings that are conscious — and therefore controllable.

 

This guest post addresses a complex and emotionally-loaded issue: the link between pharmaceutical opiates (and the questionable way they’ve been advertised and marketed) and the current “opioid crisis” or overdose epidemic. Nick does a splendid job of recounting key milestones and contextualizing them within the history of Big Pharma.

Before getting to this post, I just want to alert you to a fact-filled, beautifully referenced and highly detailed website: everything you ever wanted to know about drugs, alcohol, the disease model, addiction, and treatment. I’ve included this link in the list of relevant sites on my homepage.

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…by Nick Johns…

 With the number of regulatory departments and protective measures in place today, we as consumers are inclined to believe that a product or service has been proven safe before it’s approved for public use. We’d like to think that if something turns out to be dangerous or harmful, the responsible party will be held accountable and similar situations will be prevented in the future.

Unfortunately, in the complex and tangled world of pharmaceutical drugs, that is frequently not the case. Take for example Pradaxa, an anticoagulant and blood thinner most often prescribed to treat and prevent blood clots and reduce the risk of stroke following hip or knee replacement surgery. The medication managed to obtain FDA approval five years before its reversal agent, Praxbind (an antidote to Pradaxa designed to reverse its effects and prevent uncontrollable bleeding) became available, leading to incidents of severe bleeding and hundreds of deaths.

Companies with ties to multiple other entities and those that have major influence on the healthcare economy are able to skirt the rules and make deals with federal agencies or court systems to avoid serious legal repercussions. Pfizer, one of the world’s largest pharmaceutical companies, marketed a drug called Bextra in 2001, a Cox-2 inhibitor. While the FDA rejected the drug at high doses for acute surgical pain, Pfizer and its marketing partner Pharmacia pitched it to anesthesiologists and surgeons anyway — at doses up to twice what the FDA had approved as safe.

What effect have these historically loose controls had on the present overdose epidemic? Sidestepping regulations to bring potentially unsafe drugs to market is only part of a larger problem, and it isn’t the only method that pharmaceutical companies have employed in pursuit of profit. When it was released in 1995, Purdue Pharma’s now-infamous opiate painkiller OxyContin was hailed as a breakthrough in pain management. The active ingredient of OxyContin is oxycodone, a long-lasting narcotic with up to twice the strength of morphine (milligram by milligram). Prior to OxyContin, doctors had historically been reluctant to write prescriptions for powerful opioids outside of end-of-life care or acute cancer pain due to fear of the addictive properties of the drugs.

In order to shift this perception, Purdue Pharma launched a massive marketing campaign to diminish concerns about addiction and to promote OxyContin as a safe treatment for an increasing range of ailments. At the forefront of the campaign, and differentiating OxyContin from other narcotics on the market such as Vicodin and Percocet, was the patented time-release formula — a characteristic which Purdue claimed was responsible for the drug’s purported addiction rate of “less than 1 percent”. This, employees of Purdue claimed, made the drug a safe choice for CNCP (chronic non-cancer pain) patients.

In an effort to maximize the efficacy of their marketing efforts, Purdue compiled profiles of doctors and their prescribing habits into databases used to identify where their campaigns would have the most success. This aggressive marketing tactic coupled with an incredibly lucrative bonus structure for sales representatives (a range of $15,000 to nearly $240,000 on top of a representative’s average annual salary of $55,000 in 2001) led to a tremendous increase in the number of visits to physicians with higher than average rates of opioid prescription. While pitching OxyContin, sales representatives for Purdue even reportedly claimed to some healthcare providers that the drug, now frequently compared to heroin in terms of potency and risk of addiction, didn’t even cause a buzz.

For millions of patients, a prescription for OxyContin provided crucial relief from debilitating pain. For many, however, addiction became so severe that the period of withdrawal between doses became unbearable — especially if the recommended dosage was exceeded. Purdue’s marketing campaign for OxyContin reached its peak in the early 2000s, and sales of prescription opioids (with Oxycontin in the lead) quadrupled between 1999 and 2016. During that same period, over 200,000 people died in the U.S. from overdoses related to prescription opioids — with many cases involving a mix of other drugs and/or alcohol.

While federal regulations have since cracked down on OxyContin and tightened around pharmaceutical practices, the opioid epidemic is far from over. Patients addicted to prescription painkillers can eventually find them too expensive or too difficult to obtain, and may turn to other drugs instead — heroin in particular. Drug-related deaths are climbing at an alarming rate, and many can be linked to the addition of fentanyl to street drugs. But there’s little doubt that Oxycontin prescriptions greatly contributed to a wave of addictions that has yet to subside.

With prescription opioids potentially serving as dangerous gateways to fentanyl-laced illicit drugs, it’s clear that attention needs to shift to pharmaceutical companies, hospitals and physicians. Doctors and healthcare professionals can help by screening and regularly monitoring for substance overuse or addiction, and by prescribing painkillers only when other treatment options have proven ineffective. Patients can help by never sharing or selling prescription pain medications, and by taking steps to ensure that they are the only ones with access to their painkillers. Friends and loved ones can help by monitoring patients for correct usage of prescription pain medications, staying alert for any signs of prescription drug overuse, and questioning and challenging potentially dangerous habits before they become entrenched. The battle can be won, but we all must fight together.

The talk I gave in Amsterdam had the title, “A Brain Disease or What?” This post is about the or what? But in attempting to define addiction, I come up with three words, rather than one:

Habit

Relationship

Narrative

…and these words have to work together to explain what addiction is.

The idea that addiction is a deeply ingrained habit is relatively simple — at first. In fact that is the default definition generally posed against the disease definition. And habit is no stranger to the mind or the brain. We don’t reinvent our perceptions and conceptions; we refine and consolidate them over time. And the brain works by creating circuits which are fundamentally self-reinforcing. It doesn’t seem much of a stretch to see addiction as a habit of seeking an expected reward and going through various motions to obtain it. It’s just that, with high motivation and endless repetition, this habit is deeply ingrained.

But many also see addiction as a relationship, for example between you and your drug, your beer, or your porn collection. That’s almost correct. Except that addiction isn’t a real relationship because it doesn’t consist of two interacting partners. The drug doesn’t adjust to you. You adjust to it. And adjust and adjust until the supposed relationship, in your mind, is locked in. So I’d say that addiction is the concept of a relationship.

That’s not special in itself. The study of child-parent relationships in mainstream psychology has mostly fallen under the banner of attachment theory. Attachment theory is all about the child’s concept of the relationship with, let’s say, the mother. A secure attachment means the child expects the mother to be available when needed…emphasis on “expects.” An avoidant attachment means the child expects the mother to be unavailable. It’s not just mother’s behaviour that matters; attachment styles are predicated on child temperament as well as maternal behaviour. It’s children’s expectations that maintain their “attachment status” throughout life. An ambivalent or resistant attachment style means the child needs the mother excessively, expects disappointment, struggles against the need, and pushes away at the same time as pulling. Sound familiar? So if we think of addiction as a concept of a relationship (which I’ll call “relationship” in quotes), it seems to match an ambivalent/resistant attachment style. I want you, I need you, you’re not going to be there for me (about six hours later), you don’t help me enough, there’s no one else I can go to for the help I need.

Let’s put these first two elements, habit and “relationship,” together. “Relationships” are certainly habitual. They build on themselves over time. Many teenage or even adult children continue to berate their parents for not paying enough attention to them or not understanding them or not giving them enough, whether the parent does everything or nothing to change this conceptualization. And habits are relational. My habit of brushing my teeth involves a relationship with my toothbrush, and my dentist. So far so good.

Then what about narrative, the third element of the triad? I’ve written a fair bit about this, especially in the last chapter of my second book on addiction. We are constantly telling ourselves who we are, what we’re like, where we’ve been, where we’re going, etc. The life narrative is very much like what we might call our identity. It is not our personality — our underlying nature — but the way we construe ourselves. I’ve argued that changing one’s narrative is a potent way to move beyond addiction. I act like this because, Omigod, I was really suffering and this was the only solution I could find. So I’m not just a piece of shit; I’m a desperate seeker. But I don’t want to be doing this, and I don’t have to be doing this, and the future is changeable even if the past isn’t. The magical thing about narrative, or story, is that it is told. It doesn’t stay inside; it’s communicated with others, who can help us to hear it, hold onto it, reflect on it…and change it. Changing the narrative allows us to focus on the “relationship” more clearly, and to refashion beliefs about what that relationship entails, especially, what to expect. And it can change our habits, first by unearthing them, exposing them to the light, and then by a determined effort to choose B rather then A in situations we recognize as pivotal.

It may be that our narrative sits on top of our “relationship” (with what we’re addicted to) which rests on a set of habits. A hierarchy? I can see currents of change — deep change, “recovery” — moving down the hierarchy, from narrative to “relationship” to habit, or possibly up the hierarchy. Maybe both directions at the same time.

 

But there’s something huge missing from this analysis, and that is the role of compulsion. We have to go all the way back to habits and think about them again. Some habits, maybe most habits, are unconscious, and they trigger thoughts and behaviours before we can say “stop!” Compulsion is, for some, the defining feature of addiction. Next post, I’m going to look at how compulsion works and what to do about it.

So many of you have asked how it went last night, I thought I’d try to give you my take on it, right here.

In a nutshell, it went very well.

After working for days (sweating, obsessing, etc) on my Powerpoint presentation, Isabel forced me (don’t ask me exactly how) to redo the whole thing yesterday morning before she left for work. Isabel is a really skilled speaker, and she’s developed a style for “inspirational” talks that make intellectual and scientific points digestible, entertaining, accessible, and potent. I’m just a stodgy old academic, so I still tend to put a lot of text on my slides. Trying to make sure I cover everything and include the necessary facts and figures, even at the risk of boring or losing some of my audience. So…I’ve learned enough to do what she says.

It took the whole day, but I finally got it done: a lean, mean, presentation. Slides with few words, mostly titles and bullet points, lots of cool animation, and a step-by-step breakdown of what the “disease model” of addiction gets wrong (in my opinion) and how to adapt/replace it with a more effective way to understand addiction and help those who suffer. I’ve printed all my slides below.

We were almost late and…there was a certain amount of anxiety involved. Parking in a highly questionable spot, racing through the train station to platform 11. Isabel had generously offered to go with me, essentially to hold my hand. I was kind of nervous but not too bad. And somewhat magically, the nervousness just evaporated when we got on the train.

I edited my slides obsessively during the trip, hardly noticed changing trains in Utrecht, and I babbled to myself all the way. What might Nora Volkow say to this, and to that, and did it matter? And how to deliver what I needed to deliver without being overbearing or attacking or…too wimpy.

It was a cold night in Amsterdam, but everything glittered: the magnificent structures of the old city interspersed with modern buildings that were also imaginative and beautiful in their own way. All of it reflected off the canals. We found the venue, about a ten-minute walk from the station: a beautiful and very modern library, and in it a classy theater that could seat about 250. Isabel looked fabulous. I looked dowdy. I guess we averaged out okay.

So…there was Nora Volkow, in the flesh, We had a friendly enough greeting. She was there to receive an honorary PhD from the University of Amsterdam. I asked her how many PhDs she had now. She said she truly didn’t know. She is the most renowned and probably the busiest addiction scientist in the world. She’s earned her stripes. But of course she’s just a person, looking a bit tired and no doubt jet-lagged on this particular night.

By the time we started, the theater was completely packed. She got up on the stage and did her thing: energetic, committed, sure of herself, convinced that neuroscience was the main act when it comes to understanding addiction. She showed some colourful brain MRIs, talked about dopamine a lot, and…well if you want to know more about her message, go to the NIDA website.

One thing that did impress me (and others) was that she talked a bit about recovery from addiction. For many years, the NIDA party line has been that addiction is a chronic brain disease. People don’t recover from chronic diseases. So…maybe that’s progress. Maybe the addiction neuroscientists are starting to listen to our messages about the experience of addiction, its developmental time course, the enormous individual differences in process and outcome, the gradations in levels of intensity…and the very important issue of free will — something that Nora has long claimed gets wiped out by drugs. The hijacked brain. In my talk I emphasized that addicts do not lose their willpower — in fact they have a great deal of it. Rather, they have a hard time making choices that are good for them in the long run. And choice is not a simple thing — for anybody.

Maybe the brain scientists, including Nora Volkow, are tuning into the personal and social and societal foundations of addiction. I hope so, and I hope that those in the “psychosocial” camp start listening to the brain scientists as well. These are all pieces of the same puzzle.

Nora talked for about 20 minutes, then I went up there and did my spiel. It was a good talk. If I was a religious person, I’d say the power moved in me…or something like that. I was hardly conscious of what I was saying. It was that thing they call “flow.” But man, it felt good, because I could tell it was coming out just right, and Isabel sat in the third row and smiled hugely every time we made eye contact. And then, lots of applause — especially for the Dutch — and then a debate between Nora and me with input from a panel of three experts and the audience.

And so on and so forth. I won’t try to capture any more of it for now. The evening was recorded, and I think the talks and debate will all show up on YouTube before long. I’ll let you know.

Meanwhile, here are my slides. I’ve inserted blue arrows to try to give you a sense of what words and images appeared partway through the slides (via animation). I’ve also included some “speech balloons” to approximate the things I said that don’t appear on the slides. A lot is missing, I know. As per Isabel’s instructions, there was less to read and more just to speak.