Author: Marc

I seem to have become a movie critic.  A month ago I posted on Ben is Back and yesterday I watched A Beautiful Boy on a flight home from San Francisco. And what I get at the end of each movie is a big fat nothing. There is no conclusion, no understanding, no ground from which to move forward.

With Ben is Back, there was Julia Roberts’ compelling angst, and now, with A Beautiful Boy (which I also read), we feel that intense heartbreak of a parent who can do nothing more to help. Only to keep loving…and losing…as if his son had cancer or leprosy. I guess I’m mad and that’s why my words are coming out this way. There is something fundamentally wrong in these portrayals. Yes, they get the drama, the heartbreak, the power of drug highs. They get the agonizing schism between the teen or young adult lost in drugs and the (generally divorced) parents who still love their kid intensely. All that is worthwhile and important. But what they don’t get is the experience. They don’t even try to approximate, to estimate, to guess at what these young drug addicts are experiencing (other than deep sighs and stretches and rapturous smiles). Why is this so opaque?

I mean, if we can create film after film about the Vietnam War and experience the shame, guilt, and horror of soldiers watching their friends die and their deepest values twisted inside out, why can’t we even come close to portraying — not what the parent is feeling — yes, that’s important too — but what the young addict is experiencing? What could be more dramatic than that? (And isn’t that supposed to be the crisis of our time?)

With Ben and Nic, there are plenty of scenes that broadcast, almost prostitute, the sense of shame that these young men feel about their addictions and the deep hurt they cause their parents and siblings. Okay…shame. We get that addiction confers shame, which makes it harder to stop and harder to connect. But there’s so much more that’s missing. What is it that gets these kids to go back to their dealers and using buddies and half-empty girlfriends to do it again? To throw it all away, even after a year or more of “sobriety?”

In an online interview, Nic Sheff, the “boy” on whose story the book and movie are based, describes meth as providing “the feeling I’d been looking for my whole life.” We hear that a lot in stories of hard drug use (heroin and meth), and these movies actually provide skittery sci-fi sounds suggesting that the drugs are broadcasting an irresistible homing signal. But that’s way too easy. Rather than imagine that this was our singular goal since first grade, we need to look at the cluster of feelings that we have been trying to get away from.

This word “sobriety” might be a way in. What feels so miserable about sobriety (the kind that’s required rather than chosen)? I can tell you, in case you’ve never been there. It’s the boredom, the emptiness, the contrivance, the feeling of being who you’re supposed to be…which requires leaving  behind the compelling drive to explore your own identity, choices, and consciousness. Who in Hollywood tries to portray that? The intensely creative moment of throwing out the norms and choosing, at the risk of one’s own existence, to reach for moments of awareness defined completely on one’s own terms.

There’s nothing moral or immoral about it. Taking powerful drugs can be a creative act, often with dire consequences. It’s not about the skittering sci-fi sounds of what is supposedly happening to your brain. Or the kiss of thanatos that inspired Freud and the Velvet Underground both. It’s the reach…for something so very different…from the monotony of living in our TV-tailored culture and obeying the commandments of family and love without ever having created either one. Yes, we want that. But at 18 or 20, we can’t create it. We can only rent that property from parents who settled there and established a home there. We can only copy, and please, and behave ourselves, trading our youthful energy for the security we could never find elsewhere. And guess what: that’s not enough.

So we find our own kind of creativity and culture: the powerful technology of present-day drugs and the immensely attractive inclusion of like-minded venturers…and that moment of going  back to being entirely unbound…that’s what we seek, and often find. And sometimes that’s what destroys us…and perhaps our families too. It just disappoints me hugely that all the power and skill of Hollywood has not even ventured there, not even peered under that rock…at least not lately…in the black-and-white disease-minded culture of “you’re either one of us or you’re some unfortunate mutant.” What the fuck? We can do better than that.

(I’m aware, in re-reading this, that it’s only one slant. My target here is the middle-class confusion and emptiness that often promotes drug experimentation in teens. That’s the setting in both films. Intense socioeconomic hardships can also propel drug use, as can trauma, loss, depression, and other challenges. And yes, drugs can be addictive — which is a causal force in itself. These other drivers of addiction are discussed in many other posts by me and my guest contributors.)

Yesterday I watched “Ben is Back” — a recently released feature film about a heroin-addicted young man (Lucas Hedges) and his heroic and tenacious mother (Julia Roberts) who tries her best to keep him “clean.” Ben is around 20 years old (at which age I too was also shooting heroin). He scams a trip home from his residential rehab so that he can spend Christmas with his family.

Ben seems to be trying with great determination to keep away from drugs. Yet the demon of addiction is doing pushups in the parking lot, just as they warn at the 12-step meeting he attends with his mom. He finds a bag of dope in the attic, but manages to avoid taking it and gives it to his mother instead. He looks the other way when dealers and drug buddies from his former life show up magically on elevators and at car windows. He bravely endures the cultural ambiguity of an American Christmas and tries his best to connect with his sibs and step-sibs. He’s a good guy, and he fights the good fight, but…well I don’t want to spoil it in case you decide to watch it.

I thought it was a pretty good movie (I love Julia Roberts) with a half-assed ending, but there were a few impressions I want to share with you — impressions that epitomize a lot of what’s wrong with the mainstream perception of drug addiction.

Although the subtext of the movie is clearly the overdose epidemic, there is hardly a wave at the real causes of overdose deaths: fentanyl in street drugs, drug/alcohol/drug interactions among pharmaceutical users, and impediments to getting methadone or suboxone when needed. (However, to its credit, the film provides a snapshot of the lunacy of pharmacies unwilling to dispense naloxone.) See Maia Szalavitz’s excellent synopsis of what we’re thinking and doing wrong.

Instead, the usual “Reader’s Digest” simplifications are offered. For example, Mom meets the doctor who first prescribed pain pills, which got Ben “hooked” years ago, and says she hopes he dies a horrible death. We know that the OxyContin surge in the 80’s and 90’s did increase exposure to opiates and fueled increased rates of addiction. But to continue to blame doctors is insane. As Maia Szalavitz (and I) have made clear with arguments and statistics, doctors aren’t the problem, and the result of blaming them is the cutback of pain meds for people who really need them, while driving addicts to the street — to heroin that’s laced or replaced with fentanyl.

The 12-step presence is portrayed somewhat accurately. Both the good (fellowship, honesty, and mutual respect) and the not-so-good (brain washing, propaganda, and the all-or-none trappings of the disease model) correspond well enough with reality.

There is some recognition that addicts have choices. Ben fights his impulses bravely, and he makes sensible choices to avoid contact with the people and places that serve as triggers. And yet there is this creepy sense of fatalism sneaking up on Ben and other addicts. As though whatever choices they think they’re making, they’re bound to succumb. By the way, addiction isn’t referred to as “a disease” in this movie. Yet the miasma of an alien presence or infection lurks behind much of the dialogue and plot.

Junkies are portrayed as zombies. They are the opposite of clean. They’re dirty. They hover in alleyways, under bridges, around trashcans brimming with burning litter. It’s a classic and grossly overdone stereotype. When I was shooting heroin or morphine in my twenties , garbage-strewn alleys and river banks were not my preferred home away from home.

Despite the biases, stereotypes, and omissions, the movie does portray the struggle to avoid temptation rather well. And despite the Hollywood heroism and unlikely confrontations between good and evil, the plot and characters are engaging. The movie may well be worth seeing.

But here’s my biggest beef. People who take drugs are shown to be occupied by some demonic force (or disease, or what have you) that makes them another species. They are not anything like normal people. They live in a different world, they’re not to be trusted, and they ought to be sent away to residential rehabs (where they won’t infect the rest of us) until the demon is exorcised — itself a rare event. This dichotomous “us vs them” perspective is the real message of the movie.

An alternative message, which I hope you’ve encountered in my posts and the comments and guest posts of others on this blog, is that people who use drugs are so crushed by emotional confusion and pain, much of which is served up by American culture itself, that they seek and sometimes find substances and activities that help them turn down the volume of their anxiety and depression and bring a semblance of balance to their lives — what I referred to as “substance” last post. The cause of addiction can be found in mall culture itself (portrayed in the movie as a sort of heaven on earth), the rampant commercialism that sucks meaning out of day-to-day life, the often immutable stamp of privilege vs. poverty and the stultifying dead-end lives of those who don’t make the cut. Not to mention the sheer hypocrisy of a society that proclaims Christian values but rewards self-serving, self-protective priorities. I wonder if Ben was infected by these horrors rather than a magical drug high, and whether that’s what made it so hard for him to quit.

The word “substance” may have a double-meaning when it comes to addiction. The basic meaning is obvious: the substance is a chemical that we want badly and pursue relentlessly. But the second meaning of “substance” is suggested by a well-documented phenomenon: the parallel between substance addictions and behavioural addictions.

The feelings, actions, and brain changes seen with compulsive gambling, sex addiction, porn addiction, and many eating disorders (e.g., binge-eating disorder) look very similar to those seen in substance addictions. The feelings and behaviours include craving, gorging, risk-taking, reduced inhibition and compulsive repetition. The brain changes include sensitization of the dopamine system and reduced interaction between the prefrontal cortex and certain subcortical regions (in specific contexts). Because attractive drugs and attractive activities are craved and pursued in similar ways, it might not be too far-fetched to give “substance” a second meaning. The substance common to drug addictions and behavioral addictions may be the feeling of wholeness, once lost, now regained.

A substance is what fills up a space. The lack of substance equals, well, nothingness. When people talk about their addiction they often talk about a sense of profound emptiness, a psychological void, that gets filled by a something they can only get from what they’re addicted to. To replace a sense of nothingness with a sense of somethingness (what else to call it!) is more powerful than words like “pleasure,” “relief,” or “satisfaction” can possibly convey.

At first glance it seems that chemicals provide pleasure directly while certain behaviours provide pleasure through taking action, and that’s the whole story. But in real life, you need to take action to get those nice chemicals, to put them into your body, and that’s what the dopamine system is triggered by: not just reward but reward-seeking. Hundreds of studies have shown that dopamine release in the “craving centre” (the ventral striatum or nucleus accumbens) corresponds with effortful action, not with pleasure per se.

So whether we think we’re addicted to chemicals or to actions (behaviours) doesn’t much matter to the brain. Actions (like gambling) release dopamine because they are pathways to a monetary reward. Actions like shooting heroin release dopamine because they are pathways to a chemical reward. In both cases, the hook is a feeling state that springs from an action more than an outcome. To put it another way, it’s not really the heroin that you get addicted to. Heroin will bequeath satisfaction or pleasure. But what you get addicted to is the feeling of acquiring this special something: anticipating it, going after it, and getting it.

One of my favourite models of addiction (and one highly regarded in the field) is Robinson & Berridge’s theory of “incentive sensitization.” This phrase means that dopamine release in the brain (e.g., in the striatum) gets triggered, more and more predictably, by cues connected with the thing you’re addicted to. These authors specify that dopamine uptake signals wanting, not liking, a drug or other reward, and this has been a major contribution to our understanding of addiction. But to bring this understanding home, we have to clarify what incentive we’re talking about. Does “incentive” just mean urge, attraction, or motive? Just “wanting”? No, the incentive that powers addiction — what the brain gets sensitized to — is the availability of something you not only want but feel you need.

Berridge has compared this urge to the desperation of a starving animal seeking food. So it may be useful to view substance and behavioural addictions as fulfilling biological needs, or at least their psychological expression. Whether we take pills, snort powder, smoke, or inject, we are putting something into our bodies. This “inputting” is a behavioural prototype. It’s primal. It’s how we eat. In the case of binge eating, the target of the behaviour makes obvious biological sense. But perhaps all behavioural addictions relate to biological needs: e.g., winning against competitors (gambling), sexual needs (obviously sex and porn addiction), even social inclusion (internet addiction) and resource acquisition (compulsive shopping). In my book, The Biology of Desire, I make the case that addiction serves symbolic goals. For example, the warm feeling you get from opiates symbolizes the warmth that comes from being hugged or cuddled (no small matter for us mammals).

This may all sound a bit abstract. But the feeling of emptiness we (addicts) feel when we don’t have, or can’t do, or can’t get the thing we’re addicted to is very concrete, and very palpable. It’s the feeling of an empty day that can’t be filled. It’s the total eclipse of purpose, when there’s no point in doing anything. This is what I mean by the absence of substance.

Many see addiction as an attempt to repair a rupture in attachment (as in child-to-parent attachment) or care (by a parent, lover or even oneself). Certainly these are biologically-grounded needs. Gabor Maté’s study of addicts in downtown Vancouver, mostly aboriginal, mostly from foster homes, mostly abused or neglected in childhood, highlights the enormous holes in the lives of people with devastated attachment histories — holes filled by drug use. Bruce Alexander extends this idea of loss to groups cut off from their cultural roots and resources. What’s lost for these people isn’t just pleasure or relief; it isn’t just something they like or want. Rather, it’s something they feel they need. In the words of Johann Hari, it’s connection itself. People who have lost this “something” walk around with a sense of their own emptiness, and it hurts like nothing else. By filling that emptiness, a drug (or habitual behaviour) becomes the main source, maybe the only source, of the substance they have gone without.

The paper I recently published in the New England Journal of Medicine (linked here, summary linked here) detailed my best arguments against the disease model of addiction. But it also explored new territory, and that’s the topic of today’s post.

I emphasized (as I have for years) that addiction is learned. It is not a pathology but a learned package of desires, actions and expectancies that keep leading back to the same reward. We call it a reward, but most of us who’ve been through it know that the experience itself gets less rewarding even as the desires and expectancies continue to strengthen. Is that pathological? No more than being in love with a hurtful partner, or praying to an unresponsive god, or being devoted to a sports team despite their string of losses. When the power of a reward arises from strong emotions and needs, the tendency to pursue it isn’t rational. When we seek and find that thing again and again, then, through learning, the synapses of our brain form into dense networks (pathways of connected neurons) that become very difficult to circumvent. Learning on overdrive, through repetitive need-satisfaction, is habit formation — addiction is a deep and insidious habit.

Well, you’ve heard me go on about this before, and my second addiction book, The Biology of Desire, makes the point pretty well. But my recent article came out in a journal read by more doctors than any other journal in the world. To convince that audience, I tried (with the help of Shaun Shelly, who co-wrote or edited much of it) to show that each of the brain changes highlighted by the disease model are not pathological. They’re the sorts of brain changes you’d expect when expectancies and emotions become attached to a specific goal, leading to behaviours that are partly automatic — and partly not. Habit formation results in automaticity,  sensitization to some rewards, and desensitization to others. The brain changes seen in addiction are just the biological underpinnings of this natural learning progression. And…they can continue to update; they’re not carved in stone.

The new territory I wanted to explore sits outside the brain, in the world, in the environment of the addict (I use that term without disdain or judgement, having been one myself). Our environment, especially our social environment, consists of the people we care about, many of whom care about us, and of opportunities for care, for sharing, for pleasure, for relief, for a sense of fulfillment. These opportunities require certain resources, such as social skills, knowledge, self-esteem (at least a little), financial stability, the capacity to understand others. Opportunities are bridges between our needs and their satisfaction. Resources are the capital we use to pursue them.

When people fall into addiction, their environments shrink around them. Good friends, stable romantic partners, available, loving family members, physical comforts such as a safe place to live, job opportunities, and all the rest of it, gradually become less available. The opportunities for getting them back also become less available. Our attention and motivation, riveted now to just one source of satisfaction, lose their connection with the other sources of satisfaction that “normal” people enjoy. I see this as a literal narrowing or shrinking of the environment. Because of what I’ve called “now appeal” — or simply habit strength or deeply learned habitual behaviour patterns — we focus only on what’s in front of us and forget how to go after other rewards. So other rewards fade in availability. They evaporate. They get lost.

When I was an addict, I lost close friends, I lost a woman I loved, I lost the opportunity to communicate honestly with my parents, I lost money, I lost a sense of social and physical safety, I got kicked out of school and lost that opportunity (for a while) and all the rest of it. This picture is typical, one way or another.

But what blows me away conceptually is how this narrowing of the available, reachable, usable social environment precisely parallels the narrowing going on in one’s brain. My synapses fell in line, in pathways and networks that had a single purpose, so to speak, rather than multiple pathways supporting multiple purposes. This “narrowing” in the brain corresponded with a shrinking or narrowing in my available environment. Neither is pathological. Both, especially both together, create a kind of prison.

Perhaps of interest to those into philosophy or psychology, this tendency has been studied as a universal feature of living organisms. The sensory and behavioural specialties of a species get synchronized with aspects of that species’ environment. Both change together. This can happen over evolutionary time. But it can also happen at the scale of human development, as I’m talking about here. The study of this process is called “embodied cognition.” Google it.

One more point made in the article that Shaun and I thought was crucially important: people who study addiction know that there are massive correlations between early adversity (e.g., neglect, abuse, poverty, racial segregation, parental depression, parental alcoholism — in childhood or adolescence) and the probability of becoming addicted later in life. When thinking about how the narrowing environment corresponds with the narrowing of brain function, we can see that the addict’s environment starts off narrow! Kids with happy, healthy social-emotional worlds, who have not experienced trauma, rarely become addicts.

It’s really so simple. The narrowing begins early, sometimes even before birth — look to the family of origin. (Gabor Maté has emphasized the impact of adversity in early childhood. Bruce Alexander targets sociocultural adversity.) This helps us understand how environments and brains influence each other all the way along. If your childhood is hampered by obstacles and dead-ends, whether emotional, social, financial, or some combination of these, the narrowing has already begun.

It’s been 2 1/2 weeks since I put up that summary of Maia Szalavitz’s excellent article. Busy time since then. But now I’m in Boston, visiting my friend Matt Robert and a few others, and sitting in on SMART recovery meetings. Matt has been a SMART facilitator for over six years. I came here to learn more about SMART and to hang out and relax with a dear friend.

A couple of things happened recently. First, I haven’t told you that my review article (summarized here) was finally published in the New England Journal of Medicine. It came out roughly two weeks ago. This is a very high-impact journal — (approximately) every doctor in the Western world subscribes to it. And I’m pretty proud that I published a paper criticizing the disease model of addiction in a medical journal. I’m going to tell you more about that paper (and the blowback it provoked) in an upcoming post. But for now I feel two things: (1) that’s the last scientific journal article I’m ever going to write, because it takes so much f…ing effort, and (2) I’m really good at rational argument — I’m a pro!

But my most moving experience lately wasn’t resting on my laurels. It was the realization that I’m not such a pro when it comes to influencing people’s thinking, changing their minds.

I was talking with someone I know here in Boston… Just a conversation in the backseat of a car. We were talking about this and that, and then the topic of gun ownership came up. Both Jane (pseudonym) and I are lefties, very much opposed to the proliferation of gun ownership in the US and the political voices that advocate it. I guess you could say it’s an emotional topic for both of us. But we differed on a sort of thought experiment: What would it be like if people could make guns on a 3D printer and those guns were entirely untraceable? Would that be a bad thing because there’d be more guns around (her point) or a good thing because the NRA and its right-wing supporters would lose their influence (my point)? The content of the argument hardly matters. Neither of us had ever thought about plastic guns before. We were speculating, and then discussing, and then debating.

Things got heated. Jane said what she thought; I said what I thought. Of course she countered the points I made and I countered the points she made. That’s what an argument is — right? — and arguments can be valuable. But something else was emerging. My motive was no longer to arrive at a consensus or even a conclusion. My motive was to win. I’m making really good points, I told myself. I’m winning the debate. Through parry and thrust (in the language of fencing) I tried to take her down. To defeat her. All I really cared about was being right.

What I didn’t see until the next day was that Jane was hurt. She perceived my arguments as weapons — and indeed they were. I had thought: given competing positions,  someone’s going to win, and that’s going to be me. She had thought: why is he putting me down? Why is he trying to cast my opinions as groundless and stupid?

When I realized I’d caused her to feel attacked, I felt like shit of course. But that sensitivity dial had been tuned to zero during our argument.

So what?

I spend a lot of time refuting, invalidating, quashing, debunking the disease model of addiction — as I’m sure you know. The question that confronts me now is how am I going about it? Do I really want to change the minds of people steeped in medical thinking, addicts who believe they’re ill, their families, their doctors? Or do I just want to win a debate?

So I’m watching Matt facilitate a SMART meeting in Boston last night. SMART sometimes construes itself as “the alternative to AA.” SMART offers psychological tools, such as focusing on one’s own thought patterns and beliefs, and the potential that offers for behaviour change, even by small increments. SMART lends itself to mindfulness practices, it neither shames nor exonerates those who’ve “relapsed.” It is inclusive, it does its best to avoid dogma. And it values honesty and fellowship — as does its sometimes querulous cousin, AA.

But what impressed me more than any of these qualities was the warmth and sensitivity that characterized last night’s meeting. Here were 9 or 10 very vulnerable people, all of whom were “in recovery.” At the start of the meeting they seemed shy and uncertain. Matt’s job was (in part) to encourage them to to review and modify their thinking habits, to see their substance use more rationally, more comprehensively. But more than that, he was listening carefully to what people said and grasping what they were feeling: their fears, vulnerabilities, and their (often tattered) self-esteem.

The result was a spreading aura of self-acceptance, mutual acceptance, honesty, and empathy. By the end of the meeting, people were smiling and patting each other on the back or hugging and saying “until next week.”

That’s how to change minds — and hearts. Not to pound them with the superiority of one’s logical arguments, grounded in evidence. Who really has evidence for their claims when it comes to the hard questions, like whether it’s best to define addiction as a disease or not?

I still see things the way I see them. (I still don’t want to call addiction a disease.) But maybe I can do a better job of seeing things the way other people see them. Wouldn’t that be valuable? Either in the case of intellectual argument (as in journal articles) or in sharing emotional concerns in the backseat of the car.