Cousins, not twins

A few people commented on my last post that addiction was not the same as OCD. I agree: they overlap, but they’re certainly not synonymous. What I’ve been ruminating about is a related matter: the implication that substance addictions and behavioral addictions are the same. No, I don’t think they’re the same either. I called them cousins, not twins.

There are important things to say about differences in brain mechanisms and other physiological matters. I’m not going to deal with these much here, but the main point is this: Substances such as drugs and alcohol “talk to the brain in its own language,” as I say somewhere in my book. What they provide for the user is immediate, even intimate, in that they directly alter what’s going on in your synapses — the physical medium through which you experience…everything! Their effect does not need to be mediated by actions or events. They affect the brain directly. The implications are huge, but greatest among them is the certainty they provide. Without the middlemen of actions and events to pick up some of the slack, you can be pretty sure you’ll get what you paid for.

In this post I’m going to look more closely at what it is you get — what I got — by examining my own experiences. In doing so, I hope to pinpoint what I think is unique about substance addiction.

My addiction was mostly to opiates, though I also had a great fondness for cocaine at times. And though that was 31 years in the past, I managed to revisit my addiction about two years ago. I don’t often talk about this, but I don’t hide it either. In fact I wrote an essay about my partial re-addiction,  published in Toronto Life (one of the most popular life/culture/news magazines in Canada), and that essay is available for all to see on this website.  I had been through some pretty serious back surgery, and I was in a lot of pain for about 6 months. Which meant 6 months of painkillers. Which meant I got to experience the joys of QUITTING all over again.

It wasn’t nearly as bad as it was the last time. I hadn’t broken any laws and I hadn’t compromised my life. But it was…a potent reminder of what it’s like to have a substance play an unduly prominent role in one’s psychological life, and the step-down I went through with my doctor was a reminder of the ferocity of withdrawal symptoms — this time properly managed, thank goodness.

In any case, my memories remain pretty fresh.

pills&moneyBeing a substance addict always meant the same thing to me. It meant putting a huge amount of value in a thing or things. Pills, for example. The substance was hard currency. You could save it up, you could collect it at the back of your drawer. You could sit up at night and count it. I don’t suppose you can do that with internet addiction or sex addiction, though I could be wrong. But for me, the substance, the thing itself, the currency, had enormous symbolic value — as currencies generally do. And the value was that I could cash it in for a feeling any time I wanted.

Most important, the exchange rate was pretty reliable, given a certain amount of slippage — inflation — due to tolerance. So this currency gave me instant and predictable access to a feeling, just by putting something inside my body. Unlike gambling, where you have to be lucky, or like food addiction, where what you feel is a complex blend between calories, flavour, and your distance to the nearest Seven-Eleven, drugs gave me reliable access to a warm feeling that itself was (at least partly) symbolic. A symbol of a symbol? Sounds complicated. In fact it was very simple. The warm feeling was a version of some fundamental state of calm, contentment, peace… But it was really just a version. It was a nice feeling, but not quite the real thing.

Certainly other addictive rewards are symbolic: winning at cards, beating on-line opponents, having sex with…let’s not even go there. So I don’t think that’s the main difference between substance and behavioral addictions. The main thing, for me anyway, was spoonfulthat I had possession of these things, these pills. That gave me total control of the cascade of symbols and feelings that I had become attached to. Substances are….there. They’re objects, in three dimensions, solid, liquid, or even gas, I suppose, if you count nitrous oxide. You can hold them in your hand and take them when you want to. (Until they run out, of course.)

And what that means, dear friends, as I’m sure most of you know, is that you don’t have to get good feelings from other people or other activities. You don’t have to get good feelings from being at one with yourself, from loving yourself. You have this direct access to good feelings — sitting in your drawer. That gives you control. And control is the one thing we simply don’t have with other people, or with life in general. In fact the opposite of control is helplessness, and I believe that helplessness is the fundamental state we spend most of our time and energy trying to get away from. Brain-altering substances are just a little more efficient than anything else — at turning our backs on our helplessness.

pilltongueI think that the bottom-line value of all addictive acts is that they give us access to feelings that are not accessible without them. I think that must be true of gambling and sex and the internet and crack, speed, booze, and everything else. But behavioral addictions don’t affect your brain directly. They require you at least to DO something — which involves more work, more symbolism, more uncertainty. Substance addictions simply require you to open your mouth, your nose, or your veins.

36 thoughts on “Cousins, not twins

  1. Shaun Shelly March 26, 2013 at 5:41 am #

    Marc, once again you make my mind stretch! Absolutely agree with almost all of what you are saying here, and you nail the addictive experience – as usual. “I think that the bottom-line value of all addictive acts is that they give us access to feelings that are not accessible without them.” I always wonder about people who say they use to “stop feeling”. Rather I would say they use to feel something different.

    Where I would like to add to your ideas is that drug addiction has both components – the direct affect, as well as the “do” aspect. Think about your getting drugs. For me there was as much attraction in that as the using, and even after I stopped using I missed the “mission” of scoring. I missed the “process addiction” side of things. CRAZY but true.

    As a dealer, I found that when I had large quantities available, I used less. I had “currency” in the “bank”! But I loved the thrill of the buy – will I make it, will I get caught? will I get screwed over by my supplier? A kind of real-life Grand Theft Auto PS3 game. A roulette wheel of life.

    • Cindy March 26, 2013 at 11:04 am #

      So very true for me. The entire process of the planning, getting, hiding, using, then trying to mask my intoxication, was very thrilling and a game. Adrenalin rush.
      I was told to get a hobby early in recovery. I had no clue of the enormity of
      control I thought I had (but really didn’t)

    • Marc March 28, 2013 at 6:54 pm #

      Yes, Shaun and Cindy, I know what you’re talking about. There is a huge amount of MEANING that gathers like an encrustation of barnacles on the hull of a ship, changing it’s shape in the water. A lot of that is composed of rituals, as all three of us are recalling. There’s the scoring — that’s a big one — and the the preparing, the chopping, or dissolving, or slicing or dicing. Then the rituals get even more disturbing. There’s the “needle play” when you inject stuff. I found the needle to be immensely symbolic, and I even felt sexual excitement at the thought of it. Sort of sick, I know, but there it was. And then…for some of us, indeed the hiding and lying become another layer of symbolic ritual, exciting when it’s happening, missed when it’s over and done with.

      A dirty business, isn’t it.

      Yet, even though substance and behavioral addictions share these symbolic encrustations, I still think that the primal act is different. You are putting something into your brain, the centre of your experiencing self, not into your life, where it requires some additional interpretation.

      Shaun, you speak of the ritualization as a behavioral addiction built on top of the substance addiction. A roulette wheel…a gambling addiction. Maybe so.

  2. Joe S. March 26, 2013 at 5:54 am #

    Marc: Once again you’ve nailed it. This is a revelation for me. I always knew drugs and drink were like food, sex or social rewards but not exactly the same. This pinpoints the difference. Total control and reliability.

    • Marc March 28, 2013 at 6:58 pm #

      Yes, but I guess not quite total control. Like when you go to a new supplier and you don’t know exactly what you’re getting.

  3. Richard Henry March 26, 2013 at 8:10 am #

    The torment of wrong doings of my past in my mind kept me in constant pursuit of happiness and the avoidance of sadness, through alcohol and drugs. Little did I realize at the time this abuse only compounded those feelings of helplessness, and hopelessness. Although I achieved moments of escape, the over all ending was still the same, torment of the mind. It wasn’t till I sobered up long enough to bring closure to these issue did I even have a chance at accepting my life and learning to love myself again. Today I work hard at not dwelling on issues, I deal with each one as they come, bring closure, grieving, crying, what ever it takes. I came up short to long, to many years not to seek out help when I need it. Today I am blessed with happy thoughts and am enjoying all the little things in life.
    Regards Richard

    • Marc March 28, 2013 at 7:00 pm #

      Great to hear. I really do appreciate hearing about happy endings, like yours.

      • Janet April 1, 2013 at 4:26 pm #

        Thank you, Richard Henry. I like what your wrote here. Janet

  4. Elizabeth March 26, 2013 at 8:57 am #

    I’m actually a bit confused by this post. I do appreciate that there are differences in the way that behavioral addictions/OCD and drug addictions affect the brain. There are probably even differences in the different types of behavioral addictions and perhaps even the way that individuals view drug use. However, what struck me about this post was not that your experience seemed different from mine, but remarkably similar. This one really hit home:

    “The main thing, for me anyway, was that I had possession of these things, these pills. That gave me total control of the cascade of symbols and feelings that I had become attached to”.

    I felt EXACTLY the same way; planning meals, reaching milestones, feeling good about achieving my goals for the day, even a bit energized by it. It was probably not the same physiological response (e.g., abnormally large transient DA release in the striatum, surge of opiates, etc..), but it subjectively sounds the same to me. I’m very curious to see how you expand upon this topic: we know the brain activity isn’t exactly the same, but can the subjective experiences be similar? Also, what does this say about the value of neuroimaging studies correlating brain activation and subjective experience? (this was a debate we had recently when we were arguing over the value of fMRI data in anesthetized mice exposed to food or drug-paired scent cues).

    • Marc March 26, 2013 at 6:49 pm #

      Elizabeth, I think the brain processes look pretty much the same. So I think I’m saying the opposite of what you’re saying. The basic mechanisms of craving, impulsivity, and compulsivity are similar across behavioural and substance addictions. But what I’m saying is that the psychological fine points are somewhat different. And at that level of detail, brain scans can’t see the differences. The science is not that advanced.

      Let’s talk more about the psychological differences and not worry too much about brain parallels for now. I emphasized ownership, predictability, reliability, and a ready-made propensity for hoarding. What do you think about that?

      • Elizabeth March 26, 2013 at 9:26 pm #

        I totally agree that, at a gross level, the brain processes don’t look all that different. There’s some evidence that natural and drug rewards engage different populations of dopamine neurons in the striatum. I’m not sure if that holds when behaviors surrounding the consumption of both natural and drug reward become compulsive. I guess it’s been a salient topic in my mind.

        In regards to the psychological differences, I honestly do feel like the factors you highlighted were VERY much a part of my behaviors as well. I loved having a predictable, reliable reinforcer I could always turn to, especially during times of unpredictable stress and uncertainty, even if that reinforcer was what some regard as a “negative” reinforcer (i.e., avoiding caloric intake).

        • Marc March 28, 2013 at 6:27 pm #

          I can see how any addiction, behavioral or substance related, offers more control and certainty than going without. In fact that is fundamental to the nature of addiction. But I still think that there is a different kind of control and certainty when you put the neuromodulators right into your brain — or stick in secondary chemicals that release specific neuromodulators or block their uptake, which almost amounts to the same thing.

          With food addictions, it seems that the symbolic chain is longer. Maybe it contains an additional node or two. Whether feeding or starving yourself, the impact on your feelings, your brain, must pass through a lens — the lens of what the food MEANS. With drugs, you are willing to forego the meaning for the effect…at least that’s how it seems. Granted, the effect itself must have meaning.

          I’m willing to admit my ignorance. I’ve only ever been a substance addict, and I don’t know much about behavioral addictions through my own experience. So this dialogue can be very illuminating to me as well as others.

          • Elizabeth March 28, 2013 at 6:39 pm #

            I think this goes back to the developmental perspective of addiction that you eloquently present; perhaps the major differences are in the early stages. Drugs produce an immediate “high” (massive striatal DA release) that foods cannot replicate. Perhaps, over time, we arrive to the same feelings and behaviors surrounding our “addictions” as we transition to compulsivity. However, there seemingly has to be a difference in the two at onset, right?

            To me, it takes a synergy between stress, chronic food restriction/restriction and binge food consumption, and time to develop similar patterns of compulsivity that are observed with drugs; corresponding to changes in mesolimbic DA circuits. Drugs have an amazing ability to bypass the whole time thing and directly alter DA circuitry at the onset of use. Foods have to take an extra step to get to alter DA circuits (through the ppt?). This seems to make sense to me…

            • Marc March 28, 2013 at 7:04 pm #

              Yes, I agree. Whether through stimulants or opioids, or just GABA agonists, you are directly releasing DA into the striatum. And yes, I think food and drug addictions have quite different profiles at the start but end up highly overlapping when they reach the stage of compulsive action.

  5. Julia March 26, 2013 at 9:50 am #

    I agree with the cousins analogy in that the differences are a matter of degree and outward form rather than fundamental mechanism or subjective experience. As Shaun says there is work involved with substance use as well. Whether it’s simply getting the money to buy the substance, going to the liquor store and choosing (and having to be seen by the store owner, etc.) or, in the case of illegal substances, the risk involved in acquiring the substance.

    I think the issue of control is very central to all types of addiction, in the sense that being focused on the pursuit of one’s addiction gives a feeling of control, the feeling that once I achieve the goal, whether taking the pill or engaging in sex or whatever, one will get a predictable experience.

    Having had a very destructive relationship with food many years ago, I speak from my own experience. The getting of the food was often not at all pleasurable. It usually involved being secretive and at times even stealing. Sometimes it was somewhat pleasurable when I was simply buying items in anticipation. But even then I was always somewhat paranoid about what the cashier might think and would try not to patronize the same stores too often. Either way, the getting was more a necessary effort but one I was both driven to make and willing to endure for the final reward.

    I do suspect that chemicals such as alcohol, cocaine, etc. have simpler, more direct and possibly more powerful effects on brain chemistry and I’ve heard there’s some research showing that long term use may permanently alter neurological function even after recovery.

    But there is certainly no less of an element of compulsion and potential damage from behavioral addictions.Lives are ruined and even lost. I believe I came close to killing myself with my food addiction. And even whether they cause permanent changes to the brain may be moot since the experience of having lived with the behavior for any extended period permanently imprints on one’s life story. I can never honestly tell my life story without including my bulimia, nor can I get back the experience I might have had if that had not been my close companion all those years. I cannot create a parallel life where I participated in life without that very large barrier/handicap.

    Finally, I just had one question for you Marc about your recent “re-addiction.” I’ve heard it said many times that when pain killers are taken to relieve pain (and taken properly according to prescription) that they do NOT cause addiction. Are you saying that this is not true, at least for you? There is much discussion in medical and policy arenas about whether there is a danger when prescribing medications for legitimate pain management. Thoughts?

    • Elizabeth March 26, 2013 at 9:33 pm #

      Hi Julia! I was just reading through and found your post. I, like you, have experienced extremely distructive relationships with food (down to the buying separate “binge” items at different convenience stores in hope that they won’t figure out what I’m doing). Despite all the guilt, there was at times a rush to all this planning and procurement of “forbidden” items. Did you feel that way as well?

      • Julia March 27, 2013 at 9:25 am #

        HI Elizabeth, It’s been a very long time (25+ years) since I was bulimic but my memory is that I did not get any rush really from the procurement except in the sense that there was a sense of relief and freedom from the otherwise constant control I had to maintain over my eating. But I did not really look forward to any of it, the getting, the eating, the purging. It all felt like a chore in a lot of ways but one I could manage and one that provided some relief, if not simply major distraction, from the overwhelm of my real life anxieties and isolation. I had figured out early on (in my teens) that my eating problems were simply a cover up for more fundamental problems of living. So all along while I was using food as a kind of pain killer I was also pursuing help and understanding of what was really going on underneath. I think I was only able to stop the bulimic behavior when I had grown and healed enough to endure facing life without that cushion. Anyway, it sounds like you also have left the destructive behavior behind so I congratulate you for that. How we each learn to live with fear, loss, pain and make our way is simply a miracle! Take care, Julia

        • Marc April 6, 2013 at 6:32 am #

          Fascinating and heart warming. Defenses…are such a chore. Even Freud saw that. But they work. They just don’t work very well.

          I think that the commonality with drug addiction is clear. I once stayed in a hotel in Delhi for ten days, waiting for a flight. It was super cheap. A dorm, actually. The guy in the next bed would shoot one vial of morphine every four hours. Then, most often, go back to sleep.

          He kept the vials under his bed. Nobody wanted to take them.

    • Serena February 21, 2014 at 6:26 pm #

      Painkillers have about a 1-5% chance of causing addiction if taken properly for a specific physical pain condition, from the best I can figure out, and it’s toward the lower end of that range if other methods of pain control are integrated with the medication. If you take them for physical pain but not under supervision it’s higher, maybe 6-10%, and if you take them recreationally or socially it’s higher yet (I’d say 40% or so), but if you take them for mental issues or emotional pain it’s almost certain addiction will follow. Your tolerance goes up faster, I guess (based on personal experience). But if you already have a related addiction (painkillers, opium, heroin, alcohol), even using painkillers under supervision can easily trigger readdiction. I’m not a professional, but these are approximately the figures I gather from my own experience, from trying to reconcile stuff I found online, and from talking to other people in recovery.

  6. JLK March 26, 2013 at 12:01 pm #

    Hi Marc

    Ten years ago, when I was still consuming my “drug of choice” (for some reason I don’t get addicted to pain killers and have never shot or consumed the ultimate nasty: crack cocaine.)

    Before I had a better understanding of the “disease” I went to an expensive fluff-and-buff, the plan being to stay a month and be relieved of my addiction.

    After one night I decided to get outta Dodge as I felt like I was in prison. My girlfriend and others were not happy.but here is why I did it.

    The resident physician, a former Hydrocodone addict himself (40 x10/325/day.. whew!) talked me into going to two lectures he designed for me. He knew I would never make it without being convinced that what I had was PHYSICAL as well as psychological. He created some charts showing how addiction works. If what he said was true then non-drug addiction is as Marc says, a cousin at the most the only relation being compulsive behavior. Anyway the Doctor talked me into AA instead because I had the “Yuck” and “God” problem before our discussion but he knew it was the only way out for me. It worked for me anyway.

    AA has a whole lot of knock-offs for everything from cigarettes to compulsive gathering, gambling etc. And from what I hear non work as well as AA.

    AA was designed for the alcoholic therefore is the most effective for alcoholics. I personally have recommended to many people that counseling is a much better start if alcohol is not the basis of a person’s difficulties.

    That said the compulsivity accompanying alcoholism causes a lot of concomitant problems such as gambling addiction. I would hazard a wild guess that at least 10% of alcoholics are also gambling addicts. We have one surgeon in the group who used to drop $30k or more at a whack. Of course he was an Oncological Surgeon in NYC so I am sure he made a LOT of money. He now collects Ferraris instead of gambling debts.


    • Marc April 6, 2013 at 6:42 am #

      The link of compulsivity….maybe it’s not a huge brain region, but it’s got a hell of a lot of influence. And it’s neighbour, impulsivity, not far behind. Booze and drugs are close cousins indeed.

      After being addicted to most substances, the striatum becomes LESS activated except when in the presence of the thing of choice. Know what that means? Life becomes very dull, except when….

      So in order to get your dopamine pump going, risk-taking behaviour is an excellent choice. Hence the link with gambling. I’ll get to all this soon next post, about the Reward Deficiency Syndrome.

  7. Eric March 26, 2013 at 12:12 pm #

    Thanks again. As I mentioned before, the clients at the treatment center I work at eat this stuff up. So much so, that they often request I relay the info found in your book and blogs to their family members. Not only does it help to de-personalize it for the addicts, but it helps de-stigmatize it all for their family members who ask questions like, “where is their will power, or why can’t they just stop?”. Due to all these requests, once a month, for each group in our 28 day program, I give a 2 hour lecture on addiction and “the fundamental chemistry of learning” (Does that term sound familiar? Like the thief I was for almost 25 years of supporting my heroin addiction, I stole that from you.) for the clients and their family members. I often try to elicit those very questions from them, and when they say “why can’t they just stop?” I say, “I’ll tell you what, go home and try not to eat for a couple days, and when you get back, we’ll talk about addiction”. I also get a lot of responses about whether or not it is a “disease”. I then explain how it’s a good model, and then go into what I’ve learned from you. They seem to appreciate that they don’t have to decide whether or not it’s a disease. Anyway, I’m rambling. But I wanted to thank you, because I’m doing one of these lectures for the family group this weekend, and since I’m mostly a hack researcher, your material has given me and our clients so much. More than I ever got on the brain and addiction in college, and in a way that is so easy to pass on. I often get questions about the relation between substance addictions and behavioral addictions, and a whole lot of what I just read in this blog will be repeated in my lecture this weekend. The simple way you just described how drugs speak the same language as the brain is priceless. So call a cop if you want, because you just got robbed again.
    Thanks, man.

    • Marc April 6, 2013 at 6:53 am #

      Eric, This is embarrassing, but I just read your comment to my wife, Isabel, who commanded me to send it to her parents, which I did.

      Not much more for me to say. You’ve made me/us very happy and proud.
      Take care,

      P.S. I did a lot of stealing too. A lot! So….my turn to take it on the chin.

  8. peter sheath March 26, 2013 at 4:10 pm #

    Hi Marc
    I was talking to a guy I sponsor the other night about what he was going through whilst trying to stop smoking. He described feeling apart from, unconnected, socially awkward, sensitive, and emotional. We talked for some time, well I listened, he did most of the talking. I was trying to help him find the present and settle in to it.
    The thing that became very apparent to me was that, in recognising these feelings from my own experience, I realised that, for me and probably him, substances were a solution for these very unpleasant feelings. My use of them became very problematic but they did, for a time, stop these feelings.
    I have also talked to many people who have become addicted to something and almost everyone had some kind of obsessive/compulsive thing going on. Some talked about counting things like red cars and having a sense of impending doom if the final number was odd or, for some, even. I have met people who clean and tidy up obsessively, some will not step on cracks on the pavement whilst others have definite hypochondriac tendencies. Almost everyone described these OCD-type things subsiding during substance use but returning with a vengeance post detox.
    I guess what I’m saying that addiction in and of itself is a pretty insane aspect of the human condition. But maybe the real insanity is the reason why we use and/or behave in certain ways in the first place?

    • Marc April 6, 2013 at 7:11 am #

      Hi Peter. Unconnected, sensitive, emotional… that is the unholy trinity. And that’s often just the way it is. It is a real drag to have these rational minds, full of idealizations, memories of good times, plans for improvement, and yet live in the real world — where we are most often tossing in the currents of uncertainty, luck, chance. I think that discrepancy, between how it “could” or “should” be and how it is…..I think that’s what drives us into addiction.

      So what else can we do? Are we to just stand there in the cold rushing water, getting bitten by mosquitoes and scorched by the sun? I don’t mean to be so poetic, but I’m suddenly thinking of that movie, “Into the Wild”. Check it out if you haven’t seen it. It’s great. Probably that doesn’t work either.

      What’s left? Find a modicum of warmth and a little bit of certainty in our lives, trust others to care for us as much as possible (which has definite limits), trust ourselves to make up some of the balance, and endure the hot and cold currents and stinging bugs when we have to.

  9. Denise March 26, 2013 at 5:59 pm #

    Hi Marc, I learned of you while viewing the online Recovery conference. I enjoyed what you had to say and am enjoying your book even more. I am almost exactly your age, am a psychiatric social worker, writer, and addict. I’m of the belief that everyone is an addict of one sort or another. Some addictions are good and healthy, some aren’t. The most insidious are the ones that have physiological effects, such as drugs and alcohol, and to a lesser degree, cigarettes, food, caffeine, sugar, etc. Behavioral addictions take all forms, again, some good, some not good. I can’t help but think this when I hear/read you saying people get single-minded about their addictions. Well, I think that’s human nature whether it’s about getting high, getting a grant for research, or caring for your kids. Being addicted is part of the human condition. If we love something whether it’s a person, an activity, or a possession, we have a very hard time giving it up. What compounds this for certain addicts is the actual physical addiction. I believe you touched on this during the conference (and perhaps in your book, I’m only about a third into it) when you spoke about Buddhism. It’s almost impossible for us not to be attached to whatever it is we value.

    The relevance here is that most, if not all, behaviors have at least some degree of compulsivity to them. I would say that all addictions are compulsive but not all compulsions are addictive. Or, to put it another way, compulsions and addictions arise from different causes.

    Thanks for this blog!

    • Marc April 6, 2013 at 7:24 am #

      Hi Denise and welcome. I could not agree with you more. That is why I make such a fuss about NOT calling addiction a disease. The mechanisms of being human include deep, blinding attachments to the things we’re attracted to, and, yes, the development of mindless habits to maintain those attachments and keep ourselves safe. These mechanisms are of course neurological as well as psychological. We are all driven by them.

      When normal mechanisms and drives lead to abnormal conditions, we are really challenged as to how to think about them. And yet, there are always gradations between what we call normal and what we call abnormal. And you certainly don’t need substances to be an addict.

      Are there ever actually positive addictions? That’s a good question!

      • Denise April 6, 2013 at 9:40 pm #

        I would say yes, absolutely, unless we’re restricting the use of the word “addiction” to habitual behaviors that have a negative outcome. If it’s not just a question of the definition of the word “addiction” then I would think it’s safe to say that there are many positive addictions. Look at someone wedded to their profession, or someone who has a talent that requires hours of daily practice. Don’t their worlds become that profession or practice? And then, there are the twelve step programs which for many people replace their negative addiction. At the few meetings I’ve been to I met a couple of people who seemed as fanatical about the program as they must have been about their substance.

        I do believe that as you say it’s part of human nature to have qualities of getting attached to things and activities, and to forming habits and rituals. We get in trouble when we choose (if that’s the right word!) ones that harm us.

  10. Persephone March 27, 2013 at 9:56 am #

    Thanks for sharing this, Marc. I had a recent experience with illness leading to what was a very small and very managed bit of (prescribed) opiate use. What shocked me was that I took this medication knowing it was short term, and because I was out of control (flu, high fever, etc.) of the normal state of my life. I was too ill to even enjoy a “high” or remember much of it.

    The shock came when I got well and just stopped, ready to resume my normal Monday back to business as usual–and felt terrible symptoms that I recognized immediately as withdrawal. Physical as well as psychological. What amazed me was the sheer force of the catastrophic thinking that is common in withdrawal returning so strongly and after such a short period of use. I suppose the body, or rather the brain and the receptors you unwittingly (or wittingly, depending) play around with, remember and fall back into a certain mode even if your conscious brain has no plan to do so.

    Great to be reading your posts again!

    • Marc April 9, 2013 at 9:17 am #

      Hi Persephone, That sounds pretty miserable….but not so surprising. I was also moved by how thoroughly the old mind-set established itself, how tenacious it was, and how I both missed it and loathed it.

      These habits — of wanting a particular thing above all else, and feeling bereft without it — are so deeply reinforced. The synaptic pathways are not just streams in a field, they’re more like trenches. When the rain falls on that part of the terrain, there is only one path for the rivulets to take. They follow the old routes. And we can imagine those routes as having emotional call-out buttons at every point along the way, so they suck in neuromodulators that empower them, increasingly as the water rises.

      • Persephone April 9, 2013 at 10:38 am #

        I actually can’t believe I even posted that. A testament to how much it freaked me out.

        What I wanted more than anything was to not be sick, and to go back to my normal schedule, sadly. I took less than necessary (or prescribed) and for such a short period that I was shocked to have had any symptoms at all. Admittedly, they weren’t of the variety that had me so sick previously, but they were there. But just over 2 weeks and my brain responded to that degree. Thankfully, I was able to wean for a few days and not be incapacitated completely.

        The old anger, however, resurfaced along with the symptoms, that a substance had dictated my life’s course to me instead of me doing so myself, and my resolve has been strengthened due to the experience. The “never again” has returned. No one as sensitive to medications (and trust me, it’s not just opiates, as my doctors will attest) as me should be on them at all. I knew this and avoided them prior to developing the medical issue-then-injury that caused me to be prescribed opiates in the first place.

        Live and learn, eh? I just wish my brain could learn what my conscious mind has learned and not fly back to its old reactions, especially since it didn’t in terms of the “craving” aspect (perhaps because you really aren’t thinking in those terms with that high of a fever). Oh well, just something else for you to ponder in terms of the “learning” aspects of the brain, if it interests you.

        • Marc April 15, 2013 at 9:30 am #

          I’ve got LOTS to ponder…. But what I resonate to most in you comment is the sudden, unpredicted anger. I also felt that anger toward the drug(s) that had dominated my life. As in: What the fuck do you think you’re doing?!?!? Get away from me!!! Very therapeutic, ain’t it.

          Whether our brains are cooperative or whether they sneakily go and collude with the enemy….we have our weapons in reserve.

  11. NN April 3, 2013 at 12:09 am #

    Marc, below are some critical passages of your post, in **xxx** and my response. Great topic!

    **Substances such as drugs and alcohol “talk to the brain in its own language,” as I say somewhere in my book. What they provide for the user is immediate, even intimate, in that they directly alter what’s going on in your synapses — the physical medium through which you experience…everything! Their effect does not need to be mediated by actions or events. They affect the brain directly. The implications are huge, but greatest among them is the certainty they provide.**

    Good points, Marc. No one can deny how cocaine directly affects neurotransmitters. Leaving aside the IV route (the most direct), there are certain other “actions or events”: ‘snorting’ is an action, and supplies a pretty direct route.
    But taking a pill is not so direct. Takes minutes to get into bloodstream, I think, no?
    I timed it; accessed a graphic encrypted porn pic, in about a minute. Graphic sexual details of the adult human female affect the brain pretty directly; I think such sexual ‘sights’ may well be hardwired as triggers. So heart is going and also more localized reactions. Certainty, yes.

    You omit to mention that once one has a pill or bag of powder from the street at least, it’s far from certain what’s there.

    (Not all ‘hoards’ are of the quality that you apparently managed!) Hence ‘bad trips’ and other nasty effects, or maybe just ‘nothing.’ So, not always certainty.

    To take a less immediate example; visiting a sex worker. Yes, there is the doing you mention, but as Shaun pointed out, the *preparation process* gives an immediate effect. I call her on the phone and make an appointment. Again, 5 mins; pretty comparable to lots of pills, I bet.

    **The substance was hard currency. You could save it up, you could collect it at the back of your drawer. **

    In the old days, the porn mags; now the files on the computer. “Hoarding”? Well, suppose one had several gigabytes, compulsively classified. A gig represents 5000 pics.

    The list of sex workers’ phone numbers is a hoard, too, no?

    **Their effect does not need to be mediated by actions or events. They affect the brain directly. **

    Yes indeed. I grant the basic point. IV heroin gets to the opiate receptors, in a second, speaking their language. As you pointed out, however, the whole routine has its appeal, and helps constitute the addiction. And that routine is not different from visiting a sex worker or contacting her on the street. There are various symbols and conditioned associations at work that I won’t go into, now.

    All said, I agree about the ‘brain’s language,’ but for at least some sex-behavioral compulsions, the brain is engaged pretty thoroughly—though perhaps to a lesser degree measured in levels of neurochemicals. That said, the level may not be a direct indicator of the strength of the compulsion.

  12. Marc April 9, 2013 at 9:33 am #

    Hi NN. Your points are very well-taken. Very thoughtful. In fact, these are arguments that are hard to refute, and I’m not sure I want to refute them. By identifying differences between substance and behavioral addictions, I wanted to set up a debate, and you stepped right in.

    But I can argue with some of your points. While pills are slow to act, and a graphic sexual image can be accessed much more quickly than a high from a pill, both consist of an end-state and a waiting period. So let’s think about these separately. Also, it’s true that the waiting period can be filled with activities, such as chopping up the coke or calling the sex worker, that are themselves very stimulating. They are fun and exciting because they are secondary reinforcers, with huge effects on dopamine metabolism in the striatum.

    But perhaps there is still an important difference in the end-state. When I said that drugs give you a response that is reliable, certain, etc, I wasn’t thinking about the quality of the substance. Of course that can’t be guaranteed with street drugs, nor with any drugs, given the uncanny fluctuations in tolerance. What I meant was that opiates activate opioid receptors, coke activates dopamine and norepinephrine release and reuptake. Theses neural responses feel a certain way, almost regardless of where you are, what you’re doing, and so forth. And the way they feel is highly correlated with the drug (including booze). In fact the trade name of the drug is often whatever one calls that feeling: speed, smack, etc. I’m wondering: does an orgasm or an eating binge or a winning streak in poker always feel a certain way? I don’t really know, but it seems that they are, if nothing else, more complicated.

    I’m not intent on winning this argument, but I’m glad to play it out and see what we find.

  13. NN April 14, 2013 at 1:52 pm #

    Hi Marc,

    Thanks for your generous reply. I’m not sure what the exact issue for argument is, since an overlap of ‘substance’ and ‘behavioral’ addictions is granted by both of us and many in the field (even DSM folks, to a degree).

    To your main point that the predictability you refer to is in the state and levels of certain key biochemicals, such as norepinephrine, ok. And yes, perhaps there’s a range of these, in the brains of horse race betting ‘addicts. But would also grant that talking about the state of brain chemistry, *particularly in gross terms*, e.g. by levels of standard markers such as serotonin, does not tell, univocally, about the subjective experience, nor like the experienced ‘compulsion’ involved? If that’s true, then, as you elsewhere state, then that’s consistent with what you say to the effect that the experience of chemical abusers widely varies, according to the vagaries of circumstance, tolerance, etc, even assuming they get the ‘pure’ substance.

    Perhaps though it’s worth addressing the generally issue: should be label all ‘stuck’ behaviors as addictions, as seems to be the fad. Shapiro’s classic “Neurotic Styles” was certaily about persistent patterns, hard to change, esp. on one’s own; styles that
    get rationalized neatly most of the time (so called, now, Inner Addict’s talk). Of course some ‘stuck’ behaviors have marked highs and lows, and frantic ‘searching’ for something; maybe those are somewhat analogous to ‘substance use disorders’ and their frantic behaviors at times. So there dramatically ebbing and flowing compulsions, and more calmly gripping ones.

    I’m generally wondering why everyone wants the ‘addict’ label, besides for insurance reasons. I suspect it’s sometimes the romance of it: ‘I’ve got a persistent problem dragging me down and i’m slowly improving,’ is not so dramatic and compelling a tale as “I hit bottom. I turned over my life. I’ve been sober for 15 years.” And the last tale, one learn,s may well be incomplete. E.g. if they stopping drinking and gained 100 pounds.

    • Marc April 15, 2013 at 9:57 am #

      Such good points you make. I KNEW that you would come back with that argument. It’s a good one, and I don’t think I can (or even want to) rebut it. So, maybe you reliably get more NE and DA, and less serotonin reuptake….but then there’s massive variability in what all that means and what it feels like. Absolutely true. In fact, a good case in point is the immense variability in people’s response to SSRIs. A nice, pure pharmacological agent….which makes some people happier, some people more hyper, some more relaxed, and some….suicidal!

      I have to think about this…..and see if my argument still has any legs to stand on.

      Meanwhile, you also gave me an excellent idea. I’ve been toying with the idea of addiction as personality development…for a long time. And you just mentioned Shapiro’s book, which I’ve also read. The stuckness is irrefutable, of course, but the definition always had one logical problem. How do you model a personality development that starts off in middle adulthood? And the answer is; why not? Lots of powerful events — religious moments, marriage, having children, losing one’s parents, getting raped, or imprisoned, or winning a lotttery — lots of events DO trigger new trajectories in personality development. So…I’m liking the idea more….and I think I can use it in my next book.


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