Hi guys…I’ve missed you. I’ve missed putting up regular posts for the last couple of months and I’ve kept mostly out of the discussions and debates in the comment sections….but scanned them enough to see that you are still in top form. I encourage all readers to take a look at the comments on the last few posts. There are some really valuable views, arguments, and insights being posted.
Anyway, for now, I wanted to wish you all a good year and maybe touch on some current controversies that will affect us in the coming months.
What have I been up to? Mostly editing and proof-reading a couple of articles, updating a talk that I plan to give next Saturday in London on sex addiction, planning a new talk circuit, and zillions of little things that I can’t name or categorize or even remember half the time. Paying backlogged bills, replying to emails buried in my inbox, trying once more to learn Dutch, changing light-bulbs, driving or biking (with) my kids around to various lessons, shopping, etc., and doing a fair bit of psychotherapy. Remember I mentioned that I’m starting a Skype-based counselling/psychotherapy practice for people “in addiction”? Well, it’s happening. I have about six clients so far, and I really like it. Sometimes I feel like I’m good at it, and sometimes I even seem to be helping people, which of course feels great. And relaxing…a bit more than usual…especially over the holidays. That was gooooood.
So what are some topics that should be addressed in this year’s postings? Here are some thoughts:
The “opioid epidemic” in the US. This is obviously a big issue, it’s on the front page half the time. I even get asked by people why I haven’t contributed to the debate yet. Well partly because it’s so complicated, partly because I’m not sure I understand it, and partly because it makes me sad. One avenue of debate involves prescription vs. street drugs. And that divides into two sub-themes, addiction and overdose.
First comes the evidence that most people who end up on heroin started off on prescription painkillers. What does this mean? Does it mean that getting opiates for pain is the cause of long-term addiction and all that goes with it? Not according to 
Johann Hari, as revisited in his recent op-ed piece. He reminds us (despite a spat of criticism) that by far the majority of people who take prescription meds for pain don’t get addicted. Carl Hart pounds out the same message. So is this just a rehash of the gateway drug idea — remember how they used to blame smoking weed for graduation to hard drugs? Most people ride bikes before they learn to drive cars. Does this mean that bike-riding is a dangerous precursor to auto deaths? Or is it smart for addicts to avoid heroin if they possibly can? How do we extricate the logic from the rhetoric here?
Obviously prescription opioids have to be handled with great care. Yet prescription opioids are often mixed with each other and/or with heroin, by people who want to get high, not pain-free. So how do we balance their risks against the needs of the millions who really need these drugs for pain control?
Which brings us to the overdose epidemic. Which is obviously highly interwined with the above. Although overdose deaths are reported to result from the use of prescription drugs more than from heroin, these deaths have everything to do with mixing drugs, as I’ve reported elsewhere. And this issue has taken on deadly significance now that fentanyl has entered the scene. Stanton Peele has a few things to say about that. With fentanyl so widely available (it’s entirely synthetic, you know), and with doctors getting increasingly tight-fisted (partly due to pressures from regulating bodies), what choice will addicts have other than street drugs (or abstinence)? So is legalization the only other answer? With all the problems that entails? But even without fentanyl…why exactly do people take so much dope? What does it tell us when they’re mixing heroin and methadone? I’ve touched on that one as well.
So those are a few of the headline topics that we can deal with this year. And there are others. With Trump in the US, Duterte in the Phillipines, and Putin in between, getting arrested for using drugs is starting to look more lethal than overdosing. 
What is going on in terms of the international pendulum swing between draconian repressive approaches and the ever-more-
enlightened drug policies of countries (like the UK, Canada, and Australia) where people are stepping away from the “brain disease” model and the nasty habit of throwing addicts in jail? Cannabis will soon be legal throughout both Canada and the US! And it seems they’re finally about to close Tent City — that horrible concentration camp for addicts in sunny Arizona — if they haven’t already. Are things getting better or worse?!
And there’s so much more to talk about. More acceptance of the validity of “controlled drinking,” as we heard about from James Morris a few posts ago. Ongoing turmoil but also some radical new perspectives regarding 12-step approaches and AA. See next post. And sure enough we keep learning more about the addicted brain. In a radio interview with KABC Los Angeles last week, I fell back into this interminable squabble between the brain disease model and my (alternative) no-it’s-not-a-disease-but-yes-it-still-involves-the-brain model of addiction, and all I really wanted to say, by the end of it, was: it’s time for a truce! We’re not listening to each other! Well maybe this year, on this blog, we can find a way to do that.
Please suggest other topics you’d like us to explore. That would be very welcome.
So Happy New Year, welcome back, and let’s hope it’s a good, better, maybe even best year for those of us who care so much about addicts and addiction.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
I’m guessing, as a neuroscientist, Marc, you realize that learning to listen skillfully is not much different than learning to master the violin or a three point jump shot. You need a LOT of reps. Plus some sort of practice so that your adrenals don’t repeatedly make you their bitch!
For many years I taught listening skills to aspiring clinicians. I can’t recall a single class when, by the end, students didn’t say, “Wow! I never realized how much there was to truly listening. Or how much I truly suck at it.!”
Yes, listening is a complex affair. I guess you’re talking about what I said about the two sides of the debate not listening to each other. And it goes a lot deeper than just ideological grumpiness. I have more I’d like to say about this, but let me put out a simple question:
Is there something intrinsic to the disease idea that makes it completely incompatible with a developmental-learning explanation of addiction? People often talk about developmental illnesses, like heart disease and cancer. So what’s the problem? I think there’s something weird going on, as if the psychiatric community and people like Maia Szalavitz and me belong to different religions, or species, or come from different planets.
Marc, one quick reply to your question;
The Disease model presents addicts as Patients, and a victim of a disease.
Currently, the Developmental-Learning Explanation is different and not easy to relate too, but resonates with a large percentage of people that innately do not feel or treat themselves as a patient or a victim of a disease.
The sense of self and conduct can be profoundly different.
And in this way, it is indeed completely incompatible with the Disease model.
I know what you mean, Carlton. In fact I stress these diametrically different implications when I compare the two models in my talks and writings. But y’know, there still might be room for some compromise. It startles me sometimes to remember that I was once considered a player in a field called Developmental Psychopathology. I even published in a journal with that name. So, if “development” and “psychopathology” can coexist in the same phrase, maybe there really is room for an overlap in our approaches to addiction. Developmental trajectories that stray so far from the societal norm that they dig their own grave, so to speak, might be considered “pathological”.
But I agree with you: we developmentalists will always have to distance ourselves from the *medical* tentacles of that word “pathology”… That would have to be part of the peace treaty.
Hi Marc, and a happy New year to you too! An interesting, reflective and scary post. I’ve almost finished reading Johann Hari’s excellent book “Chasing the Scream” (which I will recommend to fellow recoverers on http://www.hellosundaymorning.org, as a Must Read, so I understood your reference to Tent City.
(Remember that people outside the US aren’t so familiar with these places, unless they take a deep dive into reading and learning about all kinds of addictions….)
A subject I’m nominating is Compassion and Addiction. Is compassion (self and for others) one of the routes out of addiction? I’ve found it has really worked for me. Here I’m talking about the neuroscience, rather than religious route.
Here’s to a happy, healthy 2017 for all of us! Hope your London talk goes well, too….
Hi Annette. Yes, I think compassion is hugely important. I try to nurture compassion in my clients and in myself. I don’t think this is just a touchy-feely thing, or a religious thing…I think it’s specific and pragmatic.
Can we arrive at a neuro model of how compassion helps? Probably, yes. Already years of research into the neurobiology of mindfulness has revealed some very reliable results. Like the deactivation of the default mode network — see previous posts — and increasing activation of the left prefrontal cortex, which is responsible for viewing our own and others’ behaviour in context, in perspective, etc. Also, activation of the insula is increased in meditators, and this correlates with empathic responses in laboratory studies.
In a nutshell, I’m not bold enough to propose a specific model, but I am very sure from my own experience that compassion for self and others is essential to dampen craving. Compassion is the antidote to shame, and shame maintains the suffering that finds relief in using.
I think compassion is needed for any healing and growth, including becoming free of addiction, though I’ve never been a substance addict, so I hope I don’t sound glib. Compassion is knowing yourself, and giving yourself the time, space and resources you need, in order to heal and develop.
You don’t sound glib, and that’s a nice way to put it. Compassion *allows* us to take time, to make mistakes, to be imperfect….so that each failure doesn’t rev up the feedback cycle of self-blame and using.
They say that relapse is part of recovery. But it’s also part of not-recovery. What makes the difference between these two forks in the road is forgiving yourself for slipping and not having to punish yourself further.
Mike:january 16,2017 at 8:17pm #
In Buddhism deep listening is very closely linked with compassion. To give full attention is an act of respect, caring, compassion. When one gives respect the
odds increase that respect is returned. A potentially very rewarding cycle is
set in motion. My experience with addiction, is that it is very esteem based.
The pain of feeling unworthy. Deep listening seems indeed a step in the right
direction.
Right on. That’s what I mean about the role of shame, which is the emotional kernel of feeling unworthy. Respect for oneself is an amazing feeling, and most addicts cannot come close to it…can’t even recall what it feels like. It feels like dawn after a long long night.
Excellent post, especially for not falling into the trap of trying to simplify! It IS complicated. Life is complicated, human behavior is complicated and the world we live in is incredibly complicated! Which doesn’t mean to stop trying to understand or articulate. If anything it makes it all the more important to have spaces such as this to explore and become more comfortable with uncertainly, imperfection, limits to control and just general openness to multiple points of view.
That said, speaking about legalization, etc. I had the pleasure of hearing a speaker from an organization I knew nothing about until recently, Law Enforcement Against Prohibition. It’s composed of police and other criminal justice professionals dedicated to educating the public about the harms of drug prohibition http://leap.cc/about-us/who-we-are/. I am so inspired to know there’s a growing momentum against the “war on drugs.”
Finally, as for topics, I am always interested in personal stories, maybe using them as examples and jumping off points for specific aspects of how addictions develop, how people deal with them and to illustrate the multiplicity of experiences that challenge the effort to lump people and their lives into easily defined groups.
Happy New Year and see some of you I’m sure in DC on the 21st for the Women’s March! Julia
Julia, thanks for this great reply. Well yes, this forum is ideal for dealing with the complexities. Almost every other addiction website/publication has got an agenda, which lapses into oversimplification…. Here, we seem to start off by acknowledging that we don’t understand, and proceeding from there.
That site you dug up is fabulous. I just forwarded the link to a group of addiction specialists who are trying to compose as policy reform letter for the new US administration. Seriously! I knew there were a few voices in the wilderness, but this could be the start of a snowball effect.
I take your suggestion about stories. I also find personal memoirs and anecdotes tremendously moving and informative. I will try for more of that content. But make sure and take a look at the “Guest Memoirs” page on this website… there’s a lot there. The trick is to somehow extract generalizations from these stories that can help others.
Happy New Year!
This is sad news, but I do think I have to mention it, partly becaus of its implications:
‘CDC numbers released last week indicate that the number of heroin-related deaths in the United States rose from 10,574 in 2014 to 12,990 in 2015. That 23 percent increase occurred even though heroin use, as measured by the National Survey on Drug Use and Health (NSDUH), declined last year. This development underlines a phenomenon I’ve noted before: Heroin use is more dangerous than it used to be. Since 2002, according to NSDUH, the number of heroin users has more than doubled, but the number of drug poisoning deaths involving heroin has more than sextupled. To put it another way, heroin users are about three times as likely to die from drug poisoning as they were in 2002…
…The shift to the black market can’t be the whole story, because there was a similar divergence between consumption of legal opioids and deaths involving them. Nonmedical use of these drugs fell slightly between 2002 and 2014, when the number of deaths involving them rose by 150 percent. It seems clear that fatalities are not a simple function of use rates, which means policies aimed at driving down consumption may not be the most effective way to reduce deaths.’
http://reason.com/blog/2016/12/12/heroin-related-deaths-rise-as-heroin-use
P.S.: Could it be there is a new type of user now, particularly reckless and prone to mixing different substances to a larger degree than before?
Even more worryingly, there is this question: How do we know how many of these deaths are actually suicides?
Maia Szalavitz wrote about this a while ago:
‘Research on calls to poison centers related to opioid overdose also suggests that suicidal intentions are commonly missed in those who actually die. A 2015 study of over 184,000 calls received by these centers (including over 1,000 that were linked to deaths) found that two thirds of the cases overall involved signs of intent to commit suicide. Among those who died, the proportion was even higher: 75 percent in people aged 20 to 59 and 86 percent in those over 60.
Further, rates of known suicides are also rising, particularly in one group that is at the highest risk for opioid overdose: whites aged 45 to 54. Between 1999 and 2013, the known suicide rate in this population rose by nearly 10 percent and the poisoning death rate increased 22 percent. If many of the “accidental” OD deaths are in fact suicides, that rate would clearly have risen even higher.’
https://www.vice.com/en_us/article/how-many-drug-overdoses-are-actually-suicides
Matty, thanks for bringing these data to the table. The facts strongly suggest, as you say, that overdose rates do not correlate with rates of using, whether heroin or pharmaceuticals.
It seems very complex indeed. Are more people, especially within specific subpopulations, attempting and succeeding at suicide? Does this reflect societal issues that come before drugs enter the picture? Or do people who want to kill themselves now have an easier way to do it, since illegal opioids are more available in some areas than ever? Or is the opiate route to suicide just highlighted more, given publicity concerning the deaths of celebrities?
If there’s one thing I learned in developmental psychology, it’s that there are no linear cause-effect relationships. In real life, everything works via “multicausality” and disproportionate cause-effect relations. And sleeper effects, and a whole bunch of other complexities that make it really hard to discern causes from effects.
Like you, I sometimes think that there is a new type of user, a generation or two who like to walk on the edge even more than we did when I was young. I’ve talked with some users who seem to embody that approach. One way to confront the existential problems of mortality? And/or perhaps mixing drugs is the only way to get really high, given the increased restrictions on prescription opiates? Combine those factors with stronger drugs, more influential cartels, and the recent introduction of fentanyl and you’ve got a very complex story indeed.
Again, thanks for laying out some statistics. Let’s try to keep these in mind as we try to figure out what’s happening.
And Happy New Year to you too, despite everything!
In British Columbia, Canada there have been hundreds of over dose deaths from recreational users thinking they are doing a line of cocaine only to discover it is laced with fentanyl. These are not suicides. It feels like murder! It is not just the opiate abuser that is falling in numbers to the fentanyl crisis. I am not sure what the answer is but there is a crisis going on in this province.
I’ve heard about coke being laced with fentanyl here in Europe as well, also sometimes with deadly results. I have no idea what to make of this. From a dealer’s point of view, it makes no sense. If people are in the market for a stimulant, why give them an opiate? And if those people are your customers, why risk killing them? Does anyone have any more information about this particular issue?
Hi Marc – glad you’re back in the swing of things!
I was explaining this to someone the other day – the (as you call it)
“no-it’s-not-a-disease-but-yes-it-still-involves-the-brain” model.
So well said, you.
The attachment to addiction-as-disease is is deep as religious conviction for some, I’m finding. I think there’s also a sense that one’s sobriety/well-being/life depends on seeing it as a disease.
I wasn’t as effective as I wanted to be that day… but I’ll keep on with it. There’s so much value in it.
Thanks, and here’s to 2017. Onward.
Ex-addicts that never believed addiction was a disease, live lives that are very different than those who believe in the disease model.
Studying this could lead to a new understanding of Addiction.
Hi Joanna, Not sure what you mean by your last sentence, but as far as clinging to the disease model, yes, I hear this again and again. Many addicts take comfort in the idea that what they’re doing is not their fault. And while I wouldn’t want to take away someone’s security blanket, the “it’s not my fault” belief makes it harder to stop. This is not just common sense or speculation. There are now half a dozen studies that show correlations between the disease “belief” and higher rates of relapse.
Check out the comment sections below my Guardian articles that target the disease model. Many of those comments are protests, and some are quite angry.
Marc, in response to your question about lacing cocaine with fentanyl, there are multiple incentives for the dealer. Fentanyl is cheaper than coke so it’s a way to stretch your product. It’s also more addictive, so it’s in the interest of the dealer to (covertly) upsell, as it were, in hopes of getting customers dependent on a more tenacious drug. Plus, many dedicated drug users are not so particular about what they get high on so long as they get high on something—like whatever the dealer has on offer.
On the other hand, novice users may be looking to party with some coke, rightfully fearful about dabbling in opiates. But a wily dealer can slip it to them surreptitiously as a way of introducing the product to those who may find it tasty after all. I’ve also seen it done as a goof. As in, watch what happens when this lightweight gets hit with something he isn’t expecting. Har-har. Dealers don’t intentionally kill customers; however, they don’t necessarily know how strong their product is. I remember in the early 1980s when fentanyl was first hitting the streets, it was being sold as China White heroin. People weren’t accustomed to its potency and there were a slew of ODs.
As far as topics I’d like to see developed, I’m interested in exploring addiction and epigenetics. I was catching up on my New Yorkers this week and came across a fascinating piece about histones and epigenetics. Though it’s not about addiction per se, it included this morsel:
The neuroscientist and psychiatrist Eric Nestler, who studies addiction, gave mice repeated injections of cocaine, and found that the histones were altered in the reward-recognizing region of the brain. When the histone modification was chemically blocked, the mice were less likely to become addicted. http://www.newyorker.com/magazine/2016/05/02/breakthroughs-in-epigenetics
What might the implications of this be for human addicts? And what is involved in histone modification anyway?
Thanks, Lisa….you seem to hit many nails on the head here. The reasons you supply for fentanyl-laced coke are believable….especially, in my mind, concerning new users. If they don’t know what coke is “supposed” to feel like, then they might just like whatever it is they’re getting. Then, indeed, physical dependency sneaks in the door. The high from such a mixture is what we used to call a “speedball” — the roller coaster ride from a coke stimulation onset to an opiate soft landing. Very attractive actually, and very dangerous.
Thanks for suggesting a look at epigenetics. I’ve never explored this in depth, and it’s certainly time to do so. For those of you who don’t know the term, it refers to the way environmental learning (e.g., normal learning) can actually affect the way genes operate, or turn them on or off, without changing the genome (the DNA) itself. This idea has been a bombshell in the field of behavioural genetics.
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