A new act to control the prescription of narcotics (we assume they mean opioids) just went into law in Ontario on November 1. (Similar acts are not unlikely in the rest of Canada.) This act will presumably make it harder for people to forge prescriptions, use alternate names, borrow prescriptions, and so forth. One of the hallmarks of the act seems to be better enforcement of the recording of information never previously required, including the registration number for the prescriber (doctor) and an identification number for the drug itself. It’s hard to get specific, based on the wording of the act, but the upshot is that pharmaceutical opiates will be more difficult to obtain. What does that mean for those of you who treat or study addiction? What does it mean for those of you who use opiates?
Let’s start with the last question first. If users use less, if the problem really diminishes, then those who treat users will have less work to do. But if users get more desperate, or more clever, if they have to pay more, steal more, lie more, etc, then those who treat users may have more work to do. So all we need to do is figure out the consequences for users.
But it’s complicated. Like the age-0ld competition between cops and robbers, or rulers and rebels, there has been an ever-escalating stalemate between attempts to banish drugs and attempts to procure them. The dopamine-pumped addict, like the starved animal he resembles neurobiologically, has one goal and one goal only. All that dopamine crashing around in the nervous system…. When it doesn’t lead you directly to the goal, it supports the most effective, efficient, creative thinking on how to get around the obstacles and get you there regardless. Dopamine is good for thinking, planning, strategizing, and conniving. People with ADHD, and who can’t keep enough dopamine in their synapses, suffer from the dissolution of focused attention. They can’t keep their goals in mind. Dopamine-stoked addicts have the opposite problem. The goal is all they have in mind.
Also, dopamine makes you desperate, just like the starving animal. Contrary to the out-of-date view that dopamine is part of a pleasure circuit, dopamine is about doing when the goal is available and craving or striving when the goal is out of reach. That has pretty stark consequences for the law of supply and demand. When the supply of opiates is diminished (but not eradicated), the demand goes up. Way up. That’s why addicts of various stripes resort to poor quality drugs, hugely expensive drugs, and drugs mixed with all kinds of nonsense. It’s also why alcoholics on a low budget traditionally drink after-shave, cooking wine, or even rubbing alcohol (which is poison).
So picture the addict, with all that dopamine and no place to go, frothing wavelets rising higher and higher in the tank of the self. That dopamine has got to be good for something, and that something is success, regardless of the obstacles. Natural selection didn’t preserve dopamine because it helps you spit out watermelon seeds. Dopamine means business. Dopamine circuitry evolved to help achieve goals, difficult goals, despite the barriers of competition, scarcity, and natural enemies. Well, I suppose drug enforcement policy is a natural enemy for drug users.
Now if opiate drugs could be made completely unavailable, that would certainly diminish the problem of opiate addiction. But is that possible? If not, we’ll see what new tactics users adopt, with this latest plugged leak in the dopamine bucket.
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
As usual, your writing paints a picture like nothing else. You gave a visual of dopamine that describes it in action like nothing I ever read in my university text books.
This blog is excellent, a nice companion to the book, and I look forward to your comments.
I’m still slowly savouring the book, I’m at the point where you give up California and move to Asia. I love your writing Marc. Keep it up!
Best!
Dave
Thanks, Dave. I will keep it up. For now I’ll keep hammering away at this blog and a cousin blog I’m just starting on the Psychology Today website. The fact that university courses in neuroscience were generally boring began to seem almost sacreligious to me, a few years ago. Which is one of the reasons I wanted to bring the brain to life in my book, and to recount my life experiences (primarily with drugs and addiction) in terms that were simpatico, as much as possible, with what was (presumably) going on in my brain.
Cheers,
Marc
Hi Marc:
You have the broadest overview possible I should think. Is it your opinion that people could be reliant on an opiate and still look after themselves? Once we make H scarce people will make almost any sacrifice to get the drug as this accords with the priority established by the brain and so they ruin their health. I wonder if you have seen images of Krokodil addicts from Russia yet? No sacrifice is too high for some, apparently.
If we had a small experimental population of 100 addicts BEFORE they began the big plunge in terms of living standards and gave them opiates without counselling could they have some sort of acceptable life from their point of view. Let us just exclude employment related complications.
Hi Marc:
I am especially interested in the point that opiates do not damage the brain and this seems preferable to any other of the current intoxicants.
These are thought experiments of course but could all the other intoxicants be prohibited and Heroin provided at minimal expense? What could the stuff actually be worth to produce?
Forget the legalities, please. If Heroin were “recommended” by the medical community as the alternative to self medication would that work? Would enough addicts of all stripes accept this trade off? You are speculating here but who else might comment in a meaningful way on this?
Mike, I don’t think heroin would be of much interest to people who get high on pot, meth, coke, and quite a few other things. Drug addictions seem to be an acquired taste. And more importantly, people are drawn to their drug of choice by needs, holes, and gaps in their personality — which differ quite a bit from person to person. People who seek warmth and safety go for opioids. People who seek excitement and power go for meth or coke. This is not an absolute rule, of course, but it would seem to argue against any one-drug-fits-all solution. And besides, it just so happens that heroin is highly addictive. Even if it doesn’t destroy the brain and body, it certainly paralyzes the will and shuts down the mind.
Doc:
You are the voice from the darkness so to speak but just a thought experiment:
If all other substances were illegal and suppressed actively and heroin was sold at cost do you think it is possible that addicts would self convert?
I fully take your point on personal choices when it is all illegal and priced accordingly. I am trying to figure out how to narrow the problem.
If you insist on being addicted do I not want you addicted to something “safer”?
I know that when I had my first LSD I really felt it was “The Answer” but I do not know about heroin by use and might be too old to start 🙂 Have used opium/hash blend a little bit so I have a small idea. Certainly you were no trouble to anyone.
If a person were committed involuntarily for any drug addiction could you convert them to heroin reliably via syringe?
I have too many talented acquaintances wiped out by coke and H and have supported those in need.
Really need to see some way to go on this, not hope but a route to try any way. These friends are not just objects of general social concern. The crime is a big deal along with all the viruses and resistant bacteria but the human waste here is staggering, seriously.
Hi Mike, I was a bit glib in my recent response. I’m sorry about your friends and acquaintances “wiped out by coke and H”. A reader recently sent a link to an amateur video about drugs and terminal addiction on the streets of Vancouver: http://arch1design.com/blog/vancouver-addiction-homelessness-poverty/ I don’t agree with the main message, that harm reduction is wrong if not plain evil. I think harm reduction is a great way to go if you can’t quit. But the video does show very powerful images of people addicted to heroin or crack. Nobody — just nobody — wants to live like that. A friend of mine finally got on methadone after years of addiction to prescription drugs. He felt fine for a while, then he just felt bored. He finally got on crack and killed himself.
I don’t think shovelling all addictions into one bin, then adding chemical x every few hours, is a great solution to the problem. There are many reasons for that opinion, but one is that addiction to anything commits one’s life to a cycle that is one-dimensional and stupidly repetitive. That provides structure, but it trashes vivacity, creativity, and spontaneity. So…let’s keep thinking.
OK Doc:
I will try to see it your way and I do see the point but to me the primary case is that these people are being DONE TO DEATH as a matter of policy and it is this extermination program which has to be halted first.
The “authorities” keep these people right on the edge of death and hope, after they are fully exploited, that they die by engineered mischances.
Each addict is generating 100s of dollars a day of revenue into the Narcotics Marketing Board. Once they are too wrecked to hook or steal it is hoped that they off themselves by OD. The Government realizes it cannot simply gas them but the similarity of these people to totally worked out residents of Nazi Concentration Camps is unmistakable to me. In that case the SS contracted them as slave labour out to german industrialists on an 800 calorie/day diet and when they were reduced to skeletons like these junkies they were gassed.
In BC we contract the addicts out to the gangs for employment as prostitutes and petty criminals paid in drugs instead of money for the loot.
Since there is a constant supply of new addicts from the schools and the work is not complicated deaths eliminate super exploited workers.
The supply of fresh needles and pipes is designed to lessen the load of AIDS on the medical system which upsets the provincial budget. We want you out of the hospitals and on the street earning right up until the moment you die of an OD.
My idea is to close the Downtown Eastside Extermination Camp and then maybe you and other doctors who are NOT bent can look into helping them.
The police have been instructed to do as little as possible in terms of disrupting the trade in flesh, dope, or stolen property as long as you do the business in assigned areas.
They will step in when the bullets start flying or if the murder is the result of violence like with a hammer or other but that is it.
There is more and it is worse but I will not go there.
So how to figure: there is an avalanche of dirt cheap dope falling onto society – UNLIMITED SUPPLY – and the Justice System does nothing other than assure orderly markets.
It is coming from above.
Hi Marc:
I would like to note that opiates and coke and their derivatives are available in unlimited supply in this area and the prices are so low dealers offer credit and home delivery.
For some reason doctors and pharmacists are obsessed 🙂 to avoid prescribing pain killers and mood modifiers on the notion that you MIGHT abuse them. This might make sense if they were not available in unlimited quantities on the street at competitive pricing so my reaction to the Ontario program is this will likely tighten the legal supply but the illegal supply is virtually unlimited.
The only possible effect is to shift narcotic distribution to the Justice Department and away from the pharmaceutical industry. For those preferring pills alternate supply pathways will be established.
In Canada we have a lot of experience smuggling contraband tobacco, alcohol, narcotics, and humans into the USA. Our suppliers will create false invoices showing that they are shipping the Oxy to some foreign country but the actual dope will stay right here and be handed over to the gangs for distribution.
I tend to agree that the street will provide what the government denies. The detours around Prohibition are a great example. Whether they should provide narcs at the LCBO is another matter. What will happen on Sundays, when they’re closed?
Hi Doc:
Well the deal is now for safe injection that the addict leaves the site and in time commits a crime, scores from a dealer and then heads back to the site. Meanwhile nurses wait to assist in a safe journey.
The sharks have to stay out of sight.
Why not pass out the H too, you skip the crime,the poison and the ODs too!
Currently this is much better for the dealers but a little tough on the citizenry who subsidize all this from crime though I did like your joke 😉
It could be made self funding like the alcohol and gambling abuse programs.
Areas in downtown Vancouver are like Hogarth’s “Gin Lane” if you have seen that painting.
You can get into Hospice when you are finally dying, that is a perk that comes with single payer health insurance.
Hey Mike, give me a minute! It’s been dark for hours over here in the Netherlands. I’ll read and write more when the sun comes up…. if the sun comes up.
Hi Marc,
Thought this might interest you.
http://www.beliefnet.com/Health/Healthy-Living/Ecstasy-Hope-or-Hallucination.aspx?source=NEWSLETTER&nlsource=13&ppc=&utm_campaign=Buddhist&utm_source=NL&utm_medium=newsletter&utm_term=sympatico.ca
I’m sure you’re familiar with Dr. Gabor Mate’s work with ayahuasca, Any comments?
Hi Linda, My brother and I met Gabor Mate last October during my book tour. We walked him while he was walking his dog through a lovely neighbourhood in Vancouver, and he told us his ideas about using ayahuasca to treat addiction.
As you might know, Mate sees addiction as an attempt to fill holes, or at least numb negative emotions, that have sprouted from childhood trauma: http://www.youtube.com/watch?v=_-APGWvYupU A good way to treat addiction is to face the trauma and its results in one way or another. Ayahuasca brings on a profound and personal vision that apparently is powerful enough to change fundamental features of ones’ personality, by putting you in touch with your own fears or pain and pointing your way through to the other side. And it has been used to treat addiction in the Amazon area for many years.
Mate has organized several therapeutic retreats for addicts, based on the use of ayahuasca. He says that a good deal of guidance and support is necessary to make the ayahuasca experience productive, rather than confusing or possibly terrifying. And he has been working on learning how to provide that type of support. The beneficial result, he says, is that addicts can sometimes give up their addictions, even after many years of continuous heroin use, for example, after a single ayahuasca experience. They are willing and able to go through withdrawal, in preference to going back to their addiction.
Unfortunately, Health Canada recently threatened Mate with prosecution if he continues his ayahuasca tea parties. See: http://ayaproject.posterous.com/doctor-gabor-mate-ordered-by-health-canada-to He says he will comply with the order, but I hope that doesn’t stop research efforts, whether formal or informal, to explore the potential benefits of this fascinating drug.
To gauge just how much the quantity of dopamine receptors had affected the rats’ eating behavior, Kenny and Johnson inserted a virus into the brains of a test group of the animals to knock out their striatal dopamine D2 receptors, which are known in humans to be at low levels in many substance abusers. They found that rather than gradually increasing rat brain reward thresholds and accompanying overeating behavior these rats almost immediately had higher thresholds and took to overeating immediately when given access to a high-fat diet. This connection, Kenny says, shows that for people who have lower levels of D2 receptors, “it could predispose you to developing this kind of habitual behavior.”
It makes sense to me that the effect would be immediate, not gradual, given that the dopamine knock-out is immediate. But the connection between dopamine and addiction seems no longer to be in doubt. Rather, there is still some dispute as to whether dopamine receptivity supplies pleasure (the older view) or whether it mediates attraction and goal pursuit. I take the latter view, following Berridge and Robinson.
Interesting also that psychostimulants diminish dopamine receptor density, but opiates do not. My sense is that’s because psychostimulants are not only attractive, but their effect is based on attraction — fulfilled attraction perhaps — but that is a big part of their reward value, rather than pleasure per se.
To gauge just how much the quantity of dopamine receptors had affected the rats’ eating behavior, Kenny and Johnson inserted a virus into the brains of a test group of the animals to knock out their striatal dopamine D2 receptors, which are known in humans to be at low levels in many substance abusers. They found that rather than gradually increasing rat brain reward thresholds and accompanying overeating behavior these rats almost immediately had higher thresholds and took to overeating immediately when given access to a high-fat diet. This connection, Kenny says, shows that for people who have lower levels of D2 receptors, “it could predispose you to developing this kind of habitual behavior.”