Substance (not just substances) in addiction

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.

woman with nothing to doA 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.

starving dogBerridge 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 bingingexpression. 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 sex addict suffers(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 aboriginalof 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 poor whitesrelief; 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.


52 thoughts on “Substance (not just substances) in addiction

  1. Mark January 11, 2019 at 7:30 am #

    “…wanting, not liking, a drug or other reward, and this has been a major contribution to our understanding of addiction.”

    Things get REALLY interesting – not to mention complex – when you consider the Buddhist perspective that a human incarnation is the underlying “wanting” we are all fundamentally addicted to.

  2. William Abbott January 11, 2019 at 9:54 am #

    Some time ago I heard a talk about addiction to etoh as a progression from liking to wanting to needing.

    All this before you and Berridge and the DL /

    But to me most of the language used around this like ” substance” or ” addiction” or ” recovery” is sloppy and slippery . Until the ” scientists” clean up the terms, well have trouble dealing with the problem .

    Neuroscience and not medicine or psychology , must lead the way

  3. Carlton January 11, 2019 at 11:38 am #

    Marc, Yes, agreed:

    “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.”

    To add to that, and in hindsight, replacing this is something that “occurs” just like love “occurs” to a person.. it is not something a person “does”.

    In all seriousness, here is food for thought:

    From the current point-of-view of the addiction field, would Romeo and Juliette be considered “Addicts” that could have benefited from treatment, perhaps even
    by prescription?

    • April January 13, 2019 at 6:59 am #

      But of course! They were classic love addicts. Where is Stanton Peele when we need him? Dopamine drove them to unfortunate ends. If only they had had access to heroin, they could have used that instead of becoming so obsessed with each other. I may seem to be joking, but if you imagine a world where medical heroin is legal and can be prescribed, it might not be such a bad idea.

      These days, I imagine they’d be given drugs intended to calm people down, ironically either benzos or versions of speed like Adderall. Their obsession with each other would definitely been pathologized and someone would have attempted to get them into a 12 Step program to make them obsessed with the group and pleasing their sponsor and Higher Power, or to medicate them. Or both.

      If only they had lived in a society where natural urges can be acted upon without social death (if not physical death), they could have just had a nice fling and gotten on with life, as most of us did in college and so on. The repression of desire opens to door to all sorts of addiction. Sometimes, I think, it’s better to just have a slice of chocolate cake or a beer than to spend your life obsessing about the idea that you can’t. And believe me, I’ve tried both.

      • Carlton January 13, 2019 at 12:13 pm #

        But people universally believe that experiencing such an endlessly deep and unbound feeling of love like that is what we all aspire too.

        ( in their case, it was the hate and confrontation of the families that tragically ended their lives indirectly, but that is not a point here).

        A point I am trying to make is that people outside of the Addiction Field have a different point-of-view than people inside the Field of Addiction.

        It is probably why the Field of Addiction rarely hears from the addicts that have recovered on their own, or who leave recovery programs.

        Answers to ongoing and puzzling questions, and a truer understanding of Addiction and Recovery could occur is this large number of addicts.. or ex-addicts, was researched and considered.

        April, although you were being a bit lighthearted, I bet a-lot of people in the Addiction Field would readily agree with your post ! 🙂

    • Mike Johnson January 20, 2019 at 9:08 am #

      R&J is a hyper romantic fantasy created to sell tickets and is not a case history. though a doctor could have been written in of course though cleric would have been more period correct. R&J are a couple of wealthy teens with immature brains whose lack of judgement leads to personal catastrophe well within the range of reasonably expected outcomes. Shakespeare writes them off in a cautionary tale of course but what they needed was effective guidance as they were created by S. as incompetents. They needed engaged parenting and broader social support not available in drugs.

      • Claire April 7, 2019 at 3:24 am #

        Ditto, Mike.

  4. Helen Meline January 11, 2019 at 12:44 pm #

    Putting the anticipation of
    “wholeness” into a perspective. Words that describe the visual landscape in US today. From food to video games, and tied to the reward system of “Fill me up…please”
    Thank you for this article. Sharing with my colleagues.

  5. Katie January 11, 2019 at 1:44 pm #

    Nailed it, again. Thanks for making me feel understood. I wish I could find a therapist up for ‘going there’ with me.

    • Marc January 11, 2019 at 3:24 pm #

      I’m up for “going there” with my clients in online psychotherapy. It’s a place I’m familiar with, as you can tell. Let me know if you want to try connecting this way, by contacting me through the far-right tab at the top of the page.

      • April January 13, 2019 at 7:04 am #

        If only I had known about people like you and Adi Jaffe who do online psychotherapy when I was in crisis. Later on I found such people, who made a tremendous difference in my life, but the money spent on rehab could have much better gone to treatment that would not have left me scarred with fear. In the end, I found people who treated me completely for free. A list of trauma therapists provided by some of the top people in harm reduction psychotherapy were too expensive, and when I finally found a group that would have residents treat people with little money, they did a two hour phone interview intake and assessed me as too severe a case to be seen by anyone less than their most senior person, who cost $500/hour. And yes, I’m still mad. Of course people need to make a living, but it’s such a tragedy that money is thrown at rehabs that unnecessarily lock people up when it could be spent on less invasive, more effective treatment.

  6. Teresa Rodden January 11, 2019 at 4:44 pm #

    “The substance common to drug addictions and behavioral addictions may be the feeling of wholeness, once lost, now regained…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.”

    I have found this to be true with my clients and for my own sobriety. My next book (The Primed Drinker) shares two case studies that the above two paragraphs (really much of the post) could have been used to explain how they learned to misuse alcohol. Both women had lost a sense of self. It wasn’t so much the drinking (alcohol) that gave them a sense of power but in TAKING the time to drink. They assumed alcohol was the problem, but as we explored their life as a whole we discovered it was the claiming of time, space, self, that they craved.

    One trying to figure out how she can squeeze a drink in between wife and mother duties and the other escaping from aging parent duties.

    Both were able to take charge of their relationship with alcohol.

    Thank you for all you contribute to broadening the view of addiction.

    • April January 13, 2019 at 7:05 am #

      So very true – I must read your book! I dislike the term “sobriety” and don’t see that as the only goal, but definitely have seen how especially women use alcohol as a way to claim one tiny sliver of life to ourselves.

      Adi Jaffe writes quite a lot about that in The Abstinence Myth as well.

      • Teresa Rodden January 13, 2019 at 11:51 am #

        April, I didn’t like the term sobriety for most of my abstinent years, but that’s because I didn’t understand the true meaning of ‘being’ sober. The true definition of sober boils down to is to be clear of mind, not abstinence. I go much deeper in the book. But when we take abstinence off the table and focus on how you really wish to live your life, I mean with all your heart identify your true desires, to go after that life requires a clear mind. Shifting your energy and focus from not drinking to filling up on life. It may seem simple, but I’m living proof, and it’s been remarkably effective for my clients.

        Marc touches on this in the Biology of Desire, “addiction can only be beaten by the alignment of desire with personally derived, future-oriented goals.”

        Sober is freedom for me to go after life, intentionally. I have swung the full pendulum with all the language around this challenge. Language matters.

    • Carlton January 13, 2019 at 9:55 am #

      “I have found this to be true with my clients and for my own sobriety.”

      r.e the term, “sobriety.”.

      A life-changing realization can be that sobriety is a default-by-nature…it does not need to be maintained.

      What a person is actually actively maintaining is a deliberate effort and control of doing something to NOT be sober.

      This is not just semantics.

      To deeply realize that if you do nothing, you are sober, is one of the ultimately liberating realizations a person can have during the recovery process.

      • Marc January 14, 2019 at 11:48 am #

        Fascinating point, Carlton. It seems obvious. And yet.. So much energy devoted to REcovery seems to drown out the idea that sobriety is actually just settling into the here and now. Of course, we don’t always like the here and now, which is why we spend so much energy trying to get away from it. And then we seem to have to spend just as much energy, maybe more, to get back there. Seems like a terrible irony.

        Some of the “unpleasantness” of sobriety, of just being here, comes from tangible sources of suffering, as we’ve all talked about. But there’s also a belief or attitude, lying deep within our culture, that says that suffering is NOT okay and we’ve got to paper it over — viz, get loaded.

        The Buddha had a few things to say about that.

        • Carlton January 16, 2019 at 9:04 pm #

          The “Sword of Damocles” of Addiction can disappear when a person realizes that they can be doing things and be anywhere again..and only by their specific actions and effort can they NOT be sober.

          To truly realize it was the ADDICTION that required maintenance, not Sobriety, can be part of a persons life-changing experience.

        • Li January 18, 2019 at 6:55 pm #

          I was enchanted by Buddhism for a long time.

  7. April January 13, 2019 at 7:15 am #

    Another excellent piece – no surprise there!

    I’ve been thinking lately about how repression of two natural drives drove me to drinking. I was a very late blooming drinker – I didn’t really start to drink seriously until 27. I had been a super over-achiever, overcoming difficult economic circumstances and various childhood traumas to go to an Ivy League school, excel, and rise to the top of my field by the age of 27. I was supervising 10 people and running a campaign with a budget of $1 million that turned out to be the biggest success in the country in that field that year. I was also supervising a group of female bullies who treated me so cruelly that I went into what I would now recognize as PTSD.

    The two drives targeted were:

    a: ambition/power: I was the supervisor, and very good at it, and they hated authority
    b: sex: I was having a completely consensual relationship with someone I worked with, but who was not in a supervisory role over me. He also happened to be the most attractive man in the state (it was a small state, to be fair, but he was its most eligible bachelor) and they attacked me brutally over it. I was literally called a whore in a staff meeting. They attacked my clothing, my long hair, the fact that I get my nails done (you’re probably starting to guess the small state by now, as it obviously was not New Jersey). At one point I was physically threatened by a woman whom we later found out had a record of assaulting people.

    I came back fragile, unable to keep down food, and a shadow of my former self. I also started drinking… led down that path by a huge drinker who was quite confident that both he and alcohol could make all these difficulties go away.

    Women are still punished for wanting power and sex. I repressed those desires by drinking. Many repress them by eating.

    This is why I recommend watching Game of Thrones as therapy for the woman suffering with shame from drinking. It has strong female characters who overcome trauma by seizing power. “There’s no justice in the world unless we make it,” says one character, right before she slices off the head of the person who sold her to a sadist.

    I don’t recommend chopping off heads, but perhaps finding ways to satisfy the needs for intellectual growth, mastery of topics, competition (women can be hunters too! and also very competitive gatherers) and sex would be a good part of therapy.

    Instead, most therapy tries to convince us to fit the mold, repress the desires, and become good little girls again.

    • alison lewis January 13, 2019 at 2:03 pm #

      April- I very much agree with your comments that we need to stop spending more and more money on rehabs, this system sucks, sorry…. I go to two different rehabs weekly…it doesn’t work for a lot of people….
      And then people are “blamed” when “rehab doesnt work” and told they don’t have “an open mind”… ugh!

      And I agree with what you said about the “intakes” that therapists or tx providers do that determine someone is “too complex” to be treated…..I deal with this almost daily, as an advocate and I scream with rage! WE ARE ALL HUMAN. There is way TOO much judgement in the treatment field. Labeling and diagnosing people creates this environment of “us and them”.

      Counseling is not about judgment, this is why people aren’t finding what they need. And counselors have to be risk takers, they have to be willing to get into the messy…but everyone is so afraid of “liablity” that they don’t treat people….

      I finally started my own foundation to build community, and promote acceptance cause my heart was starting to break…and I felt like: how can I keep working in this field, that is itself in denial…..I feel like I’m apart of this sickness..

      Recently, I had 2 doctors say they would not authorize more time for rehab, that a person asked for, unless the person took medication assisted therapy! And the doctors said they weren’t being “coersive” ….WHAT IS YOUR DEFINTION OF COERSION?
      The doctor’s argument was “Statistics state that addicted people can ONLY get better on medication assisted therapy”. No meds no rehab time…..yeah your own made up statistics…..! Fantasyland!

      And, on your women comment: I totally agree that women are suppose to fit the mold and repress desires, about power and sex. I was raised in catholic schools. As a senior in high school, I was a terribly shy kid with a repressed nun teaching that any thought of sex was a “sin” and sexual engagement of any kind was sending you to hell. One day, as a shy kid who couldn’t open her mouth to say anything in class, I quietly but forcefully said, “No” out loud in class. (….I was recently sexually active and feeling so confused by this nun sending me to hell)
      The nun was shocked, and took me outside the classroom asking what I was doing, an “nice quiet” girl like myself. Too shy to say more, tears about to come from my eyes, I just remained silent with a dead stare on my face. She said she would give me a warning this time, but if that happened again it would be dealt with.
      I have finally turned my back on the Catholic church, I find it ironic that they were the ones repressing desire, and that ended up hurting thousands and thousands of children sexually abused…..I know that nun damaged me…cause her “teachings” sent me on more of a path of rebellion…..

      And I agree we are suppose to be the “good little girls”, but society expects women and men to repress desires all round….it makes me angry.

      AND LASTLY MARC, I love this piece you did…my favorite quotes “to replace a sense of nothingness with a sense of somethingness”. and “it’s the feeling of an empty day that can’t be filled”….so so so human….thank you for your pieces they keep me hopeful…

  8. Percy Menzies January 13, 2019 at 6:18 pm #

    A brilliant piece Marc. I am going to share this article with my medical and counseling staff. The word ‘drug’ was replaced by ‘substance’ to reduce the stigma associated with ‘drug’ addiction and ‘addiction’ was also replaced by the word ‘disorder’. Drug addiction is commonly called SUD (substance use disorder). There is a common parallel between substances and behaviors. Let’s agree that ‘substances’ encompass ‘chemicals’ like drugs, food, gambling, sex etc.

    The human biological instincts of survival is very vulnerable to substances and the environment. For the vast majority of us, the frontal lobe (the ‘wizard’ brain) keeps the primordial brain (the lizard brain) on a straight and narrow path. The access or availability of substances is major contributing factor to the development of addictions. The fact that 40% of the US population is overweight or obese is due to the easy and cheap availability of junk food. Over 120 million people in the US have exually transmitted infection (STI) and about 48 million people have a drug or alcohol addiction which includes nicotine. All three of these impact the survival instincts and sensitized by Pavlovian Conditioning. For humans the ‘bell’ rings in the form of people, places, things, time of day associated with the substance use.

    A further complicating factor is the behavior associated in obtaining substances like heroin, meth or cocaine. The subject is forced to develop unhealthy ‘connections’ like lying, cheating, stealing etc. to obtain the drugs. This behavior can be even more ‘addicting’ than the substance.

    Recovery is not an easy process. For the vast majority of patients the recovery has to occur while they continue living in the ‘swamp’. There is no easy way to drain the swamp. Indeed, it is filling up faster with newer and more potent drugs like fentanyl. Patients going away to residential treatment return home often to an bigger swamp. It is easier to reconnect with the unhealthy connections than make new and healthy connection. Bruce Alexander’s Rat Park does not exist – patients have to make their own ‘recovery’ park! Small wonder, the overdose rates have increased every single year since 2000. The number one goal is to keep patents alive by distributing opioid reversal drugs like naloxone and hope they get into treatment.

    We have finally realized that taking patients out of the toxic home environment is a good strategy. At our clinics in St Louis, the state is paying for housing these patients. Patients are offered a range of medical and psychiatric services and the housing component is a critical for long-term recovery. As usual, we do not have the funds to provide treatment and housing for everyone. Recovery is much more than palliative care with anticraving medications – we have to create an environment for healthy attachments or connections.

    • Marc January 17, 2019 at 12:27 am #

      Hi Percy. It’s good to hear from you. I’m noticing that your insights about addiction and recovery seem to be broader, more inclusive, and less formulaic than in the past. I think you see the big picture admirably. It’s important to emphasize that most addicts have to recover within the “swamp” or their home environments, which makes it all the more difficult to succeed. You also recognize that returning from residential treatment, back to the swamp, presents an even more challenging scenario. Most of all, it’s good to hear that your clinics offer choices in several domains, including the all-important domain of housing, as well as the different pharmacological aids that really can help people through the rough times. I’m glad that your focus on naltrexone seems to be less extreme. While naltrexone certainly can help some, there are many for whom it is not the preferred treatment strategy, as recently highlighted by Maia Szalavitz in Vice:

      Anyway, we both seem to be discovering and exploring new horizons, strategies, and harsh realities that are crucial for progress. Congratulations to you for your continuing contributions and your open-minded attitude.

    • Mike Johnson January 20, 2019 at 9:59 am #

      Great post! Yes, the human brain barely works and is very easily short circuited by many things especially drugs but not limited to them. As you say the “wizard” executive system does attempt to manage what we call ‘lower brain centers’ but this is intermittent at best with the reliance on training and conditioning where good training and conditioning has been installed as education. On the macro level society is being completely overrun especially by the unlimited supply of synthetic drugs. Some people can save themselves and more with help but, broadly, there is no possible source of funding for even a fraction of an ever growing catastrophe. Try to carve a decent life out of this as it is possible. Marc is our model here going from street junkie to the top 5% economically and I am quite sincere here. Yes this is a personal and public health catastrophe but it is also a huge industry in any possible terms including cash turnover and this is key! Decades ago I was introduced to the Synanon System if you like and eventually I realized that one could move from being the raw resources of an industry to being an active economic participant. Stealing and peddling dope is risky and unreliable for the struggling junkie victims so, if possible, try to stay in catastrophe management/administration and with work and luck you are vacationing in Switzerland too- well Jackson Hole anyway!

      • Marc January 20, 2019 at 10:51 am #

        I agree that we’re being overrun. But whether it’s a catastrophe or not remains to be seen. And I don’t think it’s useful to see it as purely an outgrowth of capitalism, with all its follies.

        Rather, it seems that technology not only contributes to human evolution but comprises its own evolutionary line — whereby one innovation gives rise to the next, etc. (e.g., heroin and methamphetamine are highly evolved technological achievements, yes?) And, interestingly, humans adapt to technology and co-evolve with it. Boredom-tolerant, strong-backed apes with butts well suited to sitting on buses and trains 😉 …lungs adapted to breathing air polluted by smoke (from whatever we need to burn for heat) and now, perhaps, humans with brains that like to go to the wild side….are best adapted to keep up with the really keen chemicals that continue to evolve.

        • Mike Johnson January 20, 2019 at 11:55 am #

          Thanks, you are very optimistic and perhaps this is good. With 70,000 plus confirmed KIA on opioids annually and rising let your readers know if a catastrophe has occurred. Sadly another 16 year old acquaintance just died OD. He was a wonderful young man from a family really about our most optimal/best sort.
          He had his jaw broken badly and was introduced to opioids by the System and it destroyed him-killed him. Of course and as you know the money from illegal dope sales has pulled the political/judicial system inside out. Now you can sell real poison on any street corner then just haul away the corpses and burn them as the elite looks on benignly. Honestly, too many minimalize the reality of money here. Is unlimited corruption of public official Capitalism? In the ongoing Guzman trial in NYC evidence is that 100 m USD was paid as a bribe to the previous President of Mexico and many of the governments South of the Rio Grande have been pulled inside out repeatedly for decades. I am sure we will agree that grotesque public corruption long predates anything we might really consider Capitalism to be. I admire you as you were a lot brighter and more centered than I ever was. Ever read “The Cunning of History” by Rubenstein I think- very insightful. Anyway hope everyone here slips that call from Authority about that OD dead child!

          • Marc January 20, 2019 at 12:11 pm #

            I never said or implied that capitalism isn’t part of what keeps the opioid overdose epidemic rolling. Of course it is, but that’s broadly known.

            In fact your attacks on what you say I”m saying never seem to come anywhere close to what I’m actually saying. Are you just talking to yourself here?

            Your vitriol and sarcasm made it almost impossible for me to communicate with you. Too bad.

  9. Carlton January 14, 2019 at 1:36 am #

    However, Romeo and Juliets’ endlessly deep and unbound feeling of love is what people universally all aspire too.

    A point I am trying to make is that the general point-of-view in the Addiction Field can be very different from point-of-view of the general society.

    Extremes of any type can be described as sick, diseased and needing treatment.

    This point-of-view is probably why the Addiction Field rarely hears from the addicts that have recovered on their own, or who leave recovery programs.

    Answers to puzzling questions, and a truer understanding of Addiction and Recovery may occur if the full spectrum of ex-addicts was researched and considered, including ex-addicts that no longer maintain sobriety through strength, control, therapy or pharmaceuticals.

    April, although you were being rather lighthearted, many of the people in the Addiction Field would readily agree with your post ! 🙂

    • Mike Johnson January 20, 2019 at 10:14 am #

      No, immature (childish) obsession is NOT what people universally aspire to. It is a vulnerability rooted in the very slowly maturing human brain at least in terms of a vaguely modern society. If we want to return to an era when many died in their 20s and women often died by 30 due directly to childbirth related complications then a neurologically compelled mating obsession in the teen years serves genetic propagation. No one really wants to end in a mess like Romeo and Juliet IF THEY THINK ABOUT IT! Thinking being the operational term here.

  10. matt January 14, 2019 at 7:12 am #

    Brilliant post and keen observations by everyone…that capture the fact that substance use and survival behaviors (overcoming or prevailing-over-risk, risky behaviors, like gambling and bungee jumping) are adaptive responses to stress in a world full of innumerable and unknowable stressors that our wizard and lizard brains can’t keep up with. Then the behaviors can become maladaptive given the right array of circumstances. That’s why many find vacationing on a deserted beach or camping in the woods actually relaxing.

    • Mike Johnson January 20, 2019 at 10:20 am #

      After the introduction of the internal combustion engine Horses were largely retired from the economy as “workers” deemed essential. The Human Ape is similarly exhausted and may gradually be retired from the economy joining the Horse as a pensioner on the beach. As a consolation we Apes are not being whipped quite as ruthlessly at the moment so there is that.

  11. deborah j barnes January 14, 2019 at 11:19 am #

    Hi Marc, thanks for helping bring addiction out of the Dark Ages. I am intrigued with nuance and relativity here, as i tend to see the “what is” as a platform of perceptions pressing to grow past the designated boundaries. Maybe the urge for a “something” is the “black hole” in the center of self, the culture, the universe! The urge to seek that which is “other” can be satisfied for a while, can be avoided or temporarily filled and yet eventually the quest for “more” starts up again. Maybe this is the call of evolution, is that something -drive, life force- that is always going towards the true and/or rmetaphoric light. Maybe the goals and story of the world we inherited do not satisfy the needs of a greater growing awareness, of who we are as human beings, how relativity and spectrums of choice and gender create necessary diversity, how to hold the sum and the parts as equally valuable, etc. I tend to mingle many disciplines as core commons is human thought, expression and the like. Anyway, this points to a new story of being and doing human. Maybe its something more in tune with the feminine side of the spectrum, i am my own “experiment” 🙂

    • Marc January 19, 2019 at 3:53 am #

      I like the idea that there is a progressive thrust toward finding an improvement in our psychological circumstances. Such that the “black hole” serves as a springboard to experiment with altered consciousness. This idea ties evolutionary thinking to the positive face of drug use. But unfortunately some drugs take us backward rather than forward. Maybe drugs really are shortcuts, doomed to be short-lived solutions.

      • deborah barnes January 19, 2019 at 10:48 am #

        Agreed, as the drug of whatever choice is always about a short term “fix.” Putting this desire into a literary field; it aligns with the hero journey myths as well as investment strategies and Wall Street pushers. This is why i challenge cultural norms that have created convenient divides and dramatic expectations. Real daily life can be a bore especially if the meaning and purpose are tied to a story that feels untenable.

        • Mike Johnson January 20, 2019 at 10:42 am #

          Myths- you got it there- myths provide a kind of cultural furniture and since human psychology/nature is fixed choosing a suitable myth already created is likely more time efficient. In a welfare state where actual basic needs are met with minimal effort life is routine and that is expected as we live in a bureaucratically administered society – sort of DMV with no walls. So add fantasy as needed to fill the long empty hours and there is always drugs. As automation proceeds a million or more US residents will be permanently furloughed to the economic margins on universal basic income.

    • Mike Johnson January 20, 2019 at 10:31 am #

      We are living in a collapsing culture and this is what you are detecting. This is cyclical over long time cycles and is not going anywhere as such. Your body is a machine created by your genes to replicate themselves. This is essentially knowledge replicating information. This is the cycle of life from one generation to another.

      • deborah barnes January 21, 2019 at 8:52 am #

        Yes, however, i really think the machine metaphor is way too limiting. I have found that i can now enjoy yoga and other “exercise” movements because i have tuned into my own cellular vibrancy, feels sparky one can then “get” the energy. Also muscles when felt , pushed give off a lush sensation. So i really think there is way more going on. I have exercised most of my life, a necessary chore. Anyway after doing some Yoga with Steve Ross and his directive to feel the energy in the body.. yup – was like i found another reality. I can go on, call some of it re-wilding , getting in tune and listening more to senses etc. Understanding our greater sensual abilities, enhances the brains ability to utilize the information consciously. I am now very sensitive to pthalates and food additives that are not useful to our bodies. Anyway, so not a machine.

        As for easy, i am living in a city that is playing the corporate growth progress sustainable hacking song, furthering economic polarities. . Saying life is easy to a homeless kid.. really? The dissonance i feel with the “meaning and purpose”via a world largely focused on on the market as run by the few and manipulated to satisfy the need for more g and p- is absurd! What i learned while getting my degree in environmental science and communications helped me prioritize values. Learning how life was perceived by the old guard leading to what most of us think to have value-diamonds, art after artists death, great facades etc- is like a reflection of an immature ego, all about the feedback and not much about fine tuning the whole – So i now am working on ways to share what seems so newly “obvious” to me.

  12. John McDowell January 17, 2019 at 12:27 am #

    I love your You Tubes-just discovered him, and would love to connect with you or how to find out where I can get further information that Marc follows or gets his information. I think he is brilliant.

  13. Percy Menzies January 19, 2019 at 8:45 am #

    HI Marc,

    I found your comments rather patronizing. I have been advocating outcomes-based treatments for the longest time. The present ‘treatment’ is based on the premise that addiction is an incurable ‘disease’ and the only viable treatment for opioid addiction is palliative care with substitution opioids like methadone and buprenorphine. Patients don’t need any more services beyond a daily dose of one of these drugs. This has led to the ‘treatment’ based on a business or commercial model. No chronic disorder is treated on such a model.

    I vehemently disagree with this model and because I am open minded, I continue to strive to offer the broadest range of services and use every medication that has shown clinical evidence in curbing cravings. For instance, our physicians routinely utilize medications like ondansetron, baclofen, amantadine to help patients overcome cravings for drugs ranging from alcohol to cocaine.. None of these meds have been approved to treat addictive disorders, but these drugs have a good safety record and the clinical studies look promising in the treatment of SUDs.

    Because the swamp is filling up with ‘crocodiles’ like fentanyl, cocaine, meth, the present approach of just a daily dose of methadone, buprenorphine or naltrexone is woefully inadequate. I convinced the powers to reimburse for expanded services. The two most critical needs in long-term recovery are safe housing and jobs. Yes, the good news is these and many other services are being reimbursed and patients are getting well.

    The ARCA clinics are in existence for over 18 years. Presently we have 23 internists, psychiatrists, nurse practitioners providing treatment for over 2400 heroin addicted patients a month! We provide telemedicine to about 30 rural sites in Missouri. In addition we have over 25 nurses, counselors, peer support specialists (these are former patients who have done well in their recovery) helping patients obtain food stamps, housing, jobs, vocational training etc. Our clinical staff also provides medical services for infections etc. To improve access to treatment we have now created a walk-in clinic. We have urgicare clinics for every medical problem, why not one for substance use disorder?

    I have repeatedly argued that addictive disorders is a form of ‘homelessness’. Just as homelessness cannot be treated by opening a soup kitchen and a shelter, much more needs to be done. The success of our clinics is humanizing the treatment and making it attractive. Addictions inverts the Maslow’s Pyramid. The goal of treatment is re-invert the Pyramid and get the patients back into a thriving mode.

    I continue to strive to improve our services. I would be grateful to you and Maia Szalavtiz to introduce me to clinics that I should emulate. I have on several occasions invited you and Maia and other interested parties to come to St Louis and spend a day or two at the clinics. You can meet with the staff, patients and their families and then write all you want – good, bad and everything in-between. I am baffled at the reluctance to visit a clinic that is setting the standard for caring for patients impacted by substance use disorder.

    • deborah barnes January 19, 2019 at 11:18 am #

      Hi Percy,

      What if the problem is in a greater problem; a story of life that needs to be dropped because we can now know more and understand more than our ancestors ever dreamed possible. However the system we inherited is rigid with ideas that come right out of the Dark Ages. From serfs, to slavery, to get a job, the concept of labor has been hinged to a worker/owner model since the early economic systems were designed.

      What if hierarchy is a default construct spurred by evolution until consciousness grew up? What if now is the time to reimagine life in a new context, with a new mission, a new story? What if we recognize that each person is a unique individual with a potential contribution that is necessary for the diversity that ecosystems need in order to be healthy. As our bodies are ecosystems (think microbiome) and our environments are ecosystems, well the whole old story just doesn’t cut it.
      Right now many jobs actually contribute to furthering problems therefor impacting more people who then feel unheard, bored, ill, angry, stressed etc.

      I think addiction is just fallout, an attempt to find something, to feel something in a world that dissed emotions for reason thousands of years ago.

      I unravel multiple histories, seeking clues. Wow, we can so do better than this!

      • Mike Johnson January 20, 2019 at 11:19 am #

        Hierarchy of one sort or another is typical of Human settlements as far back as we can look either in terms of the deep past or those isolated tribes such as those in the depths of the Amazon Basin who have remained in the early Stone Age until very recently. A deep study of REAL History and Anthropology as well as Political Science and Comparative Religion may assist you if you are truly interested but this will take decades, is a lot of routine work and sparking up a joint is a lot more fun! In all sincerity why not consult actuarial tables for people your age, estimate your known personal and family health history and take an educated guess as to how many years you have left? You are profoundly incorrect in many ways. Reason has never displaced emotions in human society. Since Rousseau what we call civilization in W. Europe and North America has become sharply more irrational, emotional, romantic, and irrational. People turn their lives into catastrophic messes because they cannot rationally manage their impulses or simply refuse to exercise what little executive function they might have. On the positive side machines seem poised to replace Apes increasingly in decision making situations so soon a simple majority of all US adults will be left to wander about. Today in the US about 96-97 million adults are permanently unemployed and this increases by 900 k per year-there are less than 130m full time jobs in the entire US economy including the cosseted government creatures and those who while listed as private are under direct government contracts.

        • deborah barnes January 22, 2019 at 10:00 am #

          Hi Mike,
          What if hierarchy is just a default organization construct. Animals and birds utilize it. It is like knowing when a male takes down another male, they get a testosterone rush so go for it.(i think women do as well, just not studied yet) Just because it is Natural, like old genetic thinking, it doesn’t mean it is an ultimatum. Nature seems to work with spectrums that are tuned to relativity and we can, as intelligent beings, learn to appreciate and work with that concept. Why limit ourselves to the past. As the observer influences the observation, our data, history collecting can be seen then as part of our cultural myopia. Every day is actually NEW!
          As for the reason thing, go back before Rousseau and find the Greeks great philosophers and the roots of logic and democracy as we understand it in the lore of western civilization. (Then the Romans copped a lot of the Greek ideas and spread it in their empire building-growth and progress agenda that helped “civilize the outlands. That they were already organized, no matter-pagans all -the other is not the us) That ideas resurface (Rousseau fine tuning and setting forward a greater perception of society) with new adaptations is great! Just maybe not great enough.

          The Romantic era and its odes to Nature, as the plunder of the plains and indigenous people and lands started to be queried and dang, was probably a marketing tool as well. Like the great landscapes commissioned by the railroad companies- go west young man!
          As for the church -have done my homework- the first corporation as it were and the taking down of the roles of women in the Medieval Era in Britain and wherever they could play their power, fear and salvation dogma for a tithe! Okay they did do good too, there is the spectrum of relationships thing again. 🙂

          As for the new king MONEY- wielded and manipulated by the lords of wall street, banks included here right? – might this be seen as another iteration of the ol empire building construct? The patterns, the habits, the addictive rushes are all part of life. It just seems time to face it, Flaws are talents in some lights etc. Understanding from another perspective like as above the daily level of the reality that is on the level (?) Is helpful. That level is not about hierarchy but is about getting higher. Like when kings realized they could understand battles better from a hill top than in the muck of it.
          PS thanks for the opportunity to discuss this stuff.

    • Marc January 20, 2019 at 1:25 pm #

      Sorry, Percy, I would never consciously try to patronize you. I’m not even sure where you got that. But…oh well. Words without intonation can give false impressions. In any case, I don’t think that providing a lengthy review of your clinic’s accomplishments, principles, etc, really clarifies what you see as “patronizing”. Is it because I haven’t visited your clinic yet? Sorry, but Arnhem is a long way from St. Louis! But hey, we’re both on the same side on most issues, including our distaste for the medical model and its commercial applications. And we agree on the value of connection, care, social and emotional scaffolding and all that. Still friends?

    • Marc January 20, 2019 at 1:33 pm #

      Oh I get it: it’s because I said that it seems your current insights are more inclusive and less formulaic than in the past. I was clearly talking about naltrexone. Didn’t you used to emphasize the benefits of naltrexone over and above other pharmacological interventions? And yet you didn’t even mention it this time around — which I assume means that you see it as one of several (many?) viable approaches.

  14. Percy Menzies January 21, 2019 at 2:57 pm #

    Hi Marc,

    I have the highest regards for you and we will remain friends even if we disagree on policy.There is a big difference between disagreement and being disagreeable. Because I think so highly of you, I would be honored to have you visit St Louis and see our clinics.I presume you come to the US 1-2 times a year and it would be nice if make a detour to St Louis on one of your trips. Obviously, I cannot underwrite the trip as this would constitute attempts to influence you.

    My goal from the day I established the clinics was offering evidence-based treatments. This is no different that clinics treating AIDS/HIV, cardiovascular disorders,
    cancer, asthma, diabetes etc. None of the clinics advertise what medications they use and don’t use and we assume that choice of medication is entirely based on obtaining the best treatment outcome for the patient. The clinician tells the patients the benefits and limitation of each medication and gets the patient’s buy-in. If the some reason the patient has problems related to efficacy, side-effects, costs etc. the clinician will switch to a different medication.

    The treatment of addictive disorders has historically taken a turn away from medicine because of two rather formidable silos; methadone and buprenorphine and these silos are not integrated within the realm of medicine. Few doctors want to be involved in a medical practice that doles out buprenorphine. Many got burned treating ‘chronic’ pain with heavy-duty opioids. Methadone clinics have little or no interest in offering broader services including buprenorphine and naltrexone. As a result, the gaps remains and is growing wider.

    All three medications work well when the patients are carefully selected for the most appropriate treatment. The selection should never be predicated on which medication is the most lucrative. ARCA from day one kept this as the primary objective. I talked about naltrexone because it still is an unknown medication for many. At the ARCA clinics, about 65% of the opioid patients are on buprenorphine formulations and about 35% on naltrexone, including the monthly injection Vivitrol. The choice is entirely left the patient and they can switch anytime. Almost a 100% of patients with alcohol use disorder are on naltrexone and just a few on Antabuse.

    We tell the patient that the present situation is so serious that they should remain on either buprenorphine or naltrexone indefinitely. Sadly the vast majority don’t listen to us, resulting in relapses and overdoses.Our present treatment system is to be blamed. It is too rigid and ideologically driven and shockingly underfunded as a result, less than 20% of the 23 million patients impacted by drugs and alcohol receive medical treatment.

    • Marc January 29, 2019 at 4:40 am #

      So what’s the real story viz Vivitrol/naltrexone? Percy, you’ve been a strong advocate of Vivitrol, and you use it quite a lot in your clinics. Can you tell us, how common is this sort of reaction: ? I mean a general suppression of affect and engagement. There must be stats on this. Or are there?

      Also, it seems like the manufacturers of Vivitrol are marketing their product as fiercely and insidiously as the makers of OxyContin (Purdue) a few decades ago. See: So Big Pharma (or Medium Pharma) isn’t so innocent after all. And it’s always the addicts who suffer when drug companies smell the strong scent of profit.

      It would be great if you could reply succinctly and factually. I think we’d all appreciate a bite-size lesson here. Thanks.

  15. Percy Menzies January 22, 2019 at 11:34 am #

    Hi Marc,

    Few people are aware about Big Treatment (BT). Yes, we have Big Pharma and Big Tobacco and we have BT! You allude to this you in one of the responses. Here is the quote: ” But hey, we’re both on the same side on most issues, including our distaste for the medical model and its commercial applications”, For patients to get well, they need a dog in the fight. let’s look at the stark contrast between treating AIDS/HIV and SUD AIDS/HIV patients just did not have a dog in the fight, they were the ‘dog’ demanding effective treatments NOW! Big Pharma worked with public and private agencies to develop a range of medications and treatments that now allow patients to lead near-normal lives. These treatments were made highly accessible and paid by the government. Patients did not have to stand line each morning to ingest the meds nor doctors required to obtain exemption from the DEA etc.The treatment of AIDS/HIV has gone even further into prevention. High risk patients who are not HIV positive are encouraged to take anti-retro viral medications (Pre-Exposure Prophylaxis).

    Contrast this the treatment of SUD. I believe the BT has made sure patients don’t have a dog in the fight. Many even question if ‘anonymous’ contributes to the stigma?
    BT has succeeded in keeping treatment outside mainstream medicine and ‘harm reduction’ as life-long treatment. We have to close ranks and demand radical changes. Continuing to blame Big Pharma is not going to do it.

    • Marc January 24, 2019 at 5:13 am #

      I agree with your position. Treatment should be available, accessible, stigma-free, and people with addiction should receive invitations rather than barriers when they seek medical intervention. So…again, I’m not really sure if you’re talking to me or making a generic statement about the lay of the land.

      I don’t think I make a hobby out of blaming big pharma. But as a powerful, profit-driven industry, I do blame drug companies for participating in and generating unhelpful propaganda. And for pursuing pharmaceutical alternatives only when they are obscenely profitable. For example, there is much “folk wisdom” concerning the benefits of kratom for quitting opioids without serious withdrawal symptoms. But the pressure from the industry pushes against its use and pharma research tanks duck away from clinical trials. Why? Because they can’t make a lot of money out of repackaging a profusely growing plant product.

  16. Jacob January 23, 2019 at 2:00 pm #

    Good point Marc.
    They are all same.. Fastfood addiction, porn addiction or chemical addiction.

    – Jacob

  17. Percy Menzies January 25, 2019 at 11:27 am #

    Hi Marc,

    I was making more of a generalized statement about the state of our field. We have to make treatment attractive. There are rouge elements in every facet of society who can do a lot of damage. A perfect example is the promotion of opioids for chronic pain. .We cannot get rid of junk food, pornography, gambling, internet, drugs, alcohol and many other substances and behaviors.We cannot suppress or let them run amok – no easy task. A small percentage of people exposed to substances need help and herein lies the rub – there are individuals and groups ready to exploit these desperate people and the tentacles of Big Treatment are everywhere.

    Let me give you an example. I was in South Africa and saw a rather big billboard claiming to ‘cure’ cocaine and heroin addiction within three days using ibogaine! The fee was rather hefty.I went to see this physician, a rather pleasant chap who admitted there is no way of knowing how these patient did when they returned home. Ibogaine has been touted as miracle drug for decades. We have treated three patients who got into trouble using kratom to detox off heroin and one patient who attempted to detox using opium tea. I don’t think Big Pharma is to be blamed – I am certain of that. Pharma has little or no interest in getting involved into substance abuse treatment because Big Treatment wants to maintain the status quo. I have written about it several times on the frustration of introducing naloxone and naltrexone. There are other medications like LAAM and acamprosate that met similar fates. Naloxone is seeing a new lease on life to reverse opioid overdoses and this drug was approved by the FDA in 1973!

    Look at the mess we have with medical and recreational marijuana! How can be stop or control the obscene commercialization? We are seeing this with vaping. We have groups calling for all drug use to be legalized.

    My message – let’s learn to use to existing medications we have in an intelligent, compassionate manner and breakdown barriers to treatment.

    • Marc January 28, 2019 at 7:47 am #

      I appreciate that you have your strong opinions, Percy. I agree with some, but not all. You say three patients got in trouble using kratom to detox. But I’d imagine that a fairly large proportion of people trying to detox from opioids will get in trouble one way or another. So what does this statement mean? I personally do not think kratom should be banned, simply because it can help and often does help to reduce withdrawal symptoms.

      The world is a complex place, and there’s room for divergent opinions. I think you and I agree that addiction treatment, when called for, should be accessible and should take advantage of proven pharmaceutical aids. But we seem to disagree on other matters. I don’t think either kratom or marijuana should be banned. And I find the issue of drug decriminalization/legalization to be complex, not simple.

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