Hi All. I just got back from a week in the French Alps. I know: poor me. But I spent the first day trying to snow-board, and fell on my ass with bone-jarring impact about once a minute. And I thought I was past the suicidal thing…
But while I was away, my US publicist sent me the link to a New York Post article, for which I was interviewed by phone in depth the week before. Most newspaper and magazine coverage of the book has been pretty good, despite various factual errors. But this article had some of my words and convictions turned completely upside down. For example:
Along with many other leaders in the field, Lewis believes that the recovery model needs an overhaul, that addiction should be treated as manageable disease, akin to HIV, rather than a curable one.
I don’t think of addiction as a disease at all. Sure, the disease metaphor resonates with aspects of addiction. But whenever I’m asked (as I was this time), I describe addiction as a form of learning. It’s a kind of learning that’s vastly accelerated and self-reinforcing. But it’s not a disease. And I would never, in my wildest dreams, compare addiction to HIV — there is NO VIRUS at work here.
But I don’t blame this columnist for trying to fit addiction into a familiar mould. The gist of her article was about inadequacies in the 12-step approach, and we were in synch on many points. In fact, her aim was to find a simple answer to a complex question. What the hell is addiction and how do we “cure” it?
My book and my other writings highlight the commonalities among addictions and among addicts. I emphasize a “common pathway” of addiction in the neurochemistry of dopamine, the role of the ventral striatum in craving, and the sculpting of synaptic pathways (in the orbitofrontal cortex) that imbue drug, drink, or whatever it is with value. Other neuroscientists also believe in a common pathway for all addictions. Along with ego fatigue, and a few other well-documented findings, these neuropsychological realities reveal something universal about addiction. So a lot of my message is that we share the same brain — with its characteristic frailties — and when we fall, we fall down the same rabbit hole, and share the same challenges when we try to climb out.
And yet…what I have learned, not only from the addiction literature but from you, dear readers, is that people recover in vastly different ways.
First come the statistics. About 5% of alcoholics stop for good on their own every year (see this opinionated but fascinating review). The rate of spontaneous recovery appears to be far higher for narcotics addicts (see the recent book by Gene Heyman. Though I disagree with some of Heyman’s arguments, his statistics on spontaneous recovery are informative.) Second, harm reduction really works: many people don’t stop using but they slow down or clean up enough to stop destroying themselves — another natural process of healing. Third, comments on this blog clearly demonstrate that, as difficult as it is to ignore craving, many of us manage to resist it or outsmart it until it becomes manageable, on our own, or with friends, or with family, or with our partners, or in the care of recovery programs (12-step based or not), or in therapeutic communities, or with private therapists, or, or, or…
I’m continuously blown away by how much diversity there is in how people get by and get out.
So what do I tell journalists who want to know the answer ? Yes, brain characteristics are fundamentally relevant to the addiction process. Yes, finding a “common pathway” in the neuroscience of addiction is critical, both for addicts and for those involved in helping them. But no, there is no common pathway to recovery. Some of us take comfort in following rules. Others abhor them. Some of us need to feel cared for before we can stop. Others need to feel more independent. And there are all those shades of grey, those mixtures and variants, among them. We are each individuals, with unique experiences, capacities, affinities, and aversions, and our creativity is probably the most important element in our recovery.
That doesn’t sound at all like a disease.
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
Hi Marc:
I understand that some of the countries in Scandinavia have had relatively large
“long life” programs where they track specific people from birth in order to study various items of sociological interest. I wonder if there has been any such work on narcotics addicts. Your life and book are actually a good example. Anyone really follow addicts for decades?
As a Doctor perhaps you know cases where a nicotine addict is completely committed to the habit up until the day that his Doctor finally convinces him that Death really is imminent and suddenly in short order the habit is dropped as a matter of Life and Death. Of course I have also known guys who continued to smoke through their tracheotomy incision after surgery so it is not a 100% but it seems very influential in any case.
It seems that in long term addictions that stretch on for years or decades “something” else must be running under the addiction even if it is simply an anxious personality simply falling apart with neurological decline or the loss of hormones also by age.
I recently heard an edition of “Piano Jazz” with Marian McPartland and she interviewed a singer who was on Heroin and in and out of prison for 40 years finally giving up “the life” he had lead 1946-86 then set out on a career as a jazz vocalist almost 80 at the time of the recording.
Naturally I thought of you 🙂 Seriously though while he is clean now did he wear in a groove then totally wear the groove out? Do addictions end when the “pathway” is finally burned through or solidly crystalized with Dopamine?
Hi Mike. I don’t think there’s anything simple about an anxious personality falling apart. The thing is that neurological decline isn’t necessary, though it can sure speed up the process. Addiction itself amplifies anxiety. Because the process is clearly self-destructive, addicts become increasingly disturbed, fragmented, even terrified. And yes, that tends to perpetuate the addiction. A vicious cycle, to be sure.
As to statistics, the book by Gene Heyman, which I link to in my post, makes reference to several long-term longitudinal studies. That’s the first place I’d go to look for more information.
Hi Marc:
I am thinking about the notion that there is an anxiety center in the brain that is attritted by the normal age related neurological decline ( as an example) which might have granted “relief” within the patient’s perspective.
Being about he same age perhaps you note this as well in those in the mid 60s.
So a personality need not “fall apart” to be “happier” and less anxious due to brain related decline.
Old age as a route to “personality change” sufficiently profound that the addict either no longer can respond to the self medication or no longer perceives the requirement.
Here is a speculative question.
Do you think a professional could addict any person to heroin assuming the subject were held in some sort of custody?
Are there people who are NOT prone to addiction to heroin? You may recall this from the French Connection where the evil trafficker catches the policeman and forces addiction on him in the dungeon.
I am not concerned with a movie review but whether there is some knowledge of people who might have an addiction resistent brain design. I am unable to quant concepts like willpower as such… 16 ounce PFC makes sense for instance.
Apparently many Vietnam veterans arrived home addicted to opiates, and yet many of them quit and never went back to it once they resumed civilian life, while others stayed stuck in their addictions. I believe the main differentiating factor was how rich and rewarding and supportive the rest of their lives were. It’s a lot harder to get rats addicted to drugs when they live in an interesting, engaging, natural environment. Very easy to get rats addicted when they are living in boring, restrictive, unnatural cages.
Yes, thanks, I do know some people in this category. Some DID draw a line when they returned. Others seem to have really good lives from the outside at least then become addicts after a serious injury like a broken back.
There are many narratives- know a world ranked artist who was a genius as a kid, became an addict, became a famous carver and returned to the addict life- in his case you almost HAVE TO think what he had was 100x better then Heroin but he thought not.
Thanks, Cynthia. These are very pertinent phenomena.
The spontaneous recovery of a large proportion of Viet Nam vets is one of the pillars of Gene Heyman’s argument…in the book I link to above. Statistics on spontaneous recovery (which he summarizes thoroughly) allow him to call addiction a “disorder of choice”. But I think he oversimplifies things, largely because he completely neglects brain changes brought on by drug use and addiction. The bottom line is that CHOICE is no simple matter — it’s complex and mysterious and certainly a function of brain dynamics. Heyman would probably not disagree, but he uses the book to do battle with the “disease model” and therefore gives the brain short shrift.
Regarding addicted rodents, absolutely right. Check out the famous “Rat Park” experiment (nice review at http://wikipedia.org/wiki/Rat_Park) in which rats in rich social environments (as opposed to isolated metal cages) chose to drink water rather than morphine solution, unlike their less fortunate peers. A chapter in my book is entitled “Night Life in Rat Park,” based on this marvellous study and my own experience of being caged in.
Hey Mike; I have been an addict for most of my life, and in my personal life, addicts have their choice drugs that seem to address some underling issues or imbalances. In my view anyone can become addicted to heroin. Its is a common drug used in the slave traded of women and prostitution. Get the girls addicted and they need to do the tricks to get the drug. But for a person of free choice either you like it or you don’t. For some, the first time they use it, their addicted to the feeling it gives them, some how it fills a void that they have been searching for, for a long time, the escape or comfort it gives them. The side affects of the physical with draw are some thing they are in constant pursuit of avoiding. Like a person forced into prostitution and drug addiction, being under influence makes it tolerable, but it’s the sickness of the withdraw that keeps them trapped. Just My Opionion
Reg; Richard Henry
Thanks- I have been substance dependent on various things but never really an opiate addict or user. I understand the part about particular drug preferences from personal experiences and am wondering if heroin might be universally addictive if presented in the right way.
When first sold it was in a tablet form as you may know and a lot of people are negative on smoke and needles and the associations with that.
Dr. Marc is deeply into brain structures so I am wondering if 100% of the population is addiction prone assuming it were presented in the right way or some lesser percentage.
I am beginning to think that we only have discovered and undiscovered addicts.
Of the people that you have seen try herion and not like it do you recall if they had a particular objection?
I think the Joker character in “The Killing Joke” had it correct when he says: ” I’ve proved my point. I’ve demonstrated there’s no difference between me and everyone else! All it takes is one bad day to reduce the sanest man alive to lunacy. That’s how far the world is from where I am. Just one bad day.”
Dramatic…yes. But I think that when the general person walks on their road of life and they come to crossroads where they can choose “this” or “that” we take a quick and subconscious inventory of our risk and protective factors and choose.
And all it takes is *one* bad day to turn us away from everything, snip ourselves from the social fabric and become something else entirely.
There’s a book called “Straight life: The story of Art Pepper.” This guy was one of the best jazz saxophonists ever. The day he first took heroin was a massive turning point in his life. He says he finally felt at peace, for the first time. (see Richard’s comment above)
He never stopped and he died a junkie.
Yet his childhood was miserable — really awful — as the book also details. So is it really one bad day, or is it a critical moment in a not-so-great lifetime?
That’s a really good question. Bio – Psycho – Social? I know that I have an ACE (adverse childhood experience) score of 8 (range of 1=low and 10=all) which is pretty high. But I still never say I was “abused” or even “neglected”, I just say “like most, my family had it’s quirks.”
When I started giving talks about how women differ from men in both their addiction and their approach to recovery, trauma is a big component and I was introduced to the ACE test ( http://www.cdc.gov/ace/outcomes.htm ).
Now I know that some things I both witnessed and experienced in my active addiction constitute trauma, but I really wasn’t investing any energy into my own childhood. I thought *everyone* had an ACE score of 8. I thought 8 was normal and anyone lower than a 4 was lying about their experiences.
During my curriculum participants are offered the chance to take the ACE test for themselves. It’s a brilliant little thing, only 10 yes or no questions. But in the time that I’ve been doing this the average score is a 2. Two!!!
So, I’ve recently had to consider some of the things that constituted my “normal” growing up may have also contributed to the fact that when heroin was introduced to my system, it finally felt like I could relax and be safe and just rest.
This is an interesting question, and one I have often pondered myself. As an ICU nurse, I have frequently seen similar cases. Fentanyl, a synthetic opiod, is a commonly used analgesic in the ICU setting. It is not uncommon to find patients on extremely high doses (1500 mcg/hr and higher). Obviously, they are also intubated and sedated (sometimes the fentanyl serving that purpose as well). As the patient’s acuity improves over the course of their stay, the fentanyl is quickly weaned off. A little too quickly. A lot of times, over the course of a day. Being in the ICU setting, however, all physical withdrawal symptoms can be controlled. Patient safety is maintained, but is this ethical?
Going back to your question, could a professional addict any person to heroin assuming the subject were held in some sort of custody. I think the answer is yes. However, that does not answer the question of who will recover successfully…
I have observed in the aforementioned instance of the patient on high fentanyl dosages that was quickly weaned down – high anxiety, accelerated vital signs, delerium, etc. – all symptoms that could be contributed to withdrawal. But I have also observed the exact opposite – patients who smoothly progress through the extubation process and are discharged later that day. I think the missing link here has to do with psychological factors.
I agree with Heyman in that individuals with underlying psychological issues are most likely going to have a more difficult time recovering from addiction. And I think it is interesting in my example of the ICU patients, that a lot of the time they are unaware of the drugs that they receive while intubated & sedated. Does this change their response to rapid weaning of analgesia? I would say that it most definitely does.
This is really great observational data, thanks!
I see the point that people who are in very tough shape ( I gather ) have so much going on they do not necessarily even notice the drugs with intubation in place and an expectation that there would be some sort of sedation applied.
Then as they are in “recovery” they expect all the gear and associated drugs to be lifted more or less as an integrated unit accompanied by a return to acuity.
Do you detect any difference between people who might be in the OR due to some extreme trauma that was a surprise like a car crash and those whose gradually deteriorated situation due perhaps to cancer has allowed them to adjust prior to the procedure?
That’s really an interesting question Mike. Of course, this is only rough observation, and I am unable to truly isolate variables, but I would say that overall, I do not notice any difference in the speculative addiction of the more acute patients versus the more long term progressive-type patient scenarios. I’m going to think on this a little more, but I like your referral to the gear & drugs as an “integrated unit”. There are so many more factors that could potentially come into play on how the patient perceives the whole experience. Not to mention all of the chemicals were loading them with… I’ll have to spend some time trying to wrap my brain around all of that. Thank you for your feedback.
Jaimee, your observations remind me of something told to me by my advisor when I worked in the rat labs at U of Toronto. She said that rats addicted to morphine would start to show withdrawal symptoms just before the time of their daily dose. Roughly an hour to a half-hour before. Thus, the body seemed to be preparing itself by “rebounding” away from the state that was expected to come — probably to achieve a physiological balance. (See the part in my book about “antireward” a term for the opioid-rebound effect.)
Anyway, this anecdote about the rats has stayed with me. It seems to show that some kind of cognitive process is involved in the withdrawal process. Rats may not be very smart, but “expectation” and “time estimation” are cognitive processes.
This may help explain why some of your patients show greatly reduced withdrawal effects, and why those who don’t know they were ever “on” fentanyl may show none at all. It is indeed a process that is partly psychological.
The interface between the psychological and the physiological remains one of the greatest mysteries facing our science.
I read the report you cited about harm reduction and we definitely want to look more closely at that though one hardly expects to see a report entitled “Harm Intensification” written since 1944.
I always tend to think of addiction in terms of individual addicts rather than as populations or subpopulations or a subculture within a city. I also think interms of addiction to powerful drugs. One part of the study that really struck me was the subpop of 51,000 referred to.
There are many people in NYC metro but at 51,000 on hard drugs plus add all the other addictions and one begins to wonder if “addiction” is not pushing to a condition of normality strictly on the basis of numbers/total.
As a professional can you comment on this statistically?
At some point it would become a kind of obesity.
51,000. That’s about 1/20th of a million. I think there are still about 8 million people in NYC. So that’s…let’s see…1/160th of the total population. Less than 1%. I’ll bet obesity is a lot more common than that.
These epidemiological studies are pretty standard when people are trying to figure out if a treatment works or not. So…even though we think of addicts as individuals, such studies are important.
True,
About 2/3rds of US adult residents are BMI 25+ and 1/3rd BMI 30%. But you can imagine what sort of broad policies might be possible.
It is beginning to sound like we need a vaccination program.
Ref. “I’m continuously blown away by how much diversity there is in how people get by and get out.” here is a fascinating thread with 150+ pages of comments of people trying to get off caffeine; http://coffeefaq.com/site/node/11?page=157
Man, that is impressive! I just glanced at some of these comments, and I see that caffeine addiction can be serious!