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The paper I recently published in the New England Journal of Medicine (linked here, summary linked here) detailed my best arguments against the disease model of addiction. But it also explored new territory, and that’s the topic of today’s post.

I emphasized (as I have for years) that addiction is learned. It is not a pathology but a learned package of desires, actions and expectancies that keep leading back to the same reward. We call it a reward, but most of us who’ve been through it know that the experience itself gets less rewarding even as the desires and expectancies continue to strengthen. Is that pathological? No more than being in love with a hurtful partner, or praying to an unresponsive god, or being devoted to a sports team despite their string of losses. When the power of a reward arises from strong emotions and needs, the tendency to pursue it isn’t rational. When we seek and find that thing again and again, then, through learning, the synapses of our brain form into dense networks (pathways of connected neurons) that become very difficult to circumvent. Learning on overdrive, through repetitive need-satisfaction, is habit formation — addiction is a deep and insidious habit.

Well, you’ve heard me go on about this before, and my second addiction book, The Biology of Desire, makes the point pretty well. But my recent article came out in a journal read by more doctors than any other journal in the world. To convince that audience, I tried (with the help of Shaun Shelly, who co-wrote or edited much of it) to show that each of the brain changes highlighted by the disease model are not pathological. They’re the sorts of brain changes you’d expect when expectancies and emotions become attached to a specific goal, leading to behaviours that are partly automatic — and partly not. Habit formation results in automaticity,  sensitization to some rewards, and desensitization to others. The brain changes seen in addiction are just the biological underpinnings of this natural learning progression. And…they can continue to update; they’re not carved in stone.

The new territory I wanted to explore sits outside the brain, in the world, in the environment of the addict (I use that term without disdain or judgement, having been one myself). Our environment, especially our social environment, consists of the people we care about, many of whom care about us, and of opportunities for care, for sharing, for pleasure, for relief, for a sense of fulfillment. These opportunities require certain resources, such as social skills, knowledge, self-esteem (at least a little), financial stability, the capacity to understand others. Opportunities are bridges between our needs and their satisfaction. Resources are the capital we use to pursue them.

When people fall into addiction, their environments shrink around them. Good friends, stable romantic partners, available, loving family members, physical comforts such as a safe place to live, job opportunities, and all the rest of it, gradually become less available. The opportunities for getting them back also become less available. Our attention and motivation, riveted now to just one source of satisfaction, lose their connection with the other sources of satisfaction that “normal” people enjoy. I see this as a literal narrowing or shrinking of the environment. Because of what I’ve called “now appeal” — or simply habit strength or deeply learned habitual behaviour patterns — we focus only on what’s in front of us and forget how to go after other rewards. So other rewards fade in availability. They evaporate. They get lost.

When I was an addict, I lost close friends, I lost a woman I loved, I lost the opportunity to communicate honestly with my parents, I lost money, I lost a sense of social and physical safety, I got kicked out of school and lost that opportunity (for a while) and all the rest of it. This picture is typical, one way or another.

But what blows me away conceptually is how this narrowing of the available, reachable, usable social environment precisely parallels the narrowing going on in one’s brain. My synapses fell in line, in pathways and networks that had a single purpose, so to speak, rather than multiple pathways supporting multiple purposes. This “narrowing” in the brain corresponded with a shrinking or narrowing in my available environment. Neither is pathological. Both, especially both together, create a kind of prison.

Perhaps of interest to those into philosophy or psychology, this tendency has been studied as a universal feature of living organisms. The sensory and behavioural specialties of a species get synchronized with aspects of that species’ environment. Both change together. This can happen over evolutionary time. But it can also happen at the scale of human development, as I’m talking about here. The study of this process is called “embodied cognition.” Google it.

One more point made in the article that Shaun and I thought was crucially important: people who study addiction know that there are massive correlations between early adversity (e.g., neglect, abuse, poverty, racial segregation, parental depression, parental alcoholism — in childhood or adolescence) and the probability of becoming addicted later in life. When thinking about how the narrowing environment corresponds with the narrowing of brain function, we can see that the addict’s environment starts off narrow! Kids with happy, healthy social-emotional worlds, who have not experienced trauma, rarely become addicts.

It’s really so simple. The narrowing begins early, sometimes even before birth — look to the family of origin. (Gabor Maté has emphasized the impact of adversity in early childhood. Bruce Alexander targets sociocultural adversity.) This helps us understand how environments and brains influence each other all the way along. If your childhood is hampered by obstacles and dead-ends, whether emotional, social, financial, or some combination of these, the narrowing has already begun.

It’s been 2 1/2 weeks since I put up that summary of Maia Szalavitz’s excellent article. Busy time since then. But now I’m in Boston, visiting my friend Matt Robert and a few others, and sitting in on SMART recovery meetings. Matt has been a SMART facilitator for over six years. I came here to learn more about SMART and to hang out and relax with a dear friend.

A couple of things happened recently. First, I haven’t told you that my review article (summarized here) was finally published in the New England Journal of Medicine. It came out roughly two weeks ago. This is a very high-impact journal — (approximately) every doctor in the Western world subscribes to it. And I’m pretty proud that I published a paper criticizing the disease model of addiction in a medical journal. I’m going to tell you more about that paper (and the blowback it provoked) in an upcoming post. But for now I feel two things: (1) that’s the last scientific journal article I’m ever going to write, because it takes so much f…ing effort, and (2) I’m really good at rational argument — I’m a pro!

But my most moving experience lately wasn’t resting on my laurels. It was the realization that I’m not such a pro when it comes to influencing people’s thinking, changing their minds.

I was talking with someone I know here in Boston… Just a conversation in the backseat of a car. We were talking about this and that, and then the topic of gun ownership came up. Both Jane (pseudonym) and I are lefties, very much opposed to the proliferation of gun ownership in the US and the political voices that advocate it. I guess you could say it’s an emotional topic for both of us. But we differed on a sort of thought experiment: What would it be like if people could make guns on a 3D printer and those guns were entirely untraceable? Would that be a bad thing because there’d be more guns around (her point) or a good thing because the NRA and its right-wing supporters would lose their influence (my point)? The content of the argument hardly matters. Neither of us had ever thought about plastic guns before. We were speculating, and then discussing, and then debating.

Things got heated. Jane said what she thought; I said what I thought. Of course she countered the points I made and I countered the points she made. That’s what an argument is — right? — and arguments can be valuable. But something else was emerging. My motive was no longer to arrive at a consensus or even a conclusion. My motive was to win. I’m making really good points, I told myself. I’m winning the debate. Through parry and thrust (in the language of fencing) I tried to take her down. To defeat her. All I really cared about was being right.

What I didn’t see until the next day was that Jane was hurt. She perceived my arguments as weapons — and indeed they were. I had thought: given competing positions,  someone’s going to win, and that’s going to be me. She had thought: why is he putting me down? Why is he trying to cast my opinions as groundless and stupid?

When I realized I’d caused her to feel attacked, I felt like shit of course. But that sensitivity dial had been tuned to zero during our argument.

So what?

I spend a lot of time refuting, invalidating, quashing, debunking the disease model of addiction — as I’m sure you know. The question that confronts me now is how am I going about it? Do I really want to change the minds of people steeped in medical thinking, addicts who believe they’re ill, their families, their doctors? Or do I just want to win a debate?

So I’m watching Matt facilitate a SMART meeting in Boston last night. SMART sometimes construes itself as “the alternative to AA.” SMART offers psychological tools, such as focusing on one’s own thought patterns and beliefs, and the potential that offers for behaviour change, even by small increments. SMART lends itself to mindfulness practices, it neither shames nor exonerates those who’ve “relapsed.” It is inclusive, it does its best to avoid dogma. And it values honesty and fellowship — as does its sometimes querulous cousin, AA.

But what impressed me more than any of these qualities was the warmth and sensitivity that characterized last night’s meeting. Here were 9 or 10 very vulnerable people, all of whom were “in recovery.” At the start of the meeting they seemed shy and uncertain. Matt’s job was (in part) to encourage them to to review and modify their thinking habits, to see their substance use more rationally, more comprehensively. But more than that, he was listening carefully to what people said and grasping what they were feeling: their fears, vulnerabilities, and their (often tattered) self-esteem.

The result was a spreading aura of self-acceptance, mutual acceptance, honesty, and empathy. By the end of the meeting, people were smiling and patting each other on the back or hugging and saying “until next week.”

That’s how to change minds — and hearts. Not to pound them with the superiority of one’s logical arguments, grounded in evidence. Who really has evidence for their claims when it comes to the hard questions, like whether it’s best to define addiction as a disease or not?

I still see things the way I see them. (I still don’t want to call addiction a disease.) But maybe I can do a better job of seeing things the way other people see them. Wouldn’t that be valuable? Either in the case of intellectual argument (as in journal articles) or in sharing emotional concerns in the backseat of the car.

 

 

For years, Maia Szalavitz has been making insightful, practical, and evidence-based contributions to the struggle against “the War on Drugs” and the harmful policies that emerge from it. With her permission, and the permission of editor Will Godfrey, I’m posting passages from an article she published in Filter, a magazine covering drug use, drug policy and human rights, on October 8, 2018. This is the most important article on opioid addiction treatment I’ve ever read.

 

The following text is Maia’s writing, though I’ve spliced and diced it and extracted only the key components (in my view).

………………..

As panel after summit after commission after white paper is put forward claiming to solve the overdose crisis, you’d think that somewhere there’d be a short, sensible guide for how to improve our health care system to better manage addiction and pain.

But most of these reports and discussions dance around the edges and bureaucratic obstacles to change. Few address the fact that deep systemic change is needed.

1) Genuinely expand access to medication treatment—yesterday.

We have two drugs that are proven to cut the death rate from opioid addiction by half or more when used long term: methadone and buprenorphine. Anyone who is addicted to opioids and  wants to get even a single dose once should be able to access these medications on demand—in hospitals, doctor’s offices, emergency rooms and syringe exchange programs…. No urines or counseling or abstinence from opioids or other substances should be required to get these drugs, just as those barriers are not imposed on people with other disorders who need medication.

The DEA and state prosecutors also need to stop targeting buprenorphine prescribers, regardless of whether they are providing optimum care. Simple access to the medication saves lives: Get out of the way!

2) Stop forced tapering of pain patients and provide real access to proven alternatives.

In response to the overdose crisis, in 2016 the Centers for Disease Control released a set of guidelines intended to reduce overuse of opioids in the treatment of chronic pain in primary care…  [T]hese were rapidly “weaponized,” as Dr. Stefan Kertesz of the University of Alabama put it in an excellent paper.

Basically, the guidelines are now seen as the national standard of care—and stepping outside the maximum recommended dosages is viewed as flirting with medical board or even prosecutorial scrutiny, even for specialists. Their recommendations are being applied indiscriminately, with even some cancer and end-of-life patients being denied adequate pain relief.

Simultaneously…many doctors have simply decided to stop prescribing opioids, period. States are also creating rigid policies while insurers and pharmacies are increasingly restricting what they will allow… The result is tens of thousands of patients—many of whom were formerly medically stable—being left in pain, increased disability and withdrawal. Dozens of suicides by pain patients have been reported. People with addictions whose prescriptions are cut are not being helped either. This simply makes their addiction more dangerous by pushing them to street drugs. It is not treatment…

No evidence shows benefit from forced taper; some suggests severe harm.

3) Create a tiered system for addiction medication access.

For harm reduction, what’s needed is a welcoming place where people can simply get a dose of medication and see some friendly faces. This…provides rapid access and guidance into care for those who decide they do want additional help…If you are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic.

For stabilization, people who want to put their lives back together need easy access to services that meet their particular needs, such as counseling, medication-friendly peer support, psychiatric care, housing and job training…. [T]he goal is no use of non-prescribed opioids, but it is flexible and nonjudgmental. For example, in an effective system, non-medical marijuana use would be ignored…

After people have been stabilized, however, they will need the third track, which [avoids] interaction with people who are still actively addicted. If you have a job and family and are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic or get further counseling.  This track—sometimes called “medical maintenance”—basically requires a once-a-month check-in to get medication via a primary care doctor and ensure all is well.

5) Create and fund a full range of harm reduction services.  

In order to save lives, we need safer consumption spaces (or better yet,  call them “overdose prevention sites”) in areas where drug use and sales are concentrated…

We also need shelters and housing, separate from those aimed at stabilization and abstinence, for people who are actively addicted, many of whom are also mentally ill and have symptoms related to severe trauma. When people have safe places to live and to use drugs, they are both much more likely to survive and much more likely to find ways to sustained recovery.

6) Decouple “beds” from treatment.

People with addiction have a wide range of individual needs, and institutional “programs” will never be able to meet all of them. Moreover, once a treatment “bed” is labeled as such, it generally becomes more expensive than an ordinary, safe place to stay. “Sober homes” also tend to be based on a 12-step ideology, which is fine for those who find that pathway amenable, but not for those who don’t—and not when that ideology is interpreted to stigmatize and discourage medication use.

For most illnesses, medical and psychiatric, people recover better when they can stay in their own home with their friends and family nearby…….

The mental health field has recognized that institutionalization is generally harmful and that, when needed, should only be used for the shortest possible time. Addiction treatment needs to catch up.

We need a system that provides a menu of individualized options—not residences staffed mainly by non-medical people that charge inpatient hospital care rates.

9) Decriminalize drug possession.

Since possession arrests do not deter drug use, raise drug prices or treat addiction, every cent spent [arresting and jailing people for drug possession] is wasted. But it’s actually more harmful than that. People arrested and jailed for opioid addiction lose their tolerance and are three-to-five times more likely to overdose after release than if they had not been incarcerated.

Worse, the primary purpose of criminalization is to stigmatize drug use and people who take drugs—if criminalization is to deter people, it must stigmatize. And that stigma, of course, is a huge barrier to getting people into treatment whether for addiction or for overdose; to making treatment more effective; to expanding harm reduction; and basically to everything we need to do to end the crisis.

10) Make universal health care happen.

While having a national health care system in the US once seemed to be a pipe dream, the increasing embrace of “Medicare for all” by Democrats and the fact that majorities now support it in polls means that—providing we survive the current administration—it may soon be possible.

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Reprinted from an article by Maia Szalavitz, October 8, 2018. Please see the full article, published by Filter. Here is the direct link. You can follow Filter on Facebook or Twitter. Maia’s recent book is available at Amazon and other outlets.

 

 

I just listened to the first 15 minutes of a lecture by Robert Sapolsky, a renowned biologist and Stanford professor. Sapolsky begins with an incisive lesson on why humans rely on categories. Categories, he says, make it easier to think about complex phenomena. And human social behaviour is nothing if not complex. My friend Tom insisted that this online lecture series was worth viewing, and he’s right. I plan to view the rest. But first, this post.

Take something a little simpler than human behaviour. If a colour falls between orange and yellow, you’ll have a harder time thinking about that colour and remembering it than if it’s either orange or yellow. Yet light frequencies fall along a continuum without boundaries. In other words, we actually invent colour boundaries, and different cultures see colour differently. It’s easier to remember a shape if you can call it a circle or a square than if it doesn’t fit any geometrical category. If the shape is squarish with rounded corners, or blob-like, you’ll have a harder time thinking about it, remembering it, and using it in a conceptual task. (Sapolsky demonstrates these examples on the white board.)

So, okay, categories are tools for simplifying perception and thought. But there are several down sides to categorical thinking. Sapolsky mentions a few, but here’s the one that inspired this post. Remember when 65 was the cut-off between a pass and a fail? (That was the cut point when I was an undergrad.) So you’ve spent much of the week partying, getting high, etc, and here comes the exam, and you cram for it that morning, give it your best shot, and wait anxiously for the result. A week later the prof hands out the exams, or you look up your grade on the bulletin board, and the thing you care about more than anything else is whether you got at least a 65. If you got a 64, you’re shit out of luck. If you got a 66, you’re sailing.

Now how much difference is there, really, between a 64 and a 66? How much information does that distinction actually give you, about your performance, your dedication, your intelligence, or your use of free time?

This isn’t the first time I’ve conceptualized addiction (intensity, duration, riskiness, etc) as a continuum — a continuum that does not lend itself at all to two categories, disease vs. health. Other addiction thinkers, researchers, treatment providers, etc, have also remarked that addiction is a spectrum, a dimension, a set of gradations at best — nothing like an all-or-nothing category. Yet the disease label cannot help but classify addiction as a category. You either have tuberculosis, or diabetes, or cancer, or you don’t. Never mind that, when it comes to addiction, the category label itself can do more harm than good. As soon as you classify addiction as a disease, you draw a line. (There is some discussion of this issue in the commentaries on an article of mine.)

Indeed, the disease labelling trend in the US and elsewhere makes it stupidly easy to put addiction in a wastebasket category. You’ve either got it or you don’t. And if you’ve got it, then free choice, self-control, empowerment, and so many other features of human thought and emotion are neatly defined. Easier to think about, right?

Sapolsky makes other cool points about how categorical thinking obscures real complexity. For example, falling into the same category doesn’t necessarily mean that two things are similar. As we know, two people, both categorized as having the disease of addiction, can be as different as giraffes and field mice (just two animals that came to mind).

Many of my readers will probably agree that categorical thinking, this mental-labour-saving device, misses so much — so much of the real complexity of addiction — that it can’t help but muddy the waters.

………………………..

This is remarkable: four hours after posting today’s post, I found an email in my inbox that contained nothing more than this link. If this man can face his addiction and challenge it, without submitting to the disease categorization, then…that’s all there is to say. The post is electrifying, extremely well written, and deeply moving. I’m honoured that my work figures in his thinking.

 

I’ve been working with a client (I’ll call him Robert) who’s trying to stop using cocaine. We’ve had some powerful sessions lately, emotionally moving for me as well as for him. I really want to help Robert — or, more to the point, I want him to succeed, with or without my help. He’s just so miserable, so alone, so desperate.

And I recognize myself in him. Not because I’m miserable and desperate these days (I’m not) but because I know exactly what it feels like to be in that place. To continue using when the pleasure is gone and the heartache starts to geyser up before you’ve even left the house to score.

One plan that made sense for Robert was to enhance self-compassion as a means for overcoming (a massive glut of) shame…(because, as we know, more shame –> more using). But then it occurred to me that the format of the plan (in therapy or in life) is more important than the content. The content will vary from one person to the next. Yet there may be one maximally effective format for beating addiction: connecting a macro project with a micro project. What I mean is, developing some skill or resource that takes time to build and refine (that’s the macro project), and deriving from it a toolkit of strategies one can activate in the moment (the micro project).

Most important, the two have to connect. What’s going to be most useful in the moment (e.g., when your dealer calls, when you’ve just had a fight with your husband, when your best friend has to go home to his family for dinner) is going to be something you’ve worked on over time.

A case in point: developing self-compassion to beat shame

The macro project: We each have a number of different selves, or voices, or modes or moods, whatever you want to call them. Each is distinct, built on a particular emotion or emotional combo. The shameful self — that’s pretty familiar. Hating to be seen, cringing from being accused or despised by others…and by oneself. Shame is hot, red like a boil, painful, laced with disgust. The shamed self often gives way to anger, the famous fuck-you reaction, or defiance, the equally famous fuck-it solution. Or it opens onto guilt and depression. Omigod, how could I have done that?! What a bastard I am. Then there’s the anxiety about being caught, seen, punished, cast out — as familiar as background music to Robert and to just about everyone I know in active addiction. Often there’s a cascade through several of these self-states that leads straight to using. But each state is also a branch of our personality, stable and familiar — a thicket of interlaced neurons.

Yet there’s another self, built on another feeling. It’s the compassionate self, based on the feeling of nurturance. Nurturance is built into our neural hardware. It’s needed for us (great apes) to effectively raise our young, since they take forever to mature. It’s the feeling we feel when we comfort a child or feed a helpless animal. But, as you probably know, the compassionate self seems a fiction, a fantasy, when you’re in active addiction, especially when it comes to compassion for yourself. Maybe you never learned self-compassion deeply enough because your parents didn’t know how to provide it or feel it or value it. Or maybe you lost it en route. It gets worn thin by repeated bouts of shame and self-loathing.

But either way, self-compassion is pretty much the only feeling that can defeat the self-destructive agony of shame in a head-to-head fight.

In The Biology of Desire I described self-compassion as one way to connect your past self (recognizing how much you’ve been hurt) with your present self (of course I want to get high — that’s how I’ve learned to hurt less) with your future self (we’re going to get to a better place — here we go). Note the use of “we” — and (P.S.) see Peter Sheath’s and Matt’s comments directly below.

Given that self-compassion looks like a field of dead weeds, the macro project is simple. Cultivate it. Grow it. Make it more familiar, more salient, more present. There are several ways to do this. ACT  and self-compassion therapy are obvious choices. Check out other therapeutic approaches suggested by readers here and here.  But what I recommended to Robert was to meditate, just 10 minutes in the morning for now, and start to sense it, like an almost totally blind person sensing light. Feel that first bit of coziness behind your eyelids, in your body, and stay with it, let it warm you. I suggested he try using a meditation app, like Headspace, Insight Timer, or Buddhify. These apps can help by connecting us to a voice that’s comforting as well as skilled. And DO IT every day until it starts to take — usually within a week. Also, just talking to yourself in a kind voice (either out loud or silently) can be very powerful. Try it.

The micro project: Most of us know that just being off drugs or booze for a few days is already a plus. Shame and self-reproach start to recede. Maybe you get a little pride, a sense of forward thrust. Some hope. Some trust in yourself. But stopping, even for one day, can be insanely difficult, so most forms of addiction treatment try to teach mental tricks for diverting or overcoming the urge.

These tricks include “fuck no!” (sort of the opposite of “fuck it” — using defiance for good, not evil). They include distraction, finding something else to do, exercise, sports, prayer, connecting to a friend or sponsor. They include avoiding temptations, focusing on future goals, “urge surfing,” finding a replacement substance that’s easier to quit. These cognitive acts can get you through the night. They’re the things you might learn from CBT, or motivational interviewing, or DBT, or SMART. And they are valuable!

But the one cognitive trick that’s usually missing from this list is, I think, the most valuable: finding your compassionate, accepting self, right here and now, because that softens and neutralizes shame (and averts the rest of the cascade). Now you have somewhere to go that isn’t agonizing, that feels good enough to replace getting high.

And the best way to make this micro project work is to link it with the macro project of finding and cultivating the compassionate self. Which may take weeks or months. It won’t happen overnight.

So my suggestion to people trying to help people in addiction, to people in addiction (like Robert) and to my own self is: Get to work on the macro project of cultivating the compassionate self WHETHER OR NOT there’s a smidgen of “improvement” when it comes to using — or anything else. And then, when it’s time, call on that self, get it on board, at 7:45 on a Friday night or a dreary Monday morning.

But you gotta do your homework, your macro project, first — at least get it started — or the micro project isn’t going to work very well.