Understanding Addiction

A new act to control the prescription of narcotics (we assume they mean opioids) just went into law in Ontario on November 1. (Similar acts are not unlikely in the rest of Canada.) This act will presumably make it harder for people to forge prescriptions, use alternate names, borrow prescriptions, and so forth. One of the hallmarks of the act seems to be better enforcement of the recording of information never previously required, including the registration number for the prescriber (doctor) and an identification number for the drug itself. It’s hard to get specific, based on the wording of the act, but the upshot is that pharmaceutical opiates will be more difficult to obtain. What does that mean for those of you who treat or study addiction? What does it mean for those of you who use opiates?

Let’s start with the last question first. If users use less, if the problem really diminishes, then those who treat users will have less work to do. But if users get more desperate, or more clever, if they have to pay more, steal more, lie more, etc, then those who treat users may have more work to do. So all we need to do is figure out the consequences for users.

But it’s complicated. Like the age-0ld competition between cops and robbers, or rulers and rebels, there has been an ever-escalating stalemate between attempts to banish drugs and attempts to procure them. The dopamine-pumped addict, like the starved animal he resembles neurobiologically, has one goal and one goal only. All that dopamine crashing around in the nervous system…. When it doesn’t lead you directly to the goal, it supports the most effective, efficient, creative thinking on how to get around the obstacles and get you there regardless. Dopamine is good for thinking, planning, strategizing, and conniving. People with ADHD, and who can’t keep enough dopamine in their synapses, suffer from the dissolution of focused attention. They can’t keep their goals in mind. Dopamine-stoked addicts have the opposite problem. The goal is all they have in mind.

Also, dopamine makes you desperate, just like the starving animal. Contrary to the out-of-date view that dopamine is part of a pleasure circuit, dopamine is about doing when the goal is available and craving or striving when the goal is out of reach. That has pretty stark consequences for the law of supply and demand. When the supply of opiates is diminished (but not eradicated), the demand goes up. Way up. That’s why addicts of various stripes resort to poor quality drugs, hugely expensive drugs, and drugs mixed with all kinds of nonsense. It’s also why alcoholics on a low budget traditionally drink after-shave, cooking wine, or even rubbing alcohol (which is poison).

So picture the addict, with all that dopamine and no place to go, frothing wavelets rising higher and higher in the tank of the self. That dopamine has got to be good for something, and that something is success, regardless of the obstacles. Natural selection didn’t preserve dopamine because it helps you spit out watermelon seeds. Dopamine means business. Dopamine circuitry evolved to help achieve goals, difficult goals, despite the barriers of competition, scarcity, and natural enemies. Well, I suppose drug enforcement policy is a natural enemy for drug users.

Now if opiate drugs could be made completely unavailable, that would certainly diminish the problem of opiate addiction. But is that possible? If not, we’ll see what new tactics users adopt, with this latest plugged leak in the dopamine bucket.

As neuroscience explodes with new ideas, new technologies, and new findings, ordinary people have a hard time absorbing the information that emerges. We are learning more details about networks in the cortex responsible for different kinds of thinking, reflecting, observing, and we know about regions lying beneath the cortex responsible for emotion and motivation. What are we supposed to do with this knowledge? Why is it so hard to integrate into our daily lives?

I think the main reason is that our thinking and feeling, our personalities, and consciousness itself are so immediate, so personal, that we can’t entertain the idea that they emerge from electrochemical pulses among a bunch of cells. Our experience is so intricate, nuanced, and private — it’s difficult to imagine that it comes from a remarkable bodily organ. This paradox has been a real problem for philosophers ever since the time of the Greeks. It was made famous by Descartes, who said there must be some part of us that does not come from our bodies: this was termed “mind-body dualism.”

What’s that got to do with addiction? you might ask. The thing is, most of us continue to see addiction as a personal problem, a nastiness that comes from our inner being, a reflection of the dark places we’ve been and the dark things we’ve thought and done. The dishonesty that often comes with addiction (the lying, stealing, etc) feels like an incontrovertible personal failure, unforgiveable (at some level) because…well because shouldn’t I be a better person?

The darkness, confusion, tragedy and destruction do belong to us. There’s no denying it. But they also belong to a brain that is an organ of our bodies. The brain functions according to the codes built into it over millions of years of evolution, most critically: attempt to minimize suffering and maximize relief. Stave off deprivation. And it puts those requirements above other goals, like obeying social conventions. This brain of yours has been adjusting to whatever has happened to you every single day since (and before) your birth. And some of what’s happened to you has no doubt been frightening, uncontrollable, and perhaps deeply traumatic.

Through all this your brain continues to adapt.

To accept that our thoughts and actions really do arise from our brains does not get rid of personal responsibility — that’s not what I’m trying to say. But it can be a crucial step in understanding that the things we do that we’d rather not do aren’t simple choices between right and wrong. They arise from a sequence of developmental adaptations in an organ that does its best to keep us going in a hugely challenging world.

To accept that your addictive impulses come from your brain opens an avenue to self-forgiveness. But remember: brains have developed incredible capacities to think, plan, and reason about consequences. Self-control is one of the brain’s crowning achievements. And since addiction leads irrevocably to suffering, maybe you can work with your brain, sort of as a partner, to make your life a lot happier than it is.

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P.S.  Thanks for the comments so far, guys. I love this community. Meanwhile, I wanted to share a link to a work-in-progress dramatization (a theatre piece) of a very serious gambling problem, especially in the UK and Australia. The problem is the deployment of rapid-fire electronic gambling machines called Fixed Odds Betting Terminals — a new generation of machines that can take enormous amounts of money in a very brief time. These things are destroying lives as quickly as any drug. Take a look at this.

By the way, the title “Crack Cocaine” is a misnomer — they plan to change it soon.

You probably didn’t think it was possible. How could this be? It’s scandalous! Providing opioids for the very people who are trying so desperately to get off them. But since this is Week 2 of our be-nice-to-12-step extravaganza, let me tell you the story.

In the comments following my last post, Elizabeth told us of a study (Coan and colleagues, 2006) showing that hand-holding can diminish people’s response to threat. Unfortunately the link only takes you to a brief summary of the study. I went back and read the full version, and this is what happened.

Fifteen women who reported high quality marriages were put into an fMRI scanner, with their husbands and the experimenter remaining outside in the room. The women were shown cues on a screen several seconds before an electric shock was possibly administered to their ankle by an electrode. These electrical zaps are generally only slightly painful (in psychological experiments). But the cue on the screen, coming a few seconds earlier, is bound to make one anxious. Especially because it announces that a shock may come, but it may not. In other words, the subject is in a state of uncertainty and anxiety, waiting to see if the shock will come or not.

This experimentally-induced state of threat or anxiety is, of course, meant to simulate real-life stress. And I think that’s fair enough. Let’s get specific about opiate addicts. Will I be okay? Will I be able to restrain myself today? Or will things get so shitty that I’ll fall off the wagon — again? And if I do, there will be hell to pay when I get home…etc, etc, etc. We all know the drill. Being an opiate addict in recovery is being in a state of anxiety or stress — for much of the time — and the only relief may be…a shot of heroin (or pills, or whatever) OR a visit to your local NA group. That makes you feel better too. That’s why you go.

Little did we know that the group makes you feel better for the same reason (at the cellular level) as a shot of heroin.

Some very prominent emotion scientists have theorized that opioids (made inside our brains) are at the root of human attachment. Mother’s milk is rich with opioid molecules. In other words, nature found a surefire way to soothe the baby with its mother’s milk, using the same chemical formula that’s responsible for the soothing feeling of heroin. Jaak Panksepp theorizes that all social attachment is based on the release of opioids within the brain. Here’s a quote from him, referring to his early attempts to publish this work, cited in a very nice review for the non-scientist:

“When we first tried to publish our paper on the role of opioids in social attachment in three species, we submitted it to Science,” he said. When he asked the editor [why the paper was rejected, he was told], “‘We decided it was too hot to handle. If love and attachment ride on the same system as narcotic addiction, that’s too scary…’ ”

The review goes on to show how parents also get opioids from their kids. They feel great gobs of love and mush because their own brains produce a glut of opiods just at the sight of those sweet little faces. But let’s get back to Coan and colleagues’ experiment.

When the woman in the scanner was holding her husband’s hand, through a little hole in the side of the machine, many brain regions involved in stress or negative emotion showed reduced activation. On some trials, the hand she held was not her husband’s but that of the experimenter, a friendly male stranger. Even on those trials, many of the same brain regions showed reduced activation. Now here’s the kicker: The brain regions that got calmed down by hand-holding (including regions of the ventral ACC, ventral prefrontal cortex, striatum, and insula) are the same brain regions that have a high density of opioid receptors! The authors speculate (and I think it’s very likely) that opioid release is what causes the deactivation of these emotional hot spots. The subjects also reported less unpleasantness when they were holding hands while anticipating the shock. And, get this, the reduction in unpleasantness was correlated with the reduction in brain activity in these hot spots.

Thanks for the opioids, dear.

Elizabeth said in her comment that she heard a lecture by the same researcher, reporting that some of the same neural calming effect was found when the person’s partner was just in the same room with them, never mind hand-holding. So you don’t need to hold someone’s hand to get opioid soothing. You just need someone who cares for you to be in the same room.

In a recent debate on this blog, I argued that a supportive group like NA makes sense as a primary treatment for addiction–not a secondary one. Certainly members of NA or AA see their group experience — with or without hand-holding — to be the most powerful antidote to their feelings of anxiety, stress, loneliness, and all the other negative variants that can lead to relapse. Now we can point to a very concrete, biological mechanism responsible for the soothing function of the group: when you are in close contact with people who care about you (even a little), your own brain releases opioids. And, in a sense, those opioids replace the opioids you’d otherwise be buying on the street.

A final word: this is not some cheap trick the brain is playing on you. Internal opioids are not like methadone maintenance. Opioids have been nature’s way of soothing our pain and our stress, for tens of millions of years of evolution! That’s why we need them. That’s why we like them. NA, and other forms of intimate group experience, help us to get them from our connections to other humans (something we’ve perhaps forgotten how to do) rather than the guy on the street corner.

That’s what nature intended.

…by Matt Robert…

This will be our last post of the season. Not only is it smart and sensitive but it’s also warm hearted and optimistic. An ideal note to end on — until January. In the meantime, I wish you all an incredibly happy or at least reasonably happy holiday, however you define “holiday” and however you define “happy.”

Most people know the word “trigger” as a cue that can initiate a negative behavior. It can be a person, a place, a familiar situation—anything that may compel somebody to return to a behavior they are trying abstain from. Common triggers include seeing a familiar bar or liquor store, running into a using buddy from the old neighborhood, something that causes undue stress… These are things people spend a lot of time avoiding in early recovery and figuring out strategies to manage more effectively.

But what do we call the things that help re-engage a person in life—that give life meaning? Exercise, meditation, walking the dog, going to church—the things that help us hold on to sobriety, not threaten to wrench it away like triggers do. We don’t have a word for things people try to learn or rediscover in recovery, to fill the gap once filled by using. These things are specific activities or events, just like triggers are, and they vary from person to person. Yet there is no general, generic term for these restorative habits and activities. “When I’m tense, I visit my grandchildren. That helps me stay sober and not want to drink. That’s a real (blank) for me.” That’s a real anchor? Refuge? A lifeline? A solace? That’s a real safety? The thing that stops the trigger? The diversity of what “trigger” connotes would be mirrored by its positive counterpart, although a widely accepted term doesn’t exist.

“Trigger” is a useful term mostly because it is a salient metaphor for the particular experience of being influenced to do something reflexively that you are trying to avoid. So what are some metaphors for a scenario that aids, or protects, or bolsters one’s recovery? Does it restrain you? Does it shield you? Does it protect you? Does it free you? Does it ground you? Does it support you?

One possibility is the word “tether.” It has several shades of meaning, all related to connection, protective restraint and safety. For example, a boat tethered to the dock is safe because its mooring prevents it from being carried out into the open sea. A tether can be a lifeline followed to safety in a blinding blizzard. A tether is the air hose of a deep sea diver, connecting him to the surface, to air, to safety. A tether connects a novice to a more experienced mountain climber. A tether keeps a spacewalking astronaut from floating off into the darkness. A tether keeps a dog close to its home, so it doesn’t run off and harm itself or others.

A tether can be used by an addict to stay attached and close to sobriety, not venturing past unsafe boundaries. And with time, the tether can be lengthened more and more, until it is no longer necessary. A tether is a metaphor for a connection to safety and sobriety. “After work, I always take a run to ease the stress of the day. That’s been a real tether for me.” Having a generic term for these activities or states could facilitate productive, forward-looking dialogue. And it could reinforce the primary importance of this aspect of recovery.

“Trigger” and “tether” are words that describe the two most important states in recovery—the urge to use and the capacity to abstain. They can be natural partners in our discussions, because they highlight both the negative and the positive aspects of recovery. What to pursue and what to avoid. Such discussions can support a healthier balance and move the focus toward the positive, not just the negative—from the prohibitive to the productive—and eventually the freeing.

The world of recovery has plenty of negative terms for relapse and its causes. Wouldn’t it be helpful to have a reliable, generic term for the positive stuff we do to keep it together?

Please contribute to the blog with any preferences, suggestions or recommendations for something to fill this void and enhance our discussions of recovery.

I haven’t been blogging much lately, mainly because I’ve been busy with other things. One of those things has been writing a review of Jordan Peterson’s book, 12 Rules for Life: An Antidote to Chaos. The review was commissioned by the Literary Review of Canada (LRC) — the Canadian cousin of the New York Review of Books. And it really got me thinking on how to solve the central problems in overcoming addiction (what many call “recovery”).

(Addendum: my review just got published. You can find it here.)

Peterson is an international phenomenon by almost any standard. He has amassed millions of YouTube followers and a stream of interviews from talk show hosts. His book was the top seller (overall!) on Amazon for at least two months and is still #6, four months after publication. A professor of psychology at the University of Toronto, Peterson has been cheered and even glorified for his radical approach to self-improvement — presented in his new book and his many online lectures. What he proposes is a set of guidelines highlighting self-honesty, personal responsibility, and what we in the addiction world have long emphasized as the bedrock of growth, empowerment — believing in your own intentions, intuitions and capacities for change. But Peterson has also been a lighting-rod for criticism. His detractors claim that he is anti-feminist, anti-LGBT, anti-social justice, and a voice for the politically incorrect (shudder) alt-right. This reaction has activated a subset of Peterson followers who are indeed highly conservative or libertarian, and sometimes quite vicious in their attacks on Peterson’s critics. But we have to extract Peterson’s message from the surrounding political hubbub. In my view he’s neither left-wing nor right-wing. As I emphasize in my review, he speaks as an individual, not a political movement.

If you haven’t heard of Peterson or listened to any of his many online lectures, here are a few goodies: A discussion of the book in a lengthy interview with Dave Rubin. A shorter version, in lecture format. An oft-clicked, contentious interview with Cathy Newman, a feminist British reporter and presenter.

So what’s all this got to do with addiction? I had to get pretty deeply into the book, and in the process listened to a lot of Peterson online, in order to write an intelligent review. In doing so, I found myself very often drawn to Peterson’s recipe for self-improvement. I think his advice is both practical and potent for people struggling with addiction, and I intend to use it more and more in my own work.

People in addiction have three main problems:

1. They want to create a massive change in their lives, but the change is so massive that it overwhelms their capacity for self-control, self-direction, choice, or whatever you want to call it. So they fail, again and again.

2. Because they fail at doing the one thing they know they should and must do (and usually want to do), they experience enormous levels of shame and guilt, often taking the form of a critical, self-denigrating internal dialogue.

3. The third problem is that problem #2 (self-denigration) fuels the depression and pessimism that greatly contribute to problem #1. A horribly vicious circle.

In my view, Peterson has some really good suggestions for overcoming both problems 1 and 2, which of course eliminates the existence of problem 3. I’m going to give you the gist of those suggestions here and then expand on ways of implementing them in my next two posts.

1. Peterson’s approach to problem 1 comes to the surface in this talk, about 33 minutes in:

You need a goal, but we don’t want your distance from the goal to crush you…Set a high aim, but differentiate it down so you know what the next step is. And then make the next step difficult enough so that you have to push yourself past where you are, but also provide yourself with a reasonable probability of success.

Of course the next question should be, How do you set up incremental sub-goals in the case of drug addiction? Shouldn’t you Just Say No to Drugs? I don’t think so. In my psychotherapy with people in addiction, I try to aim at steps in the right direction, beginning with controlled use or harm reduction. More on that to come.

2. Peterson’s approach to problem 2 is also highly practical but a bit more nuanced. To give you a sense of it, I’ll quote a few sentences from my review:

Peterson says “the self-denigrating voice…weaves a devastating tale.” Engage with the internal critic, he urges. Don’t listen to its exaggerated claims that you’re completely worthless. But don’t ignore it either. “Called upon properly, the internal critic will suggest something to set in order, which you could set in order…voluntarily, without resentment.” In other words, with a little work, that voice can become a valuable ally.

Again, the question is, How? How do you turn a damning, denigrating internal critic into a negotiating partner who can help you move ahead? I’ll  provide some concrete ideas two posts from now.

Jordan Peterson seems to understand how hard it is to achieve necessary changes in how we approach life, especially when it comes to breaking entrenched habits of thought and behaviour. He approaches these challenges with both the compassion of a fellow traveller and the practical wisdom of a good clinical psychologist. He also ties his ideas to compelling lines of thought from philosophy (especially Nietzsche), social science, evolutionary theory, and even religion. A fascinating thinker, overall, with an especially helpful perspective for refashioning psychological approaches to addiction.