Understanding Addiction

…by Colin Brewer…

Last post I suggested that we can attend to (rather than reject) our cravings and pursue integration rather than abstinence. Today, a contrasting view: Colin Brewer, a renowned and controversial addiction doctor, explains how Antabuse and naltrexone can free us from endless ruminations while new habits take root and grow.

………………………………

Having plenty of spare time on Covid lockdown, can I float a couple of evidence-based ideas to this experienced readership? (My own experience is only as a physician who treated assorted addicts. Unlike many US addiction medics, most European ones are not ‘in recovery’.)

1. Though not all substance abuse represents the drowning of internal and external sorrows, quite a lot does. However, the main difference between those who drown them and those who don’t is not that the former have bigger sorrows to drown; it’s that they have got into the habit of drowning them while the others have not. Addiction is therefore to a large extent a matter of habit and habits can be unlearned as well as learned. One of our main habits is speaking only one language. To learn another language requires the unlearning of that habit for long enough to allow another linguistic habit to get established. Research — lots of it — consistently shows that the best and quickest way to learn a new language and become fluent is to be forced to speak the new language exclusively from Day 1 for hours at a time, however badly. Language schools charge big fees for creating an environment where this happens and students routinely achieve at least basic fluency within a week. You can do the same by living on your own in a village where nobody speaks English. Necessity is a great teacher.

2. In the case of drug addiction (including alcohol of course) the evidence strongly indicates — as does common sense — that people who have not responded well to previous treatment and have had several relapses with no more than a few weeks or months of abstinence, need at least 18 months of abstinence before they change their self-image from “I’m an addict/in recovery” to “I used to be an addict but now I’m different.” Keeping these treatment-resistant addicts drug-free — or at least free of their main problem drug — for 18-24 months is made a lot easier by the consistent use of drugs that deter their use. Disulfiram (Antabuse) deters alcohol use by the prospect of an unpleasant physical reaction and naltrexone deters opiate use by the prospect of an unpleasant psychological reaction.

The German OLITA study — probably the most important (and encouraging) alcoholism treatment study bar none — showed that once a group of very unpromising alcoholics with numerous treatment failures had taken disulfiram under supervision (and thus stayed dry) for at least 20 months, most of them stayed dry without disulfiram (and mostly without other treatment) for the next 7 years of follow-up. In other words, by simple daily practice and repetition, their alcohol-using habits had been abandoned and replaced by habits that didn’t include alcohol. We don’t yet have similar long-term studies of naltrexone for opiate dependence but with naltrexone implants that can last six-months or even a year in existence or in development, we soon will have. I predict that the longer-acting the implant, the better the results will be because fewer decisions to continue treatment (compared with monthly Vivitrol injections) need to be made in the crucial first few months.

A recent New Zealand study showed how disulfiram effectively removes one of the most annoying features of being an alcoholic — the endless internal arguments and conversations that patients have with themselves almost every minute of the day about whether they should or shouldn’t drink. Some patients described it as a sort of “internal homunculus that demanded alcohol.” Disulfiram replaced those endless ruminations and temptations with a mind-set in which alcohol was “simply no longer an option.” One patient described how, when he wasn’t taking disulfiram, after all the internal arguments, “at the end of it, I just go ‘fuck it, fuck it’… When I’m on Antabuse, it’s just like. Well, I can’t.” After a year or even less, that ‘Well, I can’t’ increasingly morphs into ‘Well, it doesn’t seem that important now. I’m learning to manage without it and I’ve found other things to do instead.’

Some people who have learned to become indifferent to alcohol can even progress to cautious experiments with controlled drinking, though if it gets uncontrolled, they should get the message and not try again. And I doubt whether trying controlled opiate use is ever a good idea. However, there are undoubtedly people whose brains do not adapt to long-term opiate abstinence and who are better off on long-term methadone, buprenorphine or — in Britain at least — morphine.

I’d really appreciate the views of people for whom those internal arguments are a daily experience — or were until recently; or who have left them behind. I am fortunate only to have encountered them at second hand.

…………..

Brewer C, Streel E. Antabuse treatment for alcoholism. An evidence-based handbook for medical and non-medical clinicians. Foreword by William R Miller. CreateSpace IPP. North Charleston, SC. 2018

Since well before the War on Drugs, we’ve been taught to “just say no.” Today we know the pitfalls of pure prohibition and denial. We know the value of “just saying yes” to sobriety instead. Still, especially during the period of craving that follows quitting, we do have to say No to ourselves. Perhaps many times a day.

What I’m interested in is the tone of voice we use to say it. And how we feel as a result.

I’ve written and spoken a lot about ego fatigue (ego depletion). It’s a well-studied psychological phenomenon: the loss of cognitive control that comes when we continuously try to inhibit an impulse. Ego fatigue is one form of emotional dysregulation. Other types of emotional dysregulation have been studied by psychologists and neuroscientists, and they pretty much all involve losing the capacity to inhibit impulses. Many regions of the prefrontal cortex are designed (by evolution) for inhibition. Some forms of inhibition are rapid, automatic and unconscious, some are at the borders of consciousness, and some are completely conscious. Ego fatigue may strike at several of these levels. But let’s think now about conscious inhibition: saying to yourself, “No, don’t do it!”

So there you are, craving to get high “one more time,” and saying to yourself over and over again: No, don’t do it! Then ego fatigue creeps up on you…some part of your cognitive hardware gets tired and gives up the battle. The impulse takes over. Each of the five biographical chapters in my book shows exactly how that plays out in the life of someone addicted to something. But here’s the double whammy, the Catch-22: Psychologists have shown clearly that suppression (just saying No) makes ego fatigue worse. Suppressing the impulse gives it more power. The only way to stay on top of ego fatigue is to reinterpret or reframe the situation: “that’s no fun, that’s not what I want.”

Okay, all fine in theory. But in real life, you simply can’t reframe the wish to get high every time it pops up in your brain, especially during the period of “incubation of” craving, in the weeks or months that follow quitting (see last post). You have to say No to yourself some of the time, maybe even most of the time.

But what’s the tone of that internal message? What’s the tone of the “No, don’t”? I haven’t heard much about this from other addicts or researchers, but my impression is that the tone of the internal prohibition is often one of parental authority. It’s often a tone that’s warning, disapproving, judgmental, perhaps accusing, almost menacing. “You’d better not!” it seems to say. “Or else!” it implies. It’s easy enough to dredge up images of the disaster you’re about to visit on yourself, but that might just strengthen the scolding, authoritarian voice.

So how do we feel when we receive this stern prohibition time and time again? We feel frustrated, obstructed, denied the thing we want. And what’s worse, we may feel put down, misunderstood, and unfairly punished. Don’t I deserve to get high, today of all days? No, you don’t! Be quiet!

This internal dialogue may be playing out in your head, just on the fringes of consciousness. Or maybe you are quite conscious of the sense of being denied something, the sense of being suffocated or oppressed. I know this was frequently the case for me when I ran around breaking into medical centres and stealing drugs. I felt that oppressive edict like a dark, overhanging cloud bank.

So what I would often do is rebel. I’d finally say, Fuck you, I will if I want to! And there was a palpable sense of relief, a sense of lightness, the straps of a harness being peeled off. And then I would get high for a few days. And then I would suffer.

This scenario is surely a case of ego fatigue. But it’s more than that. It’s not just a neutral signal telling you to inhibit an impulse, and then wearing thin with time and repetition. It’s also a voice that makes you feel frustrated, alone, put down, anxious, and probably angry. An ideal circumstance for going back to drugs or drink.

Our minds are full of internal voices. We are fundamentally social creatures, and our interpersonal relationships are constantly playing out, both in the real world of other people and in the private world inside our minds. When we realize this, I think we acquire the power to shift the dialogue, to make it more friendly, less hostile.

The tone of voice with which we say No to ourselves makes all the difference. It’s very possible to link the No with a Yes. To make it a message of support and hope, not just denial and obstruction. We can take on the voice of a critical parent. Or we can take on the voice of a friend, ally, loving parent, big brother or sister… Instead of saying “You’d better not…” (for which there’s a clear script inscribed on our auditory cortex), we can say, “Let’s not do this; let’s do that instead. This isn’t what we want.” Even just by making the voice say “we” instead of “you” we shift the dialogue. We make it supportive rather than punitive.

That’s one key to reframing the addictive impulse, which reduces or eliminates ego fatigue.

That’s when there’s no one there to defy.

Or at least they agree that the point is worth considering. Their review of my book is quite positive. Laura Miller, a senior writer for Salon, got most of it right, and she didn’t shy away from the details. Way better than a kick in the head.

A couple of relevant quotes:

One of those neuroscientists is Marc Lewis, a psychologist and former addict himself, also the author of a new book “The Biology of Desire: Why Addiction is Not a Disease.” Lewis’s argument is actually fairly simple: The disease theory, and the science sometimes used to support it, fail to take into account the plasticity of the human brain. Of course, “the brain changes with addiction,” he writes. “But the way it changes has to do with learning and development — not disease.” All significant and repeated experiences change the brain; adaptability and habit are the brain’s secret weapons. The changes wrought by addiction are not, however, permanent, and while they are dangerous, they’re not abnormal. Through a combination of a difficult emotional history, bad luck and the ordinary operations of the brain itself, an addict is someone whose brain has been transformed, but also someone who can be pushed further along the road toward healthy development…

One size does not fit all, and there’s a growing body of evidence that empowering addicts, rather than insisting that they embrace their powerlessness and the impossibility of ever fully shedding their addiction, can be a road to health as well. If addiction is a form of learning gone tragically wrong, it is also possible that it can be unlearned, that the brain’s native changeability can be set back on track. “Addicts aren’t diseased,” Lewis writes, “and they don’t need medical intervention in order to change their lives. What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place — while they reach toward it.”

Hi all. I haven’t been blogging for a while, partly because I wasn’t sure I had anything new to say. But the “opioid crisis” is obviously on everyone’s mind. So, I wanted to get the facts straight, and I pitched an article to The Guardian, published yesterday, based on what I found.

The response has been slightly overwhelming: more than 500 published comments in less than 24 hours (plus some emails to me personally). Most moving to me is the gratitude expressed by people in serious pain, people whose access to needed medication is being quickly cut off by the hysteria concerning the overdose epidemic. The point of my article was that most of the opioid panic is fueled by a misguided perception that opioid pharmaceuticals, prescribed and taken by patients in pain, is this diabolical force behind the wave of deaths.

I am in no way minimizing the tragedy of the overdose epidemic. But as most of you know, fentanyl and its analogues are the primary cause. But here — I’m pasting the article below, with a few additional thoughts, plus a graph from the NIH/NIDA website that helps tell the story. Or read the article in The Guardian and peruse the comment section. There’s a lot of painful reality (plus a lot of stupidity, as usual) revealed by these comments. Makes me feel good about what I wrote.

Pasted from The Guardian:

“The news media is awash with hysteria about the opioid crisis (or opioid epidemic). But what exactly are we talking about? If you Google “opioid crisis”, nine times out of 10 the first paragraph of whatever you’re reading will report on death rates. That’s right, the overdose crisis.

For example, the lead article on the “opioid crisis” on the US National Institutes of Health website begins with this sentence: “Every day, more than 90 Americans die after overdosing on opioids.”

Is the opioid crisis the same as the overdose crisis? No. One has to do with addiction rates, the other with death rates. And addiction rates aren’t rising much, if at all, except perhaps among middle-class whites. [See graph pasted below.] [And note that I should probably have added middle-aged middle-class whites.]

Let’s look a bit deeper.

The overdose crisis is unmistakable. I reported on some of the statistics and causes in the Guardian last July. I think the most striking fact is that drug overdose is the leading cause of death for Americans under 50. Some people swallow, or (more often) inject, more opioids than their body can handle, which causes the breathing reflex to shut down. But drug overdoses that include opioids (about 63%) are most often caused by a combination of drugs (or drugs and alcohol) and most often include illegal drugs (eg heroin). When prescription drugs are involved, methadone and oxycontin are at the top of the list, and these drugs are notoriously acquired and used illicitly.

Yet the most bellicose response to the overdose crisis is that we must stop doctors from prescribing opioids. Hmmm.

Yes, there has been an upsurge in the prescription of opioids in the US over the past 20 to 30 years (though prescription rates are currently decreasing). This was a response to an underprescription crisis. Severe and chronic pain were grossly undertreated for most of the 20th century. Even patients dying of cancer were left to writhe in pain until prescription policies began to ease in the 70s and 80s. The cause? An opioid scare campaign not much different from what’s happening today. (See Dreamland by Sam Quinones for details.) [I’ve updated this link.]

Certainly some doctors have been prescribing opioids too generously, and a few are motivated solely by profit. But that’s a tiny slice of the big picture. A close relative of mine is a family doctor in the US. He and his colleagues are generally scared (and angry) that they can be censured by licensing bodies for prescribing opioids to people who need them. And with all the fuss in the press right now, the pockets of overprescription are rapidly disappearing.

[I should probably have mentioned that advertising by Big Pharma also helped fuel the overprescription trend. But that’s kinda old news.]

But the news media rarely bother to distinguish between the legitimate prescription of opioids for pain and the diverting (or stealing) of pain pills for illicit use. The statistics most often reported are a hodge-podge. Take the first sentence of an article on the CNN site posted on 29 October: “Experts say the United States is in the throes of an opioid epidemic, as more than two million of Americans have become dependent on or abused prescription pain pills and street drugs.”

First, why not clarify that most of the abuse of prescription pain pills is not by those for whom they’re prescribed? Among those for whom they are prescribed, the onset of addiction (which is usually temporary) is about 10% for those with a previous drug-use history, and less than 1% for those with no such history. [Thanks to Maia Szalavitz for highlighting these statistics.] Note also the oft-repeated maxim that most heroin users start off on prescription opioids. Most divers start off as swimmers, but most swimmers don’t become divers.

Second, wouldn’t it be sensible for the media to distinguish street drugs such as heroin from pain pills? We’re talking about radically different groups of users.

Third, virtually all experts agree that fentanyl and related drugs are driving the overdose epidemic. These are many times stronger than heroin and far cheaper, so drug dealers often use them to lace or replace heroin. Yet, because fentanyl is a manufactured pharmaceutical prescribed for severe pain, the media often describe it as a prescription painkiller – however it reaches its users.

It’s remarkably irresponsible to ignore these distinctions and then use “sum total” statistics to scare doctors, policymakers and review boards into severely limiting the prescription of pain pills.

By the way, if you were either addicted to opioids or needed them badly for pain relief, what would you do if your prescription was abruptly terminated? Heroin is now easier to acquire than ever, partly because it’s available on the darknet and partly because present-day distribution networks function like independent cells rather than monolithic gangs – much harder to bust. And, of course, increased demand leads to increased supply. Addiction and pain are both serious problems, serious sources of suffering. If you were afflicted with either and couldn’t get help from your doctor, you’d try your best to get relief elsewhere. And your odds of overdosing would increase astronomically.

[A note to my readers: As you see, I’ve mentioned but somewhat underplayed the needs of people in addiction. Knowing my history and my sympathies, I think you must realize that I care very much about their needs as well.]

It’s doctors – not politicians, journalists, or professional review bodies – who are best equipped and motivated to decide what their patients need, at what doses, for what periods of time. And the vast majority of doctors are conscientious, responsible and ethical.

Addiction is not caused by drug availability. The abundant availability of alcohol doesn’t turn us all into alcoholics. No, addiction is caused by psychological (and economic) suffering, especially in childhood and adolescence (eg abuse, neglect, and other traumatic experiences), as revealed by massive correlations between adverse childhood experiences and later substance use. The US is at or near the bottom of the developed world in its record on child welfare and child poverty. No wonder there’s an addiction problem. And how easy it is to blame doctors for causing it.”

Here’s that graph that I should have pasted into the article, if I’d gotten permission and so forth. Note the almost steady rate of illicit drug use since 2002:

Pasted from a page on the NIH/NIDA website.

Hi everyone. I haven’t been writing on the blog much lately. My book was released in the UK on July 14th, and that meant shooting off articles for various publications and giving talks and interviews. So I went to London two weeks ago. It’s still there, as colourful and overwhelming as ever. Despite Englands’ majority vote to leave the European union, London is the most multiethnic city imaginable. On ever street you hear a bubbling cauldron of accents and see faces of every colour and shape. What a city!

My trip was fabulous. The first day I was interviewed by The Times, and that night I gave a talk with Johann Hari as my host and interviewer. An interesting man…complex, smart, fun, and a bit darker than expected. The next day, an interview with BBC and another with The Guardian podcast. That night I talked to nearly 400 people — the most positive audience I’ve ever had. Waves of applause and even cheers. Felt like a rock star.

But the most interesting event of my trip was meeting a man named Colin Brewer. If you google him you’ll see that he’s a wild child in British psychiatry circles. Most recently he was villainized by the media for providing supportive assessments for people seeking assisted suicide in a Swiss clinic. The trouble was that they didn’t have terminal diseases, and that’s a no-no. Was this man a monster? He’d gotten in touch with me by email and came to one of my talks. When he showed up at the foot of the stage, I recognized his face from the internet, and he certainly looked…unusual.

That night at my hotel I googled him more thoroughly and found that the people he’d helped obtain assisted suicide were actually in big trouble. One was 90 years old and in severe, untreatable pain. Another was in his seventies, going blind, another had motor neuron disease, and yet another had Alzheimer’s. It turned out that Colin was motivated by empathy and a firm belief in people’s right to die with dignity. He was no monster.

So I accepted his invitation to come for a visit and arrived at his home a few days later. He lives in a beautiful house in the heart of London. He showed me around the antique-laden interior with evident pride, swelling a bit when I complimented the taste and beauty of his home. And then, equipped with home-made elderberry cordials, we sat and talked.

Colin’s trouble started when he used his own instincts and methods to treat addicts, beginning in the 80s. He prescribed methadone, as did other doctors — no problem. But he would also provide a couple of months’ supply of methadone to people who travelled a great deal and could not renew their prescription daily or weekly. He also prescribed heroin for those who needed it (while this was still legal in Britain) as well as generous supplies of benzos and other drugs for those withdrawing from opiates or alcohol. He even supplied do-it-yourself detox kits to people who could not afford residential care. Another well-intentioned though dissident policy. The press branded his practice a drug supermarket and he was struck off the medical register in 2006.

Colin was indeed a renegade who made up his own rules for dealing with addicts. In fact, like Percy Menzies, who wrote a guest post for this blog several months ago, Colin enthusiastically prescribed naltrexone for opiate addicts as well as disulfiram (Antabuse) for alcoholics. He firmly believed in giving addicts a time-out, a substance-free period for resetting their circuitry — and he brought their families into the act, so that they could help encourage their addicted loved one to stick with the program until they were in safer waters. Far from someone who took his patients’ plights too lightly, he seems to have functioned as a deeply concerned caregiver, who wanted above all to give addicts the freedom to transform their own lives.

We wasted no time discussing whether addiction was a disease or not. We both saw the classic disease model as a dead-end. Rather, we talked about the power of placebos, the extent to which addiction includes placebo-like effects — namely the belief that taking something has particular benefits, when the belief creates the benefits. Colin introduced me to a study showing that even physical withdrawal symptoms can follow sudden termination of a placebo believed to be an addictive drug. Fascinating!

But the most important idea I left with was Colin’s belief that overcoming addiction is like learning a second language: reframing, retraining, and thus rewiring synaptic networks. I guess I already knew that, but here’s the new punchline. The best way to learn a second language is through total immersion: avoiding going back to your native tongue for some period of time. The reason my Dutch is still so shitty is because I speak English most of the time. That’s sometimes called “controlled use” in addiction parlance.

I’ll end with a quote from an article written by Colin and a colleague. It makes it pretty clear why total abstinence — at least for a time — is so very helpful.

Relapse-prevention is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behaviour and establishing new, adaptive ones. This process resembles foreign language learning…. ‘Immersion’, the most effective foreign language teaching method, discourages students from using their first language…requiring them to use the foreign language instead, however inexpertly.

Colin Brewer & Emmanuel Streel. Substance Abuse, 2003, 24(3) 157-173.