Understanding Addiction

A LOT of you replied to my brief ramblings on Harm Reduction. Some of you see it as almost poisonous — a kind of quicksand making it more difficult to quit using. Others see it as a valuable perspective for helping people “where they are,” without imposing conditions or restrictions. Some of you see it as an expression of kindness, others as short-sighted or even lazy, and some note that it does more good for the society at large than for addicts trying to recover. It’s good for all of us to be aware of this diversity of opinions.

I don’t think I can help provide unity, but here are a few more impressions I got from that conference.

I mentioned in one reply, last post, how struck I was by a speaker who looked like he was about to collapse right there on the podium. A slender young man who spoke in a halting voice, sometimes unable to find his words. He talked of being a young gay man from a traditional Chinese family. He was rejected by his family and peers with such vehemence that he ended up wandering around Toronto like a stray puppy, looking for anyone he could follow home. Not surprisingly, sex was part of that equation, and, apparently not uncommonly, so was crystal meth. Clean needles and condoms were the furthest thing from his mind. Until he got sick. Now, HIV-positive and who knows what else, he stood there, quavering, clearing his throat, telling this group of strangers all about his shameful deeds. And everybody’s heart went out to him. There wasn’t one person in the room who didn’t wish they’d gotten to him first, not to put a halt to his experimentation but to help him survive it. When he told us he’d been clean for almost four years, the room erupted in waves of applause. But it didn’t seem he’d be a poster-child for HR or anything else for very much longer.

From that moment it was clear to me that harm reduction and abstinence were not opposing goals. And I was sold. I don’t think you can fully buy into harm reduction until you stare straight into the totality of harm.

Karen, a syringe program coordinator talked with me for awhile. Big heart, yes. Weird ideas? Maybe not.

“All I want to do is house them,” she said, “give them somewhere they want to go back to. You want to make it cozy for them, help them furnish it, make it their safe place.”

You’d think that might make it more comfortable for addicts to keep on using. But that wasn’t her view.

“When that happens,” she said,  “their using levels out and the risk-taking all but disappears. They stop sharing any equipment, they stick to one dealer, they tend not to use in groups, and the quantity goes down: crystal meth, Dilaudid, old-style oxycontin, you name it.”

Okay, you might wonder, but don’t you try to get them to stop? Apparently it’s hard to do both at the same time.

“If clients fail to stop using something they said they’d stop using, then I never bring it up again,” Karen said.  “You never shame people, because shame is the hardest emotion, in my opinion. Kindness — that’s what you give them. You thank them for coming in.”

Others felt that way too. One heavily tattooed man who looked like he could bench-press his Harley told me, in the mildest voice: “The client is the boss. I’ll plan whatever you want…and at any point you want to change it, we’ll change it. Because it’s their life, not my expectations, that matter.”

I never stopped wondering whether this was precisely the right approach. But I became convinced it was a lot better than nothing for seriously down-and-out users. If you met them with restrictions, rules, shame or disapproval, they would simply disappear. Disappearing was one thing they were particularly good at. That and destroying themselves.

My talk was well received. Almost everyone there wanted to understand how addiction works, and the neurobiology was a lot of what they were missing. But policy is not my thing. And all the biology I could offer seemed a pale wand to wave at the pain that surfaced in that room.

I left feeling that harm reduction was a desperate response to a desperate situation, bound to help those who needed it most.

P.S. Check out this recent discussion forum in the New York Times. See if you can tell the good guys from the bad guys.

Since retiring from the university about a month ago, my “career” seems to be better defined than ever. I’m a science writer and a speaker. And because I get invited to write articles and give talks, I’m obliged to continue to update my understanding of my field, which happens to be addiction.

And things keep changing. In the realm of neuroscience, there is more attention to neuroplasticity, more attention to cellular changes and the molecules involved, new findings in genetics, epigenetics, the biological sequels of early trauma, and so much more. In the treatment realm, harm reduction and decriminalization have become centre stage, there is increasing opposition to court-ordered attendance at 12-step groups, and the glaring discrepancy between the brain disease model and 12-step methods continues to…well, glare. At the interface between science and treatment, there’s new thinking about the benefits of psychedelics, new research on how meditation changes the brain, investigation of smartphone apps that might help control urges, and increasing precision in the debate between the disease model and the learning model — as both sides advance their weaponry.

I want to do a few posts that identify and explore these new directions.

To start, let’s go back to the fundamental question of definition. If addiction isn’t a disease, then what is it? As you can imagine, I get asked this a lot.

My first reaction is to call addiction a habit of mind. But what on earth does that mean? Calling it a habit of mind at least avoids having to choose to focus on cognition, emotion, or behaviour: rather, all three are on the table. Which respects the finding that cognition, emotion, and behaviour can’t be clearly differentiated in brain structure or function. They overlap entirely.

But what do I mean by habit? It’s an old word, a colloquial word…how much traction can we get from such an everyday term?

To explore that question, let me tell you how scientists define a habit. And for that, we need to take a brief tour of complexity theory. According to complexity theory, a habit is a stable state in a complex system — a system composed of many interacting parts. Complex systems — such as ecosystems, societies, cultures, family dynamics, flocks of birds, herds of cattle, individual minds, individual bodies, and certainly individual brains — are made up of components (birds in a flock, family members at the dinner table, plants and animals in an ecosystem) that continue to influence each other. As a result, the relations between them continue to change, which means that the whole system (e.g., the family, the flock, the body, the mind) can continue to alter its form. Change is intrinsic; it doesn’t come from outside the system. Change means change in the interaction patterns, the relationship of the components, not the components themselves.

Your sister makes a caustic remark at the dinner table, then your mother puts down her fork, and then your father gets silent and distant, and then Aunt Jenny starts to criticize your sister. So the shape or form of the family dynamic changes, all by itself, with no particular push from the outside world.

But if complex systems can change so easily, why do they tend to fall into the same familiar patterns time after time? In fact, stable, recurrent patterns — or “habits” — are fundamental to all complex systems. They are called attractors, because they literally “attract” the system. The flock of birds continues to fall into its characteristic V shape, family arguments always devolve into a familiar but infuriating script, and individual minds fall into familiar concerns or interpretations (e.g., “nobody really understands me!” or “I’m just so cool”) every hour of every day. Attractors aren’t necessarily attractive!

When we talk about people’s minds, what do we generally call these attractors — these habits of mind? Well, if they last only a few hours, we can call them moods. But if they recur week after week, month after month, year after year, we can call them personality patterns. Personality patterns (or traits) emerge more and more predictably during childhood and adolescence. (Of course, most people have several and can even be seen switching from one to another — e.g., grumpiness to guilt — as circumstances shift.) These patterns recur, they get reinforced, they set synaptic connections into particular configurations (or recurring synaptic configurations set them, depending on how you look at it), and they stabilize. In fact they become incredibly stable. Traits consolidate with development and they perpetuate themselves, becoming  “stuck” over the lifespan.

Complex systems naturally fall into habits. Otherwise, they would waste a lot of energy trying and discarding different patterns, different forms. That’s called chaos, and nature doesn’t like chaos. Complex systems fall apart if they can’t cohere into patterns. In fact, a large-scale pattern actually maintains the interaction of its parts in a very particular (and energy-efficient) configuration, which recreates the large-scale pattern again and again. So the (global) pattern and the (local) interactions literally cause each other (called circular causality). That’s what makes habits so resilient. That’s why it’s so hard to achieve deep, lasting change through psychotherapy. Hard, but not impossible.

What does this have to do with addiction? As I see it, personality traits or habits include what we might consider mental health problems. Such as: depression, anxiety disorder, overdependency, paranoia, obsessive-compulsive disorder, aggressive or antisocial personality style, etc, etc. All those patterns emerge and stabilize over development (even if they get a boost from genetics). They usually become stuck by early adulthood, they cause a lot of misery, and they are hard (but not impossible) to change. Addiction is just another such pattern.

So addiction isn’t really different from other mental health issues: it’s a sticky, long-lasting habit in the development of the self. And when you look at how complex systems work, how they get stuck, you see that addiction is actually natural. It’s not some kind of aberration. (Of course that doesn’t mean it’s good!)

Addiction is a habit in a very real sense. It’s a self-perpetuating way of thinking, a self-cohering set of beliefs, a self-reinforcing progression of emotions (desire-excitement-disappointment), and a limited (stuck) behavioural repertoire. Addiction is a habit of mind.

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.

Last post I described common denominators between drug addiction and compulsive gambling. Today I want to ask: how do we assign responsibility for promoting products that benefit some while seriously harming others — because they are too attractive?

I got back from my trip to Australia about three days ago and I can finally see straight this morning. I came home travel weary but armed with some great new insights and perspectives. Most of what I learned was by way of the “Many Ways to Help” conference organized by the Victorian Responsible Gambling Foundation. In particular, the counsellors, case workers, policy makers, and researchers in the audience and at the podium repeatedly raised the question of responsibility — and how responsibility is related to technology, access, and profit.

Let me unpack that. Gamblers in the Melbourne area come in droves to the Crown Casino, a multi-level pleasure palace packed with every conceivable form of entertainment and an enormous number of high-tech slot machines distributed among the bars, bandstands, restaurants, craps and roulette tables…along every corridor, in every nook and cranny. These machines have been designed to appeal to a great variety of individual tastes. In some, the spinning character set settles into a poker hand — usually a losing hand. Others rely on matches among fruits, goblins, jewels, and shining, flickering, mesmerizing tokens lifted from fairy tales and Kung Fu movies. Some mix cards, dice, and fairy-tale images on their glittering screens. The variety and artistry are incredible.

What offers all this excitement, this sense of fun, and what keeps gamblers playing and losing and playing and losing, derives from innovations in design, programming, psychological modeling,  video game development, and the technological know-how to package all these in a single product. And of course the paycheques of the designers, programmers, artists, and so forth come from a casino industry that rakes in enormous profits.

The attendees at the conference were pretty pissed off. Because, despite the various placards encouraging gamblers to take it easy, and despite various government regulations that force casinos to notify gamblers when they’ve reached the danger zone, there’s a confluence of factors that attract people to play as much as possible. Especially at the slot machines, where play becomes almost mindless (see previous post). The conference attendees spend their lives trying to help people who continue to lose — not only their money but their homes, marriages, interpersonal relationships of all sorts, and even their lives — sometimes directly via suicide, sometimes slowly through the alcoholism and other forms of escape that ride on gambling addiction. It just doesn’t seem fair. The casinos know what they’re doing, and they’ve got the resources to do it very effectively.

But there’s another side to this argument. The casinos (and other gambling outlets — I’ve chosen slot machines at casinos as an overt example) are just businesses. They exist to make money, pay their employees, and increase their profits, just like any other business. Does it make sense to blame them for being good at what they do? Is it their responsibility to protect the fewer than 1% of adults in the Melbourne area who are “problem gamblers” (and the 2.4% who are “moderate-risk gamblers”)? See recent research findings here. Or should the government come down hard on an industry that brings pleasant entertainment to many but serious harm to a few? These are some of the questions at the forefront of the discussion about problem gambling in Australia. And the same questions are debated just as hotly in the US and the UK.

If the answer is “maybe,” then let’s take the argument further: Should the manufacturers of fast cars be held responsible for accidents that result from speeding? Should the makers of video games like The Sims and Candy Crush be penalized for making the most attractive (and addictive) games ever known? Should Facebook be banned? Nir Eyal has a fascinating blog that explores the issues and ethics at the core of addictive technology, and the answers to these questions aren’t simple.

Aren’t adult humans supposed to be responsible for controlling their own impulses? After all, the world is full of temptations, some of them natural, some manufactured. It’s hardly conceivable to block temptations at the source, especially when most people can steer around them quite successfully. And would we want a world that minimizes tempting attractions, even if we could achieve it?

Where this conundrum interests me most is where it intersects with the problem of drug addiction. And alcoholism. The parallels are mind-blowing. First, stigmatization, family disintegration, avenues of treatment, and support groups continue to blossom in both realms. Second is the question of making profits off people’s suffering. Third, how do we balance the suffering of the few against possible benefits to the many? The sale of addictive drugs like heroin, methamphetamine, and crack line the pockets of drug lords and gangsters, but they also pay simple farmers all over South America and Asia. And the legal addictive drugs like oxycodone and Vicodan (most famously) certainly profit Big Pharma, but they also provide badly needed relief for the millions suffering pain. Next, should we restrain what might be called the technology of attraction at all? The substances I just listed, as well as modern slot machines and internet gambling, evolved from links between profit and technology. Technology needs money (e.g., profit) to grease its wheels. Even scotch whiskey — at least the good scotch that I like — is the product of an industry that harms a portion of its users while feeding some of its profits into technological advancement. Alcoholism kills 88,000 Americans per year. Yet almost nobody recommends a return to Prohibition.

So maybe it’s the same problem in general — the same problem for gambling industries, video game makers, social media designers, drug manufacturers, and distilleries with exotic names like Glenkinchie and Laphroaig. Many of the products that make modern life fun, pleasant, interesting — or even just bearable — for many of us also make life hell for those who lose control. Should we assign blame for making, selling, or buying something that’s too desirable? Do we just turn responsibility over to the user, or is there a sensible way to restrain the dealer? Is there any concept of regulation, packaged warnings, education, or harm reduction that could help across the board?

I’d love to hear your thoughts.

In the last two posts – one by Persephone and one by me – we talked about the possibility that 12-step treatment offers a “static” rather than “developmental” approach to recovery. Persephone argued that certain features of 12-step practice kept the addict or alcoholic in a frozen state of heightened anxiety, much like PTSD. My last post was an attempt to extend and articulate some of Persephone’s points. I was really taken with the similarities between her idea of “static recovery” and PTSD, and I provided information about traumatic memory maintenance in support.

But today I want to take a different approach – and I think it provides a real reconciliation between the pro and con positions on 12-step recovery. The point I want to make is that any and all recovery has to be developmental in nature. Pure stasis simply cannot correspond with recovery.

The term neuroplasticity has been bandied around a lot. Norman Doidge seems to think he invented the concept, or at least brought it into the limelight, but it’s been around for ages. Dr. Eric Kandel of Columbia shared a Nobel Prize in 2000, reflecting decades of research on how the brain changes when learning occurs. In a nutshell, Kandel showed that the connections among neurons – synapses – must change physically if memories are to be formed. He showed this at a molecular level, validating Hebb’s famous insight from the 40s: What fires together wires together. Well all the neural change that takes place when we learn and remember things is really just neuroplasticity.

Neuroplasticity is strongly amplified when people are highly motivated to change, probably because of the strong emotions that come into play and focus one’s attention. In her wonderful book, Barbara Arrowsmith-Young describes the many cognitive exercises she devised for herself, in order to overcome her very severe learning disabilities. They worked. She went from a high-school student who could not comprehend history, who even had a hard time understanding simple sentences, to a writer and teacher who has set up roughly 70 schools for learning-disabled children in North America. Barbara, whom I met in Australia last year, has a delightful phrase for neuroplasticity dedicated to replacing bad habits with good ones.

What fires together wires together, and what fires apart wires apart!

(I don’t actually know the origin of this phrase, but I like it.)

In 1993, Mogliner and colleagues looked at the brains of people who had been plagued with webbed fingers. That means that some of their fingers could not operate separately – they functioned in total unison. After surgery was performed to allow the fingers to move independently, these authors looked at changes in the (somatosensory) cortex. What they found was that the synaptic wiring of neurons in the corresponding brain regions had changed substantially, just weeks after people started to control their fingers independently.

The parallel with addiction seems striking. You “learned” your addiction through neuroplasticity, which is how you learn everything. You maintained your addiction because you lost some of that plasticity. As if your fingers had become attached together, you could no longer separate your desire for wellbeing from your desire for drugs, booze, or whatever. Then, if you did indeed recover, whether in AA, NA, or standing naked on the 33^rd floor balcony of the Chicago Sheraton in February, that means you got your neuroplasticity back. Your brain started changing again – perhaps radically. You started to separate one set of desires from another and to act on them independently. And just as in Mogliner’s study, your brain began to regrow its synaptic patterns – to allow the change to take place, to hold onto the change, and thereby to permit a new degree of personal freedom.

The take-home message is simple: All recovery is developmental. Without developmental change in mind and brain, you would stay exactly the way you are.