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So many of you have asked how it went last night, I thought I’d try to give you my take on it, right here.

In a nutshell, it went very well.

After working for days (sweating, obsessing, etc) on my Powerpoint presentation, Isabel forced me (don’t ask me exactly how) to redo the whole thing yesterday morning before she left for work. Isabel is a really skilled speaker, and she’s developed a style for “inspirational” talks that make intellectual and scientific points digestible, entertaining, accessible, and potent. I’m just a stodgy old academic, so I still tend to put a lot of text on my slides. Trying to make sure I cover everything and include the necessary facts and figures, even at the risk of boring or losing some of my audience. So…I’ve learned enough to do what she says.

It took the whole day, but I finally got it done: a lean, mean, presentation. Slides with few words, mostly titles and bullet points, lots of cool animation, and a step-by-step breakdown of what the “disease model” of addiction gets wrong (in my opinion) and how to adapt/replace it with a more effective way to understand addiction and help those who suffer. I’ve printed all my slides below.

We were almost late and…there was a certain amount of anxiety involved. Parking in a highly questionable spot, racing through the train station to platform 11. Isabel had generously offered to go with me, essentially to hold my hand. I was kind of nervous but not too bad. And somewhat magically, the nervousness just evaporated when we got on the train.

I edited my slides obsessively during the trip, hardly noticed changing trains in Utrecht, and I babbled to myself all the way. What might Nora Volkow say to this, and to that, and did it matter? And how to deliver what I needed to deliver without being overbearing or attacking or…too wimpy.

It was a cold night in Amsterdam, but everything glittered: the magnificent structures of the old city interspersed with modern buildings that were also imaginative and beautiful in their own way. All of it reflected off the canals. We found the venue, about a ten-minute walk from the station: a beautiful and very modern library, and in it a classy theater that could seat about 250. Isabel looked fabulous. I looked dowdy. I guess we averaged out okay.

So…there was Nora Volkow, in the flesh, We had a friendly enough greeting. She was there to receive an honorary PhD from the University of Amsterdam. I asked her how many PhDs she had now. She said she truly didn’t know. She is the most renowned and probably the busiest addiction scientist in the world. She’s earned her stripes. But of course she’s just a person, looking a bit tired and no doubt jet-lagged on this particular night.

By the time we started, the theater was completely packed. She got up on the stage and did her thing: energetic, committed, sure of herself, convinced that neuroscience was the main act when it comes to understanding addiction. She showed some colourful brain MRIs, talked about dopamine a lot, and…well if you want to know more about her message, go to the NIDA website.

One thing that did impress me (and others) was that she talked a bit about recovery from addiction. For many years, the NIDA party line has been that addiction is a chronic brain disease. People don’t recover from chronic diseases. So…maybe that’s progress. Maybe the addiction neuroscientists are starting to listen to our messages about the experience of addiction, its developmental time course, the enormous individual differences in process and outcome, the gradations in levels of intensity…and the very important issue of free will — something that Nora has long claimed gets wiped out by drugs. The hijacked brain. In my talk I emphasized that addicts do not lose their willpower — in fact they have a great deal of it. Rather, they have a hard time making choices that are good for them in the long run. And choice is not a simple thing — for anybody.

Maybe the brain scientists, including Nora Volkow, are tuning into the personal and social and societal foundations of addiction. I hope so, and I hope that those in the “psychosocial” camp start listening to the brain scientists as well. These are all pieces of the same puzzle.

Nora talked for about 20 minutes, then I went up there and did my spiel. It was a good talk. If I was a religious person, I’d say the power moved in me…or something like that. I was hardly conscious of what I was saying. It was that thing they call “flow.” But man, it felt good, because I could tell it was coming out just right, and Isabel sat in the third row and smiled hugely every time we made eye contact. And then, lots of applause — especially for the Dutch — and then a debate between Nora and me with input from a panel of three experts and the audience.

And so on and so forth. I won’t try to capture any more of it for now. The evening was recorded, and I think the talks and debate will all show up on YouTube before long. I’ll let you know.

Meanwhile, here are my slides. I’ve inserted blue arrows to try to give you a sense of what words and images appeared partway through the slides (via animation). I’ve also included some “speech balloons” to approximate the things I said that don’t appear on the slides. A lot is missing, I know. As per Isabel’s instructions, there was less to read and more just to speak.

 

 

 

 

Hello readers,

Some of you have noticed that I haven’t posted much in the last few months. The last post published, by Hildur Jónsdóttir, was I thought very beautiful and meaningful. So…not a bad place to end for the season. Please take a look if you haven’t read it yet.

Blogging has been an incredibly enriching experience for me. I have made many friends through the blog, and I feel a strong emotional and intellectual connection with all who have read our posts, responded or not, and remained connected over the years. This is a fabulous blogging community, totally unlike any other in the addiction field, mostly because of the sensitivity, compassion, intelligence, expertise and openness of my readers.

Sound like I’m about to say goodbye? Well, no, not yet.

I have posted less because I’m thinking about other things, trying to write that novel, and mainly because I’m not sure what to focus on in the addiction world that’s new and interesting. Please, please, send me suggestions for topics in the world of addiction — the science, experience, policy, politics, and/or treatment aspects — that either I or colleagues (including readers!) could write about.

My own news. I’ve been in Toronto for nearly two weeks with my family — our annual vacation visit with family and friends. Everyone in my immediate family is well. My boys are now 11 and still delightful. Their experiments with preadolescence remain benign. My girl (from my previous marriage) is almost 30 and getting more interesting and sophisticated by the year. We’re flying (boys, Isabel and I) back to the Netherlands later today. From minus-15 in Toronto to plus-10 in Arnhem. Of course it will be raining when we get there. That’s a given. But I’ll trade that for the cold.

My exciting news to do with addiction: This coming Tuesday evening I will have a public debate with Nora Volkow, head of NIDA and staunch spokesperson for the brain-disease model of addiction. I’ve been wanting to debate Nora for years. I came close a couple of years ago, as I wrote about here. This time it’s a direct hit. The event will be put on by the University of Amsterdam, as part of the hoopla of awarding Nora an honorary PhD. I have a lot of respect for that woman, but we have obvious differences of opinion. I look forward to crossing swords but also finding common ground and directions for connecting brain models with social-developmental “non-disease” models of addiction — and moving toward a framework that may be less contentious and more effective for policy and care efforts all over the world.

I’ll let you know how it goes in my next post. Meanwhile, here’s the poster:

 

Wish us luck in connecting with each other in a meaningful way. And please do send me suggestions for the blog. A huge number of people are still suffering from addiction or misguided efforts to curtail it. This is no time to stop thinking, exploring, and hoping.

 

 

 

…by Hildur Jónsdóttir…

I have a problem with the term recovery. For many of us recovery implies that there once was a wholeness that was shattered through addiction, a wholeness that we need to recover, find again. I have toyed with the word restoration, but likewise, often there is little to restore. For many of us, our lives before addiction were never anything but shattered and disconnected. Yet this disconnection, these lives shattered, are the points of departure on our journey through life forward. Therefore we need to learn how to navigate from there, not back to a distant past, but to a future yet unknown to us.

Still, we have to come to terms with our past. We long for an understanding and for a meaning of our lives.

This writing is inspired by a fellow reader here who some months ago claimed in anguish: Do I have to continue to live with this shit? This shit in the basement that keeps thrusting its ugly head up into my consciousness here and now. My answer is yes. We have to live with the ogres from our past, named shame and guilt and regret and sorrow. But let me also share my contemplations on the concept of time.

I will start with an old parable from the Inuits in Greenland.

During the long, dark winter, when there is frost and snowfall, Inuits throw their waste in a heap outdoors, for it to be covered with snow in the next winter storm. A new layer of waste is added to the heap to be covered again, and then another and another. Each layer freezes into the same thick chunk of ice. When spring arrives, it is of no use to try to clear it up all at once. The only thing to do is to let each layer appear one after another as the higher chunk  thaws. So one layer thaws and is cleared away, then another, then another. No one can force their way prematurely to the bottom of the heap, but they can rest assured that every layer will finally be revealed and dealt with.

This parable corresponds beautifully with the Inuit concept of time. I have come to understand this. From the birth of man and consciousness, in earlier agricultural societies, time was circular. The rhythm of life was cyclical, from the beginning of life in spring through growth, harvest and finally death. Death was followed by rebirth, for nature and for man. The cycle would start all over again. The industrial revolution changed our concept of time, nature did not dictate it any more, but production lines did. Time became linear, just like production and progress. Peak performance was always in demand. Be productive! Act now! Consume now! Be happy now! And be greedy!

This is not to be mixed up with the concept of here-and-now as in mindfulness and meditation. These do not demand peak performance, instant happiness or suppression of emotions. Just attention – and time to be present.

The old Inuit concept of time sees no time spent, no time wasted, no time gone. Time arrives. Time only arrives. Each and every moment we receive the gift of time to be added to all the gifts of time already received. Yes, nature is cyclical, yet still unpredictable; the variations in weather, the movements of the sea animals and of the ice are never exactly the same. Nature asks of you only attention and time.

We amass abundance of time, a growing wealth of time. But time also uncovers what came before, allowing us to deal with it. Time will arrive and thaw the stiff and icy chunk of your past. And with your attention and readiness you will deal with everything that the thawing reveals, loosens and presents to you. Not all at once. Layer by layer.

The impact of this on my thinking and my relationship with my past is profound. Nothing in my life, in my traumas and experiences, in my relations to people, is ever going away. Nothing is lost and nothing is forgotten. I have nothing to “get over.” Everything is there, intact, ready to be added to, interpreted and reinterpreted, constructed, deconstructed and reconstructed. I can roam freely in my limitless treasure chest of time that reaches beyond my own physical limitations – and keep the lid open for it to receive the new gifts of time that keep coming to me.

My past, my amassed time, is therefore both intact but also constantly recreated. Because now I have the power of attention. I have the power to examine what all this once meant to me, but I also have the power to change what all this means to me now. I have gained an insight that I would almost call spiritual, where even my ancestors and the story of my extended and immediate family belong. And where all of you (in this community) belong. Instead of disconnection there is now connection, over space and over time. There is, in each moment, attention, time and power to grow.

 

Point of clarification: I didn’t mean to imply that people who take opioids for reasons other than physical pain are to blame for the opioid “crisis” or the overdose epidemic. Let me retrace my steps.

I recently pasted and posted my article, published in The Guardian, arguing that opiates prescribed for people in pain are wrongfully blamed for the overdose epidemic. All true. But I also stipulated that the illicit use of pharmaceutical opioids was a link in the chain to opioid addiction and, in the current fentanylized environment, to the overdose epidemic.

So what does that say about us former and still active opioid “abusers” and addicts? I have a pretty good sense that most of my readership, like me, went down the path of pilfering …e.g, stealing, buying, faking, or otherwise getting pharmaceutical opioids that weren’t prescribed for our physical pain. We found those pills any way we could, because we needed them to soothe another kind of pain.

I thought, since sharing my article with you, that you might feel I’m pointing the finger of blame at “you addicts” who’ve found a loophole in the prescription opioid cycle, who’ve found a way to acquire pharmaceuticals “illicitly.”

No way. Having had two spinal surgeries in the last seven years, I’m definitely attuned to the pain relief issue. In fact, though my back’s been in quite good shape since the surgeries (praise be to physio, Tai Chi, and a great healthcare system here in the Netherlands), I had a horrific episode a couple of years ago. I was attending a conference in Geneva (focused on addiction, somewhat ironically) and my back went into gridlock spasm. The pain was so intense that I literally couldn’t move, couldn’t walk, couldn’t sit. Loud noises came out of my mouth that I seemed unable to control. I had people coming up to me while I stood rigid, paralyzed, in the middle of a busy hotel lobby between session, and carry or drag me to the nearest sofa (it was a pretty plush hotel). And even sitting, I could not unspasm; my body seemed like a lighting rod that would not stop zapping. People I didn’t know — strangers — found me a wheelchair, wheeled me to the elevator, got me down to the street level and called a taxi to take me to the hospital. And the next day, at a doctor’s office near my own hotel, I was howling so bad that the doctor and his assistants dragged me out of the waiting room because I was scaring the other patients. They then lifted me into a taxi — back to the hospital again. When all I really needed was a shot of morphine or a substantial dose of oxycodone. Getting high was the furthest thing from my mind.

So why couldn’t they provide that? Even at the hospital, I had to lie on a gurney intermittently screeching in pain for over an hour before the morphine came. People passing by had pity written all over their faces. Has the opioid scare infested Europe too? Not as much as the US, but yes, seemingly, to a degree.

So physical pain is one thing, and I have immense sympathy and empathy for those who experience it regularly. (For me, thankfully, this was a rare episode).

But I’ve also experienced the other kind of pain, the overwhelming darkness that invades your thoughts and feelings to such an extent that you are paralyzed in another way. You can’t think, or feel, or communicate, because it hurts so much just to exist. Opioids can provide enormous relief from that kind of pain as well. But of course no doctor will prescribe opioids for your depression, unless you’re getting methadone or Suboxone because you’re a “registered” addict, whatever that happens to mean in your corner of the world. Maybe just lining up at some seedy clinic, maybe being sneered at, maybe not being able to get a job, maybe having your license revoked…hell, in the Philippines it means being lined up and shot.

When we’re in that kind of pain, and if we’re pretty sure that opioids can help relieve it, we’re trapped. We can’t get an opioid prescription for emotional relief.  (Don’t get me started on “antidepressants” — SSRIs — which are so much less effective than hoped, which carry their own batch of side effects, and which require as much tapering as opioids to minimize withdrawal symptoms.) So we buy, borrow, steal, forge, or do whatever we have to do to acquire the medication that can bring us back to some semblance of normality, of peace.

I just want to clarify that I don’t see you, me, us addicts — former or “active” — as villains in this scenario. Yes, we do “divert” pain pills to deal with our (sometimes enormous) psychological vulnerabilities. But we only do that because our back is against the wall. Only because there’s no other choice.

That struggle was not the point of my article, and you (us) were not the audience I was targeting. But I am so with you, you don’t even know it. And if your diverted pharmaceuticals have led to (or replaced or complemented) heroin, which might have led to fentanyl, which might kill you, I see that as a shameful tragedy. But I don’t blame you. I blame the system that has vilified, isolated, and abandoned you. I don’t blame you. In fact, the risks you (we) face are so very grave, simply because we can’t (through normal channels) get the pharmaceuticals that can help us, we move to the front of the line of sufferers.

If I had to choose between battling emotional anguish and physical pain, I’d be hard pressed to decide which to try first.

There is no reason why either kind of pain should be left untreated in this age of pharmaceutical evolution. But I’m not going to be able to convince the head of the DEA, the governor of Maine, or Donald Trump that both kinds of pain qualify for care. I’m just starting with the most obvious.

 

 

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.