Understanding Addiction

Over the last year, I’ve explored the terrain between meaning and dogma, choice and compulsion, I’ve taken you with me to Dharamsala, found surprising convergences between Buddhist philosophy and dopamine metabolism, pondered the application of mindfulness to treatment. But the theme I seem to land on most is the search for an alternative to the disease model of addiction — a way to understand addiction that does not pit disease against choice, or self-medication against self-indulgence.  So for this final post of the year, I want to bring this discussion to some sort of close. Not a final answer: no way. But a plateau where it’s possible to set up  camp and rest a bit before delving further into the wilderness of this almost intractable problem we’ve all lived with one way or another.

Because I’m feeling stuffed, indulgent and lazy, as I hope you are too this Christmas day, I’ll just copy and paste a few paragraphs from the first chapter of the book I’m working on. It’s just a draft at this point, more revision to be done, but I think this captures the kernel of what I want my book to say:

“Among the opponents of the disease model, almost no one has fought fire with fire and tackled the neuroscience behind it. Most of those arguing against the disease model, like the general public, are spellbound, if not paralyzed, by the notion of “brain change.” … It’s almost as if students of addiction make a choice: either admit the brain is a really important organ, in which case addiction is a brain disease, or put the brain back in the closet, in which case you can go on talking about choice, environmental factors, social anthropology, and all the rest of it.

This strikes me as exceptionally odd. Surely the brain that underlies addiction is the same brain that we use to perceive and respond to our environments, make choices, and reflect on the benefits of being high — in context. So it seems extremely likely that the brain is fundamental to addiction, whether we construe addiction as a disease, a choice, or a self-medication strategy.

The fact is: brains change. They’re supposed to. These days it’s called neuroplasticity. Brain change is the fundamental mechanism by which infants grow into toddlers who grow into children who grow into adults. Brain change underlies the transformations in thinking and feeling that characterize early adolescence. (By some estimates, the prefrontal cortex loses 30,000 synapses per second during this period.) Brain change is necessary for perspective-taking and language acquisition in early childhood, and for falling in love, with a partner or with one’s children, later in life. And for learning to play a musical instrument or appreciate opera. Brains have to change for learning to take place. Without physical changes in brain matter, learning is impossible. Synapses appear and self-perpetuate or weaken and dissipate. These processes alter the communication patterns between brain regions and build unique configurations of synapses (synaptic networks) that represent knowledge, familiarity, and memory itself. The relation between learning and brain change has been studied for more than 100 years, it was reasonably well understood by the 1940s, and the search for specific cellular mechanisms of learning continues to point to new levels and mechanisms of change. Whether repairing the damage caused by a minor stroke or altering emotional processes in the wake of trauma, neuroplasticity is at the top of the brain’s resumé.

Proponents of the disease model argue that addiction changes the brain. And they’re right: it does. But the brain is designed to change. It’s primary functions — to think, feel, remember, and act — are served by structural transformations at every level, from gene expression to the size and shape of the cortex itself. The premise that brain change equals brain disease is so ill-founded, it’s hard to know exactly where to start chopping.

A new model of addiction and a plan for the book

This book makes the case that addiction results from accelerated learning — the acquisition of thought patterns that rapidly self-perpetuate because of the brain’s tendency to become sensitized to highly attractive rewards. I see this as a developmental process, accelerated by a neurochemical feedback loop that’s particular to strong attractions. Like other developmental outcomes, addiction isn’t easy to reverse, because it’s based on synaptic restructuring. Like other developmental outcomes, it arises from neural plasticity and uses it up at the same time. Addiction is definitely bad news for the addict and all those within range. But the severe consequences of addiction don’t make it a disease, any more than the consequences of violence make violence a disease, or the consequences of racism make racism a disease, or the folly of loving thy neighbour’s wife make infidelity a disease. What they make it is a very bad habit…

This book shows why the disease model is wrong — and how that wrongness is maintained by a biased view of the neural data. Then it shows how we can replace the disease model, not by shunning the biology of addiction but by examining it more closely. Rather than throw the brain out with the bathwater, as some anti-disease crusaders have attempted, I examine brain changes under a microscope that integrates depth and detail. And I show them to be developmental changes in an organ designed to restructure itself. I show how common neurodevelopmental processes yield uncommon results when we become attached to a narrow set of goals that squeeze out the competition….

I show how addiction arises through neural changes that constitute development, not disease — changes that nevertheless conspire to make it increasingly hard to quit. And I show how recovery is achieved when addicts continue to develop, by strengthening new connections among desire, self-regard, and self-control.”

So, stay tuned. The book, to be released in 2014, will spell out this meta-perspective through the telling of biographical accounts, slices of the incredible life stories some of you have shared with me — or who still might talk with me when I finally catch up enough to email, skype, and/or call you. And I’ll connect these stories to the science of brain change in a way that I hope will be accessible, persuasive, and un-put-downable as they say on back covers.

But as far as this blog goes, I think I’ll give this debate a rest — and move on to other things. We all need a break.

With that in mind, Happy Holidays, Happy New Year, get some rest, some peace, some refreshment, and some fun. Thanks for going the distance with me this year…and I promise to be staring at you from your inbox, once again, in 2014.

I seem to have become a movie critic.  A month ago I posted on Ben is Back and yesterday I watched A Beautiful Boy on a flight home from San Francisco. And what I get at the end of each movie is a big fat nothing. There is no conclusion, no understanding, no ground from which to move forward.

With Ben is Back, there was Julia Roberts’ compelling angst, and now, with A Beautiful Boy (which I also read), we feel that intense heartbreak of a parent who can do nothing more to help. Only to keep loving…and losing…as if his son had cancer or leprosy. I guess I’m mad and that’s why my words are coming out this way. There is something fundamentally wrong in these portrayals. Yes, they get the drama, the heartbreak, the power of drug highs. They get the agonizing schism between the teen or young adult lost in drugs and the (generally divorced) parents who still love their kid intensely. All that is worthwhile and important. But what they don’t get is the experience. They don’t even try to approximate, to estimate, to guess at what these young drug addicts are experiencing (other than deep sighs and stretches and rapturous smiles). Why is this so opaque?

I mean, if we can create film after film about the Vietnam War and experience the shame, guilt, and horror of soldiers watching their friends die and their deepest values twisted inside out, why can’t we even come close to portraying — not what the parent is feeling — yes, that’s important too — but what the young addict is experiencing? What could be more dramatic than that? (And isn’t that supposed to be the crisis of our time?)

With Ben and Nic, there are plenty of scenes that broadcast, almost prostitute, the sense of shame that these young men feel about their addictions and the deep hurt they cause their parents and siblings. Okay…shame. We get that addiction confers shame, which makes it harder to stop and harder to connect. But there’s so much more that’s missing. What is it that gets these kids to go back to their dealers and using buddies and half-empty girlfriends to do it again? To throw it all away, even after a year or more of “sobriety?”

In an online interview, Nic Sheff, the “boy” on whose story the book and movie are based, describes meth as providing “the feeling I’d been looking for my whole life.” We hear that a lot in stories of hard drug use (heroin and meth), and these movies actually provide skittery sci-fi sounds suggesting that the drugs are broadcasting an irresistible homing signal. But that’s way too easy. Rather than imagine that this was our singular goal since first grade, we need to look at the cluster of feelings that we have been trying to get away from.

This word “sobriety” might be a way in. What feels so miserable about sobriety (the kind that’s required rather than chosen)? I can tell you, in case you’ve never been there. It’s the boredom, the emptiness, the contrivance, the feeling of being who you’re supposed to be…which requires leaving  behind the compelling drive to explore your own identity, choices, and consciousness. Who in Hollywood tries to portray that? The intensely creative moment of throwing out the norms and choosing, at the risk of one’s own existence, to reach for moments of awareness defined completely on one’s own terms.

There’s nothing moral or immoral about it. Taking powerful drugs can be a creative act, often with dire consequences. It’s not about the skittering sci-fi sounds of what is supposedly happening to your brain. Or the kiss of thanatos that inspired Freud and the Velvet Underground both. It’s the reach…for something so very different…from the monotony of living in our TV-tailored culture and obeying the commandments of family and love without ever having created either one. Yes, we want that. But at 18 or 20, we can’t create it. We can only rent that property from parents who settled there and established a home there. We can only copy, and please, and behave ourselves, trading our youthful energy for the security we could never find elsewhere. And guess what: that’s not enough.

So we find our own kind of creativity and culture: the powerful technology of present-day drugs and the immensely attractive inclusion of like-minded venturers…and that moment of going  back to being entirely unbound…that’s what we seek, and often find. And sometimes that’s what destroys us…and perhaps our families too. It just disappoints me hugely that all the power and skill of Hollywood has not even ventured there, not even peered under that rock…at least not lately…in the black-and-white disease-minded culture of “you’re either one of us or you’re some unfortunate mutant.” What the fuck? We can do better than that.

(I’m aware, in re-reading this, that it’s only one slant. My target here is the middle-class confusion and emptiness that often promotes drug experimentation in teens. That’s the setting in both films. Intense socioeconomic hardships can also propel drug use, as can trauma, loss, depression, and other challenges. And yes, drugs can be addictive — which is a causal force in itself. These other drivers of addiction are discussed in many other posts by me and my guest contributors.)

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.

Hi again. It’s me this time. No guests. I want to tell you about the debate I just had with a high priest of the Disease Church. Not the bishop, Nora Volkow. But her second in command, George Koob.

Those of us who oppose the disease label have been trying to organize a real debate for a long time. Nora Volkow has consistently ignored these requests or else replied No through her staff. But Koob made an excellent second choice. Judging by his picture and digital presence, I expected a slightly stodgy, soft-spoken academic/scientist type who saw addiction as a disease.

In fact Dr. Koob is the second author of the paper first-authored by Volkow in the January issue of the New England Journal of Medicine, the paper that made a lot of us anti-disease people more irate than usual. Here’s the title: Neurobiologic Advances from the Brain Disease Model of Addiction. And here’s a passage from the first paragraph:

In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…

I used this quote to launch a counterattack that was published last week in the Guardian. I was pleased to see my little fusillade appear on page 1 of the US edition last Tuesday. And it’s snagged over 600 comments and 2,700 shares in the first week. So a lot of people seemed to agree with my criticisms of the disease model (specifically the claim that the disease label led to an “effective” response to addiction and reduced stigma). But, if you happen to browse the comments, you’ll see that many others thought I was out to lunch.

I actually wondered whether Koob had already read my article. Because he seemed hopping mad from the first words of the debate.

Here’s how it went.

I was sitting in a flashy looking studio in Arnhem. Yes, even in my town we have studios with lots of computers and screens and expensive looking microphones. So I was sitting there in a sound-proof room in front of a state-of-the-art mic, and George Koob was in Washington. The debate was set up by CBC (Canadian Broadcasting Corp — Canada’s national radio) and will be broadcast a few weeks from now. I’ll let you know.

I was nervous. More nervous than I’ve been in any kind of talk or interview for a long time. My voice came out raspy at first. Yet I’d done my homework. I’d reread lots of stuff on changes to the dopamine system, Berridge’s review of his incentive sensitization model, findings on the desensitization of the striatum and the resultant loss of connectivity with the prefrontal cortex. I’d also scanned articles showing that these brain changes are common to drug addiction, porn addiction, obesity, “internet addiction,” and even compulsive shopping — so I had a few arguments ready.

I’d also read a few Koob papers (which I forgot I’d already read thoroughly until I found my yellow highlighting throughout) and felt completely caught up on his theory of the “dark side” of addiction, viz withdrawal, viz the rebound invoked by the “antireward” system. I was ready to talk brain science, because I had no doubt (and I still have no doubt) that George Koob is a top neuroscientist, highly respected and rightfully so. Not to mention the director of the National Institute on Alcohol Abuse and Alcoholism.

But within minutes of the word Go, I realized that I’d done all that cramming for nothing. This debate wasn’t going to be about the neuroscience of addiction. It wasn’t going to be smart, sophisticated, strategic, or fun. It was going to be a slug fest.

The moderator/host (a seasoned radio/TV person in Toronto) started things off by asking Koob: Why do you say addiction is a disease?

He replied something like: What else could it be? And when she asked for a bit more substance: Because it changes the brain. It’s as simple as that. That’s what he said, almost verbatim. And I thought: that’s the most vacuous argument he could possibly make. Everybody knows that the brain is always changing, it changes whenever we learn something, it changes massively throughout development, and there’s this thing called neuroplasticity which is basically the brain’s job description. But that’s what he said: addiction is a disease because it changes the brain. So I had to retort with…well, some version of what I just said.

It didn’t get any better. He sounded angry throughout. He was belligerent at times. He talked about how four people he was very close to had died from alcoholism, because they could not stop drinking. Absolutely could not stop. And he specifically accused me (and us anti-disease folk) of trivializing addiction by not recognizing that it’s a disease. I told him I’d lost a friend to addiction too, but I wasn’t pleased with myself for stooping to such arguments. He even said that I wanted addicts to be stigmatized and that’s why I opposed the disease label. Which was exactly the opposite of what I’d just said: that I felt the disease label merely entrenched the stigma of addiction, and there were much better ways to overcome stigma, like connection, compassion…all the things Johann Hari writes about….and understanding what it really is without giving it a simplistic label.

I’d better stop. I don’t remember everything, and maybe my memories are blurred by the adrenalin I was surfing through most of the debate….which lasted about 45 minutes.

But here’s the point I want to make. I’m pretty sure I “won” the debate because I said smarter things and backed them up better than my opponent. And I’m pretty sure I came off smelling sweeter because my tone wasn’t as antagonistic as his.

BUT IT DOESN’T MATTER.

The problem is that we weren’t talking. We were just fighting. We weren’t listening to each other. We weren’t getting to know each other’s views any better. We certainly weren’t arriving at some kind of middle ground that might benefit from both our perspectives.

And that is so sad!

Hello people. This is not a post but a request. I just got the go-ahead from my agent to begin work on a new book. Here’s the plan —

Three or four intimate biographies, of people who have had serious struggles with drugs and/or alcohol, who have become addicted, by one definition or another, and who have tried and perhaps succeeded in recovering — even if it didn’t last for good. These life stories will be the backbone of the book. I plan to connect each story to one of the major outlooks, or camps, that try to understand how addiction works: the disease camp, the “choice” camp, and the “self-medication” model, all which have some power to describe addiction, but none of which explains it completely successfully — in my view. I will use science (neuroscience and psychological science, maybe genetics, maybe treatment and prevention science) to take a deeper look at what’s going on in each of these addiction journeys, and I’ll pull it all together with an approach and an explanation that I think works the best.

I need volunteers! I have already talked to a few of you in some detail about your life stories, but I need to talk to others. Would you consider letting me write the story of your life? Of course, you don’t have to tell me everything. I don’t want to “reveal” what you don’t want to be revealed. But I do need detail. I need to know what it’s been like, what it has felt like, where you have been, where you are now, and where you think you’re going. Most of all, I need to know the facts and the feelings as only you can describe them.

Most if not all interviewing would be done via Skype or phone — at my expense of course.

I do NOT have to use your name. That’s a choice you can make, but it is not at all necessary or even very useful for the book I’m planning. Pseudonyms will be fine. And, I hope it goes without saying, I would never reveal your name, or any details attached to your name, to anyone, in any circumstances, without your express (and written) permission. I’m still a clinical psychologist (one of my hats) and I’m still bound by professional ethics. Not to mention personal ethics.

Please consider this request, and if you’d like to talk with me about it, drop me a line. It’s best to use the “contact” form that is embedded in this website. Just click on the Contact tab at the top of this page.

Thanks for any replies, suggestions, or questions,

–Marc