Understanding Addiction

I am finally finished the tapering period, finished getting off the oxycodone I was on pre- and post-surgery. It took about four weeks to go from 100 mg/day to zero. Nice and gradual, and I suffered nothing worse than a runny nose, some diarrhea, some insomnia, and a few twitches. Oh, and that sense of impending loss, depression, and despair. Did I mention that? The old circuits carrying that old message, because that’s what old circuits do.

So there I was, flickering into my “addict self,” as people like to call it, and thinking, I like this stuff and I’m not eager to stop…

I don’t remember who gave me this line — one of you, I’m sure: Quitting drugs is like going to the funeral of your best friend. Funny how it still feels like that. That’s what I anticipated. Not as intense as in the old days. But qualitatively pretty much the same.

What I wasn’t anticipating, what I’d forgotten about, was the relief I’m feeling now. An unexpected flush of freedom, breathing in lungfuls of fresh air. And feeling strong again. I feel centered, and focused, and strong. I feel like me again. It’s been awhile.

But…freedom from what? That is the big question, don’t you think? Freedom from the sense of impending loss, the sort of cowering that goes with ingesting something you imagine is enhancing your sense of okayness, knowing it’s not going to last, and putting off the inevitable. Freedom from the compulsion, the greedy hording (mentally, at any rate) of the crumbs of wellbeing that I was still getting from these pills — even on a medically supervised, perfectly legal, moral, and even necessary detox regime. I was still getting the crumbs. And the freedom I feel now is from the anxiety — pure and simple: anxiety — about losing those crumbs.

My last post addressed how it might be possible to make the future seem as good or better than the present, by adjusting the subjective value, the sense of value, of the immediate reward (drugs, booze, whatever) versus the long-term reward (that list of seeming abstractions) and/or changing their timing. And then you guys asked, and I asked myself, how exactly do you do that? How do you do it for yourself (if you’re the addict) and how do you do it for someone else (if you’re the helper, sponsor, therapist, partner)? If we’re not in some artificial experimental setting, and it’s not just a matter of changing the numerals on a computer screen (e.g., from 10 to 45 euros in the “next week” column), how do you get the future to feel like it’s worth it?! Worth whatever you have to go through to “just say NO.”

And here, ladies and gentlemen, is the answer. At least one answer.

Remind yourself or your addicted friend, lover, client or patient about this sense of relief! This feeling of being a whole person. Of being strong. Make it palpable. Get it back on the radar. Bring it to mind (hint: that’s the first half of the word “mindfulness”). This is what it feels like to finally be free of this shit! Remember? Do you get it? There is peace here.

Certainly  there are twinges of wistfulness. Yes, some kind of magical sheen, winking on and off like an old neon sign, has gone missing. Craving still bunches up in your throat like a reflex, a need to swallow — or  cough. But the place you land in, after these dust devils have passed…that place feels like home.

Now, as to the details, how exactly to do that, I’m going to turn the floor over to someone in the treatment world. First up is my friend (through this blog) and long-time contributor (to this blog), Matt. And if anyone else would like to help us out here — anyone, but especially those of you in the treatment community — please do: get in touch about writing a guest post. Soon! I think we could all use some concrete ideas about manipulating awareness, about expanding awareness beyond the upcoming delivery of today’s lollipop, about shifting your focus…away from the siren call of the moment and back to the main voyage.

I’m off to Australia for two weeks. I’ll be doing talks, public debates, etc, on the subject of gambling as well as substance addiction. Apparently gambling is a more serious public health issue than alcohol or drug addiction in Australia. I’ll also be spending some time on a farm somewhere where they shear sheep and herd cows. Should be a nice break from urban life in Holland.

So in lieu of a blog post, let me leave you with a link to an article recently published by David Schimke in the Chronicle of Higher Education, August 7, 2016. Despite the title, it’s a broad and thoughtful review of the whole gamut of current trends in the study and treatment of addiction, covering perspectives from biological science, social science, public health, psychiatry, and so forth. As a touchstone for this review, Schimke describes choice moments in a conference I participated in (along with Carl Hart, Owen Flanagan, Sheigla Murphy, Michael Pantalon, Mark Willenbring and others) a year ago in Minnesota. The talks, panel discussions, and ad-hoc debates ranged from antagonistic showdowns to insightful analyses of where we are now and where we’re going — which pretty much epitomizes the field overall.

Here are a few paragraphs, to give you a sense:

The panelists at the conference expressed a range of opinions about the disease model. Though their views did not break down entirely along disciplinary lines, the social scientists tended to be the most wary of the label. On the one hand, nearly everyone ceded, it’s an established fact that addiction alters dopamine receptors in the brain and can affect how the limbic system functions. There’s also compelling research that some drugs, such as naltrexone for opiate abusers, can help curb certain cravings, which suggests that dependence is at root a biological phenomenon.

Still, a slim majority of the panelists…did not want to emphasize the word “disease,” because it implies that chemical dependence is primarily a function of pathology, when in fact environmental factors (dysfunction at home, stress at work), learned behavioral patterns (binge drinking, for instance), and economic disparities have been shown to play a significant causal role. Clearly, the debate was not just semantic.

The disagreement over terms is rooted in the 1930s and 40s, when AA came of age and provided a life raft for chronic alcoholics, many of whom had been doomed to suffer crippling isolation, institutionalization, and early death.

Schimke then goes on to cover the goals, achievements, and failures of AA as it has evolved over the decades. He also reviews recent, cutting-edge research, the differing implications drawn from it, and the diverse politics, treatment philosophies, and public-health agendas that often come together more like a playground brawl than a maturing field of study.

Here’s another tidbit:

That institutional bias is, in large part, what upsets many social scientists. They’re concerned that precious federal funds are too often pushed toward studies and programming steeped in status-quo assumptions, instead of challenging longstanding treatment paradigms and biases.

And near the end:

Sheigla Murphy says she would like to see more gatherings like the conference at Gustavus Adolphus, where people from different disciplines can engage in public debate and, ideally, find more opportunities for mutual understanding and compromise.

Anyway, take a look and see what you think. I’ll be back in two or three weeks.

I see that I need to supply a caveat to yesterday’s post. As expressed in no uncertain terms by the first commenter, a lot of people don’t like Peterson. The comment was “Ugh, seriously?” There’s more vituperous criticism further down, of me (for appreciating Peterson) as well as Peterson himself. When I scan down the first 15 comments or so, I see huge polarization. Some people love him; others hate him. That’s a pretty accurate reflection of the Peterson phenomenon in the larger world.

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

I mentioned this political maelstrom in yesterday’s post, without getting deeply into it. I guess I should go a bit further and summarize the issues as I see them. Some of Peterson’s arguments offend, and they particularly offend people on the (perhaps far) left. For example, he explains dominance hierarchies as a product of our evolution rather than the construction of an oppressive (white, male) culture. He distinguishes sex differences, which are (he claims and I certainly agree) rooted in biology and evolution, from the social construction of gender. He analyzes the personality traits associated with women and men and argues that the asymmetrical distribution of these traits (something you may have studied in Psych 101) has much to do with the gender pay gap — which is therefore not simply a result of sexism. He certainly doesn’t deny the existence of sexism, or oppression by dominant cultural forces, or the rights of transgender people. Not at all. Yet his infusion of statistically validated facts and an evolutionary perspective into the ideological battles raging (especially in the universities) about diversity, gender, social justice and so forth has alienated and angered many on the left.

The ideas I’ve just outlined don’t seem so radical to me. I’ve heard that Peterson says more controversial things about marriage and women’s roles, etc, though I haven’t read them myself. The famous pronoun war (google it) can certainly be judged from divergent viewpoints. I suppose Peterson really is a conservative in some respects. He’s definitely not trying to be politically correct. In fact a foundational plank of his philosophy is that people should say what they believe to be true, especially if they are voicing unpopular views. He staunchly elevates free speech over “sensitivity” to the feelings of others. In a response to one interviewer (and this is worth viewing if you want more insight into his politics) he said he greatly admires Rosa Parks for standing up for herself against the systemic racism of her day.

As a result of his stated positions, Peterson has been mobbed by what he terms “social justice warriors”– people who espouse extreme leftist views. There’s no doubt that he disagrees with many of their views and he’s angry at the insulting nature of their attacks on him. He’s literally been shouted down on more than a few campuses. Does that make him a right-winger? Not yet. The view of Peterson as a (perhaps extreme) right-winger comes from the next act in this play. People who really do identify with the right, including the far right, started to proclaim their undying loyalty to Peterson, mainly because the far left seems to hate him so much. In my view, the equation is simple. If my enemy hates you then you must be my friend. Does that make him a right-winger?

This is just a superficial and no-doubt inadequate overview of the social currents surrounding the “most popular intellectual in the world” (something I read recently). But the thing about Peterson is that he’s not a political animal. He says what he thinks to be true, and he really doesn’t care too much about the fallout. I personally don’t think he enjoys being in the centre of this altercation one bit. He’s said many times in public that he’d rather people listen to, and argue with, the content of his arguments than slot him into a political ideology.

Anyway, I’m certainly no political commentator, and my understanding of the political face-off around Peterson comes from browsing articles and videos on the Internet. My own political sentiments are firmly on the left, as any regular reader of my blog surely knows. (When Trump got elected, I wrote a post entitled “Oh Shit.” I was depressed for weeks and made no secret of it.) But that doesn’t mean I have nothing to discuss with people who see things differently. And more to the point, this blog isn’t about politics. It’s about experiential, social, psychological, and neurobiological approaches to understanding addiction. I’d be glad to chat with anyone out there about the the political eruptions surrounding Peterson’s public persona. I’m sure I can learn something. Maybe over a coffee if I’m ever in your part of the world.

But I think it would be a shame to ward off Peterson’s ideas as if he were some sort of vampire, simply because of the political accusations flying back and forth. I don’t agree with everything Peterson says. In my review, soon to come out, I firmly criticize him for cherry-picking scientific factoids to support dubious assumptions and for a style of argument which violates the standards of scientific discourse — namely basing one’s authority on intuitions rather than methodical arguments grounded in data. Yet some of his ideas strike me as valid, powerful, refreshing, constructive, and of particular utility for enhancing personal growth. Whether you consider yourself to be on the right or on the left, it seems there’s much of value here, and I hope you won’t throw the baby out with the bathwater.

If you happen to click here and listen to B. B. King sing “The Thrill is Gone,” you might notice that he does not look happy. Nor does he sound happy. And he’s sweating. A lot! He says he’s free, but I somehow doubt it.

What happens when the thrill is gone? That’s a central question for addiction, as most of us know first-hand. In fact, what if the thrill was never there to begin with…?

I said I’d report to you on everything I learned at the conference on behavioral addictions in Budapest last month. First I reported on the common denominator, OCD-type states in brain and behaviour, then I tried to specify the key difference between substance and behavioral addictions, then came Elizabeth’s guest post comparing food and drug addiction, and now here’s Part 4: the genetics of thrill-seeking.

On day 2 of the conference, once my brain was seriously sweating, I met the guy who coined the term Reward Deficiency Syndrome (RDS). His name is Kenneth Blum, and he’s a smallish wiry guy, very intense, seemingly dour, but flashing the occasional dry smile. Here’s his hypothesis:

When we take drugs, or do whatever it is we’re addicted to, the brain systems that “light up” include dopamine circuits in the striatum and its neighbours. No surprise there. Blum lists half a dozen dopamine receptors that get in on the act. But the lead role goes to the D2 receptor — which controls the amount of dopamine available to synapses all over the frontal cortex and striatum. The D2 receptor is involved in attention, motor control, motivation….lots of pretty important stuff. Here’s a detailed description. So what happens when the D2 receptor population isn’t quite normal (e.g., too many or too few)? What happens is that you are more likely to suffer from a whole host of things, including OCD, ADHD, schizophrenia, and — you guessed it: addiction. Addiction to drugs, booze, gambling — that receptor has a lot of connections with the underworld of our psyches.

The problem is that the gene that’s responsible for growing D2 receptors, while we’re in the womb, has got different variants (like many genes), and one of those variants (allele A1) causes an overall reduction in the number of D2 receptors. There’s lots of evidence that addiction runs in families, and I’ve usually been reluctant to pin it all on genetics. Why? Because most scientists agree that there’s no single gene or cluster of genes that causes addiction; genetic predictors of addiction usually depend on personality factors, like impulsivity; and there is so much in behaviour and experience that can bridge generations — for example, you hardly need a genetic boost if your dad is an angry drunk and your mom is seriously depressed. But Blum cites some pretty convincing research showing that addictions shared across generations (like father, like son) correspond with this nasty dopamine allele. It shows up in more than one generation!  That is to say the allele gets passed down, along with the silverware and the porcelain figures nobody wants.

In a nutshell, some people have fewer D2 receptors, like maybe 40% fewer in some brain areas like the nucleus accumbens. So these people are not as excited about reaching their goals. Their whole “reward system” is relatively flat. Life is not as much of a buzz for them as it is for most people. As with B. B. King, the thrill is gone. In fact, maybe it was never there at all.

If you have the wrong allele of the DRD2 gene, and fewer D2 receptors, and therefore you have RDS, how are you going to get the thrills those around you seem to get? Well, drugs (including alcohol), gambling, and other super-fun stuff might be the most effective way. These “rewards” are hyper-exciting for most people. For you, who are chronically under-excited, they might be the only way to feel really engaged with life. At least until you get addicted, which seems like a step backward.

That’s the story, according to Blum. That’s what he talked about in his talk, and that’s what we argued about in the lobby for an hour. Reward deficiency leads you to seek out the biggest bang for your buck. Which makes sense, because everyone wants to feel the excitement that dopamine bestows when something special is about to happen. When I was a kid, about age eight or so, I remember making a disturbing discovery. Almost all the fun I had in life seemed to come with looking forward to things, whether a chocolate bar or a birthday present. Once the desired event was actually happening, it wasn’t as much fun anymore. (I was a weird kid, no doubt.) But for most people, a lot of pleasure comes from anticipation, from approach, and that’s what gets muted with RDS.

By the way, I’m actually working with a guy named Arnt Schellekens here in the Netherlands. He and his team are investigating low dopamine levels as a gateway to alcoholism. So this research direction is pretty close to home.

Despite its appeal, there are some serious problems with the RDS model. I’ll name just two. We know from dozens of studies that drug or alcohol use itself leads to a reduction in dopamine receptor density, or at least dopamine receptor activation, because those receptors tend to burn out or become desensitized when we keep bombarding them with fun stuff. Now that’s getting closer to B. B. King’s complaint: The thrill was there for awhile, but now it’s gone. Sound familiar? The question remains: is your dopamine landscape more determined by your genes or by how you use them? Problem #2 is that teenagers as a group are often described in terms of reward deficiency syndrome.  Teens can be seen as under-stimulated, probably because the reorganization of the nervous system in adolescence is pretty disorganized. A disorganized reorganization! That would mean that teenage thrill-seeking is not only natural, it’s inevitable, and it serves an important emotional function. Unfortunately, dangerous drugs are often part of the picnic. In other words, genetic contributions to addiction may simply be dwarfed by a tidal wave of thrill-seeking that comes with adolescence.

The jury is still out when it comes to genetic influences on addiction. Few addiction researchers doubt that such influences exist, but their exact mechanisms aren’t well understood. Blum and his colleagues are still chasing down the RDS model, and trying to connect it to other influential models, like Berridge’s incentive sensitization model.  There’s a lot to be learned, and I admire researchers like Blum and Schellekens, who keep opening new doors to find out what’s behind them.

Since the discovery of LSD’s mind-blowing properties (in the 1940s-50s) there have been several waves of research, clinical trials, and of course “recreational” tripping with LSD and its close cousins, mescaline and psilocybin (magic mushrooms). The interest and excitement of the scientific community was pretty much squelched in the US by legislation making LSD strictly illegal, a policy that continues to this day. But more enlightened countries have resumed research on LSD and psilocybin. These substances are of great interest because of their (probable) clinical value in fighting depression, chronic pain, chronic anxiety, fear of death, and — you guessed it — addiction, especially alcoholism. Take a look at this intriguing documentary trailer. Meanwhile, recreational use has continued over the decades, trending and receding in different countries at different times.

We are also finally beginning to understand LSD’s impact on the brain. A recent, multi-layered study showed that “under [LSD], regions once segregated spoke to one another.” In other words, psychedelics open lines of communication between neural regions that normally stay hived off from each other, doing their own (quasi-independent) thing. We don’t really know how this affects cognition, but participants who showed the greatest increase in cross-brain synchrony also reported greater “ego dissolution.” That makes sense. According to the lead researcher, David Nutt, “The drug can be seen as reversing the more restricted thinking we develop from infancy to adulthood…” Nutt concluded that LSD “could pull the brain out of thought patterns seen in depression and addiction.” (quotes and paraphrasing from this article). Here’s a slightly more technical but excellent review of the study.

What’s most interesting here for addiction? Well, for one thing, David Nutt has long functioned as a lead adviser to the UK government on drug policy (the equivalent of a drug czar in the US?) And he was the lead author of the study! Nutt is no nut. He’s smart, influential, highly respected as a scientist, and progressive in his views and advice about drug use. So if David Nutt is cool about exploring how acid disintegrates neural barriers, then you know that psychedelics are no longer being sneered at or ignored by scientists, that they’re being recognized as potent tools for revamping thought and perception, essentially breaking neural habits — if only for a few hours.

So what’s the word on the street? Well you’ve probably heard of ayahuasca, and if you haven’t you should really google it. You can start here, or start with Wikipedia. Ayahuasca (or its underlying molecule, DMT) is the psychedelic of the present age. Many young people know about it, some have taken it, and the reports of users are (as usual) controversial. Some have had a bad trip, some have been duped by fake shamans, but the majority have huge respect for this natural herbal brew. Many feel it has been transformative in their lives. Shamans in South America have used ayahuasca for centuries to help treat ailments of the mind or the spirit, and it is also regarded by today’s youth as “healing.” Yet for many ayahuasca drinkers, there is nothing overt that needs to be healed. For them, ayahuasca is an opportunity to learn deep lessons about who they are and how they connect to the world.

Many with addictions have gone to ayahuasca for help. And the renowned addiction expert, Gabor Maté, has become one of its strongest advocates. Maté is convinced that ayahuasca is the most direct and effective way for addicts to uncover and come to accept the pain and confusion they’ve kept inside and which perpetuates the emptiness and anxiety that locks in their addiction. He also sees it as a gateway to an uncluttered, even blissful, sense of the universe — which sounds like the kind of universe you’d choose not to damp down with heroin. Maté emphasizes the importance of taking ayahuasca in a tradition-based ceremony with an experienced shaman. He has set up various supervised ayahuasca retreats, first in Canada (specifically targeted to the addict community in Vancouver) and now (that it’s been banned in Canada) in Central America.

I don’t consider myself an addict anymore, but I still have addictive tendencies, ruminative thoughts, sporadic depression, and an attraction to alcohol (within the bounds of social drinking) to help ease my discomfort with myself. So I didn’t take ayahuasca to treat an addiction. Rather, I took it because I wanted to experience its power and potential — with some hopes that it would help free me of lingering anxieties and depression (not without some hard work — as Maté also emphasizes). I had taken a lot of LSD and related drugs when I was young, in the 60s and 70s. I think these experiences were useful to me in various ways, but they certainly didn’t smooth out all the rough edges. I suppose my last acid trip was some time in my thirties. Then I stopped. Been there, done that. But what’s all the fuss about ayahuasca? Is it really different in some fundamental way? I wanted to find out.

There are ayahuasca ceremonies in Europe every year, most if not all supervised by experienced shamans and their assistants. I’ve now taken ayahuasca five times (in five years) and I doubt I’ll ever take it again. It’s just too much for this old brain. Ayahuasca isn’t exactly fun. It can be disturbing, it can be hard work (just to endure), it can make you shit your guts out and puke violently (politely called purging). But it can also be wonderful, enlightening, and (I think) constructive in a big way — if done in the right circumstances with the right follow-up.

I’m out of space here, so I’ll tell you about my own experience in my next post. Coming soon.

Meanwhile, warning! If this little introduction makes you want to run out and try ayahuasca, do not even consider doing it without a knowledgeable, experienced shaman or other guide. You don’t do this in your high-rise apartment one night, or at parties. And you don’t do it alone. Oh and if you find a proper ceremony to attend and feel you’re ready, make sure to bring an extra pair of undies.