Understanding Addiction

…by James Morris…

The great “controlled drinking” debate has a controversial history dating back to the 1960’s. Since then, politics, addiction ideology, and evidence have often been hard to separate. In the 1970’s the Sobells were vilified for allegedly skewing the results of research showing that some dependent drinkers achieved controlled drinking, but they were later cleared of any wrongdoing. Audrey Kishline, the founder of Moderation Management (a peer support group), committed suicide after driving drunk and causing a fatal car crash. This tragic event is often cited as an example of how moderation doesn’t work.

Today, recognition of non-abstinence-oriented outcomes is less controversial. However, there is still no shortage of opponents, and not just amongst 12-steppers. Like many complex issues, the “truth” about controlled drinking may depend on which way you cut the cake.

I first became interested in this subject when after many years of abstinence I began to ask myself “could I re-learn to drink?” My relationship with alcohol had started in my early teens and then steadily progressed; by the time I was in my early twenties I drank as much as possible, often to the point of blackout, and was experiencing physical health problems. After a number of failed attempts to cut down, I began to realise I wasn’t in control. I remember thinking to myself “if I don’t act on this now, where will it end?”

Stopping drinking in my twenties was very difficult. During my early months of sobriety I struggled to stop thinking about alcohol and battled with trying to reformulate my identity and social life. Drinking pressures and cues seemed to surround me constantly, but in some ways this made me more determined.

As time passed things slowly became easier and more normal as a “non-drinker,” though initially I sought various other pursuits to try and fill the excitement gap. I also attended AA meetings for a while. Generally I found the meetings positive and could identify with a lot of what I heard, though ultimately I never felt I was powerless and therefore an “alcoholic.”

Around six years later I felt like I was in a very different place, settled with a rewarding job, happier in myself as a person and as a “non-drinker.” During this time psychotherapy helped a lot, especially with anger issues connected with my past drinking. I began to feel things were so different now that normal drinking might be possible, and after a few years of contemplation, I eventually decided to see if I could “re-learn” a problem-free relationship with alcohol.

Many people still believe anyone with an alcohol addiction can never drink again without slipping back into old habits. The disease model of addiction as a “chronic relapsing condition” and associated beliefs about “alcoholics” are deeply entwined with the idea that abstinence is the only genuine option for long-term recovery.

There are some valid reasons to be skeptical of controlled drinking for once-dependent drinkers. Long-term studies suggest only a minority of problem drinkers achieve controlled or problem-free drinking, and for people with severe alcohol addiction, abstinence is usually identified as the most successful route. Indeed, severity of dependence is a central theme in addiction theory and in the concept of “alcohol dependence syndrome” that underpins ICD-10 and DSM classifications. Even so, some controlled-drinking studies have observed success in a subset of drinkers with more severe dependence. Whilst some argue that those with less severe dependence are not really “addicted,” there is no scientifically valid cut-off point.

In fact, the role of severity of dependence as a predictor of controlled drinking is unclear. Some studies have found other measures, like the extent of “impaired control” — i.e. failing to limit one’s drinking — serve as better predictors. Another important factor may be a period of abstinence. A drinker who has had many years without drinking will be more likely to succeed than one who simply tries to cut down straight away. How much of this may be about the brain “un-learning” drinking reward pathways — and how much may be about life changes and other skills that sobriety brings about — is again hard to generalise.

I began controlled drinking six years ago, and despite anxieties that I was doing the wrong thing, there are no signs that my relationship with alcohol has become problematic again. I might drink three times a week, typically with a meal, on weekends, or out with friends, and not more than two or three drinks on an occasion — within the UK’s recommended guidelines.

However, comparing myself then and now feels like comparing two different people. Then I was young and in many ways insecure, anxious and with a lot of fire in my belly. Drinking always felt like it allowed me to let go of this nervous energy. I believe that working through past issues through psychotherapy was as crucial as my long period of abstinence. I strongly feel that this process helped me deal with issues that fuelled my destructive drinking.

Trying to answer “when is controlled drinking possible?” is a bit like asking “what’s the best treatment for addiction?” — there are no easy answers; it depends on many factors. But there are some basic principles that might help predict success. Fundamentally, it may be fair to generalise that controlled drinking tends to be less successful for people who’ve been more severely dependent, experienced adverse childhood experiences, previously failed to control their drinking, or endured excessive insecurity or stress in their lives.

To anyone with a history of alcohol problems contemplating controlled drinking, I would suggest they ask themselves what it is they truly want or expect from drinking again. Weighing up the pros and cons objectively can be difficult, and it can be easy to over-value the pleasurable effects of moderate drinking. For me alcohol may have a mild relaxant effect, but it is not to de-stress, let go, or suppress negative emotions. If I go through a tough time in the future, I believe that will be an important time not to drink. Keeping healthy and looking after myself in other ways provide protective effects that allow me to drink without problems.

The author is in no way encouraging those with former alcohol problems to attempt “controlled drinking.” The author wishes to reiterate that controlled drinking is not suitable for many drinkers who seek help for alcohol problems, and anyone considering controlled drinking should consider the possible benefits of professional help.

…by April Wilson Smith…

I used to hate the word “recovery.” To me, it was a mark of shame, stating that I was permanently damaged and different from “normies,” as they call people without substance use problems in AA. Recovery signified a lifetime of isolation, avoiding social events and going to dull nightly meetings where people wallowed in the past. It also implied that I had a disease, which I never believed.

So I refused to use the word. If it happened to come up that I had had a problem with alcohol, I’d simply say, “That’s no longer an issue for me.” I wanted to erase the period of time when I had struggled to get over my alcohol problem, and make life a well-paved road without the giant bump of my alcohol crash and stint in rehab.

Then I started to work in harm reduction. I founded a SMART Recovery meeting, and went on to become an officer in the Harm Reduction, Abstinence and Moderation Support (HAMS) group. I met people who were at all stages of the struggle, from still using to fresh out of rehab to 18 years without a problem. I met people who were deeply in pain.

As I witnessed their pain, I began to reconnect with my own. It had been too difficult, at first, to remember the pain of passing out in the street or finding out the next day what I had said or done the night before. I didn’t want to remember the horror of withdrawing from alcohol more times than I can count, sometimes throwing up blood for days on end and nailed to the bed in a panic attack. I didn’t even want to remember those early days of abstinence when my senses first came back and I could smell the flowers in summer and taste blueberries and coffee as though for the first time.

After almost two years and working with countless people with substance use problems, I could feel my own pain again. And I realized something: to deny that there is a period of time when the pain is acute, and when healing has to be a priority, is to deny an essential reality of people’s lives. Of my own life. That’s when I started to use the word “recovery” again. But I do not believe that “recovery” is a permanent state. With proper self-care, support, and meaning in life, one can heal.

My path to healing was a jagged one. When I left a traditional Twelve Step rehab, I was grateful to be out of addictive crisis, but I was even farther away from finding my true self than I had been. In rehab, we were taught to identify as “addict” and “alcoholic,” and told that all our problems were due to our “disease.” We did little to address the issues that drove our addiction. Instead, we were taught that the answer to all problems was to attend Twelve Step meetings and work the Steps.

I got home and dutifully did my 90 meetings in 90 days as instructed, but it didn’t feel right. Gradually, I discovered writers who saw addiction differently. First Marc, then onto Carl Hart, Johann Hari, and eventually Stanton Peele and Kenneth Anderson. I saw a new way of looking at addiction, not as a symptom of a disease or indication that I was damaged for life, but as a behavior over which I could have control. As I read more, I gradually began to discover my own voice, and started to write. Reclaiming my own identity, not as an “alcoholic” but as a writer, activist and scholar was my way out, not only of addiction but of the narrow, confined life that rehab and AA had defined for me as “recovery.” And I found that my own painful experiences gave me a perspective that could help others. Today, having recovered means living a life that I don’t have to medicate away.

Two years after my 28 day stay in rehab, I find myself writing about substance use and mental health full time, and I’m doing my PhD on harm reduction. I hope that my work can help people who are going through that difficult period of healing. By using the word “recovery,” I honor their pain, and I honor my own. I also honor our triumph over the pain.

My substance problem is not who I am, but it is an essential part of my life experience. It has given me insight into things I never would have known about, and a kind of empathy I never had before I woke up on the concrete.

I am grateful for recovery. I am also grateful for the ability to move on.

In my last post I explored the role of the default mode network in addiction. One conclusion was that addicts’ brains activate the default mode network more than the brains of nonaddicts.

This brought us to a paradox. Actually two paradoxes. (My wife hates it when I pun, but a pair o’ ducks already sounds like two… Ok, ignore that and we’ll proceed.) The default mode network (a set of 6-8 brain regions that often become synchronized) corresponds with daydreaming, nondirected thinking, going with the flow, imagining oneself in the past and/or future, etc.

Paradox 1: Isn’t it good to be in the default mode? Isn’t that the foundation of creativity or at least relaxed self-reflection? (well expressed by Persephone in a comment on the last post)

Paradox 2: Addiction is characterized by craving, which means highly focused attention on a single goal. I want to get some…..now! This focused state corresponds with an entirely different network of brain structures (including the dACC) — those involved in intense, planful activity, or homing in on a problem that needs to be resolved.

So how do we reconcile the “positives” of the default mode network, and the “negatives” of the task-focused network, in order to arrive at a coherent model of addictive behaviour?

And while we consider this, let’s reflect on Shaun’s lovely metaphor, also from comments on the last post:

I have always described addictive behaviour as walking through a field of tall grass. We tread a path and we become “programmed” to walk this path. We return to this path every time we feel “lost”.

Getting lost in tall grass might correspond with the unguided thinking of the default mode. But once we’re truly lost in our fantasies, we return to a single well-worn path.

My former student, Professor Rebecca Todd, suggested something similar, but in more concrete terms. Falling into an addictive act should be seen as a micro-developmental process. That means it isn’t a single event; it develops, but it develops in micro time — in seconds or minutes. Duh. Why didn’t I think of that? Almost every emotional phenomenon is best seen as a micro-developmental process — a cascade (love that word) that takes a few seconds, minutes, or even hours to unfold. Thank you, Rebecca! (I like to think I taught her to be brilliant, but maybe she just came that way.)

So here’s the beginning of a micro-developmental model that puts these ideas together:

Step 1: fantasizing. You are in the default mode. Your thoughts are running wild and free.

Step 2: Impulse. This is exactly the state from which impulsive behaviour can easily spring. Because it’s…thoughtless. Free-floating fantasies lead to images of drugs, booze, sex, food, or whatever it is that attracts you. And off you go!

Scientists have very good evidence of the link between impulsivity and drug-taking. The following is from an article by Dalley, Everitt, and Robbins, 2011:

Impulsivity is the tendency to act prematurely without foresight…. One form of impulsivity depends on the temporal discounting of reward [which means going after immediate rewards, even at the expense of long-term consequences], another on….response disinhibition [what it sounds like: just do it!]. Impulsivity is commonly associated with addiction to drugs from different pharmacological classes…

Step 3: Focused attention driven by desire. The third step is that tightly focused preoccupation with the soon-to-be (I hope, I wish) reward. Now brain activation patterns have switched over completely, from the nondirected to the directed, from the default mode to the highly-focused, task-oriented mode (which, in the case of addiction, must include hyperactivation of the nucleus accumbens / ventral striatum, spiking on dopamine). Now all your energies are directed at solving the problem: getting it and doing it — plus subsidiary problems like paying for it, lying about, and hiding it.

I believe there is a fourth step, compulsion, which is not the same thing as impulse (though they are related). More about that next post.  I also believe there are different strategies for trying to stop the cascade, depending on which step you’re in. I’d love to hear your ideas about that.

Finally, here’s Bhagavan Das, that wise / spiritual / contemplative / meditative dude with a huge beard, talking to us from a recent documentary:

You’ve got to realize one thing: you need to tame your wild and crazy mind. Your mind has a very very bad habit, which we call self-cherishing.

That may be where all the trouble starts: the free-ranging fantasies of the default mode converge on the wish to improve the way you feel.

Since most of us seem to be in vacation mode, myself included, I’m stealing the following passage from Shaun Shelly (with his permission). He in turn took it from Richard Wilmot, author of “American Euphoria: Saying ‘Know’ to Drugs“. The passage compares religious commitments to the commitments made by drug addicts (deals with the devil?). Here I’m printing a shortened version. For the full passage, and for some intriguing reflections on its implications, please see Shaun’s blog. I’m sending you there, partly because this such an unusual idea, but also because Shaun’s blog/newsletter is definitely worth exploring more broadly.

“Today one of the main criteria for a diagnosis of drug addiction/alcoholism is: continuing to consume alcohol or another drug “despite unpleasant or adverse consequences” (DSM). For the Christian martyrs the same criteria would apply. People of that time and place—Rome, 2nd century A.D.—could also say that this new Christianity was like a drug that endangered lives and that being a Christian had all the adverse financial, social, psychological and physical consequences that we now see in the lives of drug addicts and alcoholics. And yet Christians, of all ages, in spite of the consequences, continued to profess their faith… and continued to be eaten by lions.

Obviously there was something to Christianity that prevented the Christian from being abstinent from Christianity. It was something internal… an internal euphoria. It was something that could not be seen but nevertheless was something that was felt… and felt as something awesomely significant. It was something that made all the pain and suffering worthwhile: it was a religious experience.

Likewise, given contemporary social policy, adverse consequences befall those who abuse drugs. They lose the respect of their peers; they violate the expectations of family, friends, and colleagues; they miss out on educational opportunities; they have poor work performance and lose their job. They make harmful decisions. They “burn their bridges”. Their health suffers; they have overdoses, and they die.

My initial reaction to this quote was one of bemusement more than anything else. Okay, very provocative, but is there a serious point here? Is the comparison between religion and addiction just a high-level play on words? Just a number of descriptors — dedication, single-mindedness, sacrifice, isolation — that make glib connections between two fundamentally different phenomena? That was my hunch. But then I looked briefly at Wilmot’s book. He makes the case (as do others) that the urge to get high is a natural proclivity, that we all seek what are often called “peak experiences.”  In fact, this idea is not much different from the idea of a God gene, as elaborated by Shaun. So not only might we be (at least partially) hard-wired to seek religious meaning, and to seek the sort of peak experiences that come through drugs, but maybe it’s the same urge, channelled in different ways.

Then more parallels came to mind. For me, people who are intensely religious are as scary as people who are intensely addicted. Both types are impossible to engage in any meaningful dialogue, they notice only what is of immediate relevance to their particular attraction, and they devalue others’ rights, opinions, and wellbeing in their pursuit of gratification. And here’s another parallel: religion and addiction look similar to one another at two different stages. Early on, religious zeal and drug attraction are exciting, often creative, and highly fulfilling. But twenty years later, both look like shit. The dogmatic, rigidified, perseverative ramblings of a long-term religious zealot are not much different in tone, quality, or relevance than those of the long-term addict. What was once an exhilarating journey of self-realization has become a bleary-eyed funeral march.

So, maybe the comparison is more enlightened than I first thought. But make sure you go and visit Shaun’s blog to see what he has to say about it.

These two-word titles seem to capture how little I feel I have to say at the moment. “Oh shit.” “Now What?” I’m hoping that something more profound will bop me on the head, but I’m not holding my breath.

I haven’t written anything in three weeks, which is approximately how long it’s taken me to get over the election. Now, rather than a surge of horror and nausea when I read the news, I get a slight sense of dissociation, vague anxiety, mild vertigo, and my mind quickly wanders to myriad possibilities none of which seems more likely than any other.

And here I should insert a note. What do they call those alerts that commentators, lecturers, film-makers, professors and so forth are now being asked to put forth before they get into the nitty-gritty of what they have to say? Those warnings that “this material may be disturbing.” If you are particularly sensitive to anti-Trump verbiage, then you may wish to skip the rest of this post. I’m trying to make this light. I received one or two comments following my last post, criticizing me for expressing strong “political” views in an addiction blog. And I respect the commenters for saying what they felt. I really do. But I won’t hide the fact that I really hate that guy. It’s not exactly political. I just can’t stand him.

I’ll spare you all the usual listing of what’s wrong in the world, from Brexit, to the right-wing populist movements sweeping Europe, to Trump. Well I guess I didn’t spare you. But for me what it comes down to with Trump is pretty simple. He’s a liar and a cheat. Almost everything he says is a lie. He replaces it the following week or the following day — usually with another lie. And most of his campaign promises were mere strategic gambits to win votes. He’s not going to build a wall, or prosecute Hillary. Who ever imagined that he would? He’s even talking about taking a serious look at climate change and maybe endorsing the Paris Accord, which is of course good news. It’s just a shame that he got voted in on his promise to ignore the environment because climate change is a fantasy promoted by the Chinese.

I’m not quite depressed. I think I’m suffering from anhedonia or dysthymia or something… those are clinical terms for (let’s see if I can remember) not feeling particularly good but not particularly terrible either. I just looked up “dysthymia” — it’s actually defined as “persistent mild depression.” Well, that’s close.

If there’s anything useful I can say at the moment, it’s to suggest we look at the present glut of bad news as waves rather than particles. Sounds spiffy to use quantum terms. Waves seem like tendencies, currents, gusts…in a universe that is constantly in flux. Whereas particles…give the sense of matter, substance, stuff that collects in corners until there’s so much of it you really have to rent heavy machinery to get rid of it. So when the Buddha talked about impermanence as the main act, maybe he was thinking more in terms of waves than particles. Impermanence actually seems like good news at the moment.

I sometimes wonder what’s at the core of all these right-wing leanings. Let’s preserve what we’ve got. Let’s keep America American. Let’s maintain our way of life because it’s being threatened. Damn right your way of life is being threatened because….get ready…you’re going to die! What could be more threatening to anyone’s way of life?

But when I walk around in the crisp sunshine and notice how incredibly vivid and beautiful the leaves are, in their fall fashions, and when I watch one of my twins stuff missing homework into the other’s knapsack, both already mounted on their bikes, breathing steam, I think: this is just fine. This is a great moment. This wish to preserve things the way they’ve always been (as if that were a good thing)… What’s the point of that?

I once read a book by a Buddhist/cognitive scientist type scholar (Francisco Varela) who said something like this: Don’t even try to fill up your experience (viz consciousness) with yourself, with the sense of being a self, i.e., yourself. Because if you were successful, if your experience was full of yourself, then there wouldn’t be room for anything else. Nothing else coming in, or going out, no novelty, no change, no nothing. The illusion of being a distinct, essential self (yeah, you and the other 7 billion) is not only impossible to achieve but also a really bad idea. Experience is pretty amazing, so let’s not fuck it up by trying to make it stick to how we wanted it to be.

(Or as Matt so succinctly put it in a comment to the last post: “Why whine and worry about the way you want it to be, when it’s right there in front of you being what it is.”)

I guess, to follow my own advice, Trumpism is just a current of change in a world that’s already changing beyond our imagination. It won’t last either. Might as well watch it and be fascinated.