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

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

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

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

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

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

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

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

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

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

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

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

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

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

…by Hanna Anderson…

In marijuana news, the government of Canada is looking to create and finalize a bill that will legalize marijuana in the spring of 2017. Some changes are already in motion.

Just recently, Minister of Justice, Jody Wilson-Raybould, announced the Task Force for Marijuana Legalization responsible for creating Canada’s drug policy on marijuana — and it will be a great undertaking. Thus far, the illicit drug isn’t legal for recreational use, and there are many reinforced misconceptions about the soft drug that make people see it as a hard drug. What regulations can be made that will allow Canadians to see the drug in a different light?

The Current State Of Marijuana

As a soft drug, marijuana is already used for medical purposes. The psychoactive substance in marijuana, THC, is widely used to treat the side effects of certain medical conditions, like nausea experienced by cancer patients.

Currently, only medical marijuana is legal in Canada under its Marijuana for Medical Purposes Regulations (MMPR). This Health Canada program provides users with access to medical marijuana only through licensed producers with a medical document signed by an authorized healthcare practitioner.

Despite this, there are still many legal gray areas and confusion. Moreover, with only 33 licensed producers in the entire country and a policy mandating the substance be distributed only via registered mail, marijuana activists are upset by the inefficiency of the system. Marijuana entrepreneurs, on the other hand, are taking advantage of the marijuana mess.

The Gateway Overlap

In general, soft drugs like marijuana (which are usually illicit) don’t produce physical dependence and are less addictive than hard drugs (such as cocaine and heroin).

Yet it is interesting to note that some smokers may experience withdrawal symptoms that can cause a psychological dependence and use disorder. This is part of the reason why many think of marijuana as a gateway drug to harder drugs and so advocate its prohibition.

But does that indirect connection mean that strict law enforcement is needed? Does it mean strict laws and swift action will solve the problem?

In Canada, illegal dispensaries have been popping up to both establish a stake in the future market and to address the supply shortage. However, marijuana is still officially illegal. Consequently, vendors are being arrested and shut down on the basis of violating municipal zoning bylaws.

When access to medicinal marijuana is limited, drug policies and restrictions are themselves the gateway to hard drugs. Why? Because legal prohibition encourages users in need of medical marijuana to turn to the black market, opening them up to unmonitored marijuana supplies, harder drugs, and criminal charges.

Penalties On Hard Drugs And Marijuana

Currently, the penalties on hard drugs in Canada range from 7 years for possession of cocaine and heroin to life imprisonment for trafficking or possession for the purpose of trafficking the substances.

On the other hand, it takes over 3 kgs of marijuana or hashish to be considered trafficking or to be considered possession for the purpose of trafficking. The maximum penalty for both is life imprisonment. Possession of marijuana penalties range from a 6 month and $1000 fine (for up to 30 g) to 5 years less a day in prison.

The war on drugs in Canada is seen as ineffective. For example, drug-policy spending under the Conservative government (in power for the last eight years) went to apprehending, charging and defending users in possession of small amounts of marijuana! With the new Liberal government, the focus is on approaching marijuana policy with an emphasis on regulation, not prohibition.

What New Policies Should Canada Implement?

But what key areas in marijuana law and policy should Canada look at to ensure that the regulations are appropriate for a soft drug? To which countries can Canada refer?

The USA, Portugal and the Netherlands — countries that have legalized marijuana (or chosen to ignore it) — offer examples of what to expect regarding the implementation of a national framework. OMQ Law (the author’s law firm) has put together an infographic that takes a close, visual look at how these countries have legitimized marijuana use.

From the Netherlands, which allows users to smoke in openly accepted, though illegal, marijuana cafes, to Portugal, where all drugs were decriminalized and addiction treatment programs aggressively implemented, the infographic explores the nuances in soft drug policies. In the USA, though five states have legalized marijuana medically and recreationally, it still has yet to be fully legalized across the country.

Laws are constantly evolving to ensure that effective drug policies are in place. Part of the task will be to keep in mind how a legalized soft drug will impact other international drug policies, social acceptance, and the perception of hard drugs in general.

In Canada it seems likely that supply and production will be controlled at the federal level and the provinces will control distribution — in the same way that the provinces control distribution of alcohol. Some provinces are advocating or suggesting that their liquor distribution networks are an obvious choice for distribution.

Our position is that a distribution framework should be set up separately, and have room for both public and private avenues for sales. We expect there to be a phase-in period of several years, as current levels of supply will be completely inadequate to handle initial demand.

omqlaw.ca

…by Colin Brewer…

Greetings from London and thanks, everybody, for what are — amazingly for this field — almost entirely positive comments on the ‘language’ analogy that I first suggested in 1989 and that my co-author Emmanuel Streel and I have been writing about since 2003. (Emmanuel is a neuropsychologist but also a psychopharmacologist.) Since Marc has honoured me with an invitation to do a guest column, here it is, partially in response to comments following the previous post.

First, my removal from the medical register had absolutely nothing to do with rapid opiate detox under anaesthesia. From about 1995 to 2001, we detoxed over 700 people with this technique without any significant problems. It wasn’t even discussed at my hearing. I qualified in 1963 and when I saw my first heroin detox two years later, it was routine to use generous sedation if severe distress tempted patients to withdraw from treatment rather than from heroin. If patients can withdraw — slowly or quickly — without much medication, that’s fine by me, but if they can’t (and there are many in that category) I think it is the traditional duty of doctors to make unpleasant procedures as comfortable as possible. Does anyone — apart from the extreme ‘no pain, no gain’ fundamentalists — seriously disagree with that? Consequently, for patients who wanted to try or resume abstinence, we offered a wide range of withdrawal techniques, from slow tapers, through 4-5 day withdrawal with mainly oral sedation to 24hr techniques under oral and/or intramuscular sedation to i/v sedation and full General Anaesthesia. (Historical note: at one point, I was threatened with a lawsuit by the Spanish-Israeli CITA group who claimed I had infringed their ‘patented’ GA detox technique. Apart from the fact that the use of particular drugs (as opposed to the details of their manufacture) can’t be patented in Europe, I had described and published the technique, in an admittedly obscure journal, several years before they first used it.)

Because addiction treatment provided by the National Health Service (NHS) was so lousy in the 1980s and 90s (for example, the addiction establishment were very anti-methadone maintenance from 1980-1999), there were long waiting lists for in-patient withdrawal, and when they were eventually admitted, completion rates in one of our flagship centres were barely 25%, of whom nearly half had relapsed four weeks later. We therefore found ourselves treating many people who would not normally have considered — or been able to afford — private treatment, and quite a few more prosperous patients whose insurance had refused to continue paying or who had simply impoverished themselves through repeated self-funded treatment. For this large group, we devised a home detox programme that involved training the family to act as carers. As with all our detoxes, after completion and naltrexone (NTX) induction, we very strongly encouraged patients to take family-supervised oral naltrexone for at least six months and, after 1997, to have a NTX implant, to increase the chances that they would get through the crucial and often difficult first couple of months, when relapse rates are highest. We did around 2000 home detoxes before one family fatally misunderstood the instructions. Naturally, I feel bad about that but I don’t feel bad about trying to devise affordable treatment. I think that case made the difference between a reprimand and being removed from the register, but many addiction clinicians and academics in Britain (and several abroad who gave evidence for me) will tell you that the establishment were out to get me and were looking for excuses.

Marc asked me if I’d ever written anything about the hearings. I haven’t, and these are my first published comments, but the two most bizarre features were (1) some three weeks spent by the panel trying, unsuccessfully, to prove that a case not written by one of our counsellors, whose handwriting was similar to mine, had actually been written by me, even though one of his notes read: ‘Must discuss this with CB’! and (2) a serious — as in six-fold — miscalculation by two of our leading academics of the methadone equivalent of another opiate.

If Marc thinks I look a bit weird in some of the online images, that’s probably because they were taken when I was trying to force my way through a rat-pack of paparazzi after the final hearing. Fortunately, the clinic I set up continues and is still doing most of the things that we had been doing up to the hearings. Some of those — e.g. using slow-release morphine for people who don’t get on well with methadone or buprenorphine — are now pretty normal, at least outside the USA. The clinic is also expanding its patient groups to include the growing problem — though it’s still small by US standards — of prescription opiate abuse and the management of ‘therapeutic addiction’ to opiates in pain problems. I only have an advisory role these days but we hope to extend what Emmanuel and I suggested should be called ‘Antagonist-Assisted Abstinence’ (AAA – geddit?) to benzodiazepines. Using s/c or slow i/v flumazenil infusions, it’s quite easy to take people off fistfuls of diazepam and other benzodiazepines in five days with very little discomfort, and a flumazenil implant is being developed in Australia.

The clinic still does plenty of maintenance treatment, and I was told recently that the new emphasis on ‘recovery’ (read: we don’t like indefinite methadone maintenance) means that, as in the 1980s, increasing numbers of well-functioning methadone-maintenance patients — many with good jobs that they don’t want to jeopardise by having to take weeks or months off for withdrawal — are being put on forced reductions. I never claimed to be perfect (as we say in the trade, ‘if you haven’t made any mistakes. you’re not seeing enough patients’) but I don’t think that anything I did caused remotely as much misery and disaster to opiate addicts as the policies encouraged by the addiction establishment in the face of mounting evidence for the value of methadone-maintenance treatment.

Finally, I wrote a paper a few years ago suggesting that harm reduction in family planning (avoiding unwanted pregnancies) could teach some useful lessons to conventional harm reduction (avoiding unwanted addictions), in that it uses a variety of techniques and tries to fit the treatment to the particular needs of the patient, rather than the prevailing ‘one size fits all, take it or leave it’ approach of so many clinics and — even worse — rehabs. I’ll provide references to this and other papers on request.

Hi everyone. I haven’t been writing on the blog much lately. My book was released in the UK on July 14th, and that meant shooting off articles for various publications and giving talks and interviews. So I went to London two weeks ago. It’s still there, as colourful and overwhelming as ever. Despite Englands’ majority vote to leave the European union, London is the most multiethnic city imaginable. On ever street you hear a bubbling cauldron of accents and see faces of every colour and shape. What a city!

My trip was fabulous. The first day I was interviewed by The Times, and that night I gave a talk with Johann Hari as my host and interviewer. An interesting man…complex, smart, fun, and a bit darker than expected. The next day, an interview with BBC and another with The Guardian podcast. That night I talked to nearly 400 people — the most positive audience I’ve ever had. Waves of applause and even cheers. Felt like a rock star.

But the most interesting event of my trip was meeting a man named Colin Brewer. If you google him you’ll see that he’s a wild child in British psychiatry circles. Most recently he was villainized by the media for providing supportive assessments for people seeking assisted suicide in a Swiss clinic. The trouble was that they didn’t have terminal diseases, and that’s a no-no. Was this man a monster? He’d gotten in touch with me by email and came to one of my talks. When he showed up at the foot of the stage, I recognized his face from the internet, and he certainly looked…unusual.

That night at my hotel I googled him more thoroughly and found that the people he’d helped obtain assisted suicide were actually in big trouble. One was 90 years old and in severe, untreatable pain. Another was in his seventies, going blind, another had motor neuron disease, and yet another had Alzheimer’s. It turned out that Colin was motivated by empathy and a firm belief in people’s right to die with dignity. He was no monster.

So I accepted his invitation to come for a visit and arrived at his home a few days later. He lives in a beautiful house in the heart of London. He showed me around the antique-laden interior with evident pride, swelling a bit when I complimented the taste and beauty of his home. And then, equipped with home-made elderberry cordials, we sat and talked.

Colin’s trouble started when he used his own instincts and methods to treat addicts, beginning in the 80s. He prescribed methadone, as did other doctors — no problem. But he would also provide a couple of months’ supply of methadone to people who travelled a great deal and could not renew their prescription daily or weekly. He also prescribed heroin for those who needed it (while this was still legal in Britain) as well as generous supplies of benzos and other drugs for those withdrawing from opiates or alcohol. He even supplied do-it-yourself detox kits to people who could not afford residential care. Another well-intentioned though dissident policy. The press branded his practice a drug supermarket and he was struck off the medical register in 2006.

Colin was indeed a renegade who made up his own rules for dealing with addicts. In fact, like Percy Menzies, who wrote a guest post for this blog several months ago, Colin enthusiastically prescribed naltrexone for opiate addicts as well as disulfiram (Antabuse) for alcoholics. He firmly believed in giving addicts a time-out, a substance-free period for resetting their circuitry — and he brought their families into the act, so that they could help encourage their addicted loved one to stick with the program until they were in safer waters. Far from someone who took his patients’ plights too lightly, he seems to have functioned as a deeply concerned caregiver, who wanted above all to give addicts the freedom to transform their own lives.

We wasted no time discussing whether addiction was a disease or not. We both saw the classic disease model as a dead-end. Rather, we talked about the power of placebos, the extent to which addiction includes placebo-like effects — namely the belief that taking something has particular benefits, when the belief creates the benefits. Colin introduced me to a study showing that even physical withdrawal symptoms can follow sudden termination of a placebo believed to be an addictive drug. Fascinating!

But the most important idea I left with was Colin’s belief that overcoming addiction is like learning a second language: reframing, retraining, and thus rewiring synaptic networks. I guess I already knew that, but here’s the new punchline. The best way to learn a second language is through total immersion: avoiding going back to your native tongue for some period of time. The reason my Dutch is still so shitty is because I speak English most of the time. That’s sometimes called “controlled use” in addiction parlance.

I’ll end with a quote from an article written by Colin and a colleague. It makes it pretty clear why total abstinence — at least for a time — is so very helpful.

Relapse-prevention is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behaviour and establishing new, adaptive ones. This process resembles foreign language learning…. ‘Immersion’, the most effective foreign language teaching method, discourages students from using their first language…requiring them to use the foreign language instead, however inexpertly.

Colin Brewer & Emmanuel Streel. Substance Abuse, 2003, 24(3) 157-173.

 

…by Matt Robert…

There is a well-known unconscious defense mechanism in psychology—compartmentalization. All humans compartmentalize. It’s one of the ways we make sense of the world, putting things in little boxes, so we can understand and move through the world more effectively.

But compartmentalization can cause more harm than good. Especially when it comes to addiction. We learn that our addictive behavior provides us something we are missing, some relief from anxiety, some focus free of the stressful distractions of daily life. Then we notice we want to keep using it, using it in a way that may not be acceptable to us or to our community. We want the resulting ambivalence and cognitive dissonance to go away. So we put the addiction in a compartment, over to the side in our psyche. A little box of respite and relief when we need it, and no one else needs to know about it or disapprove.

The problem is that, in addiction, the compartment starts to leak. The tendrils of our secret start to surround us to the point where everyone else can see that it’s a problem–before we do. We think it’s still back in its box, there for when we need it. But now it’s taking up more and more space in our mind and in our life. And the leaky compartment is getting more and more difficult to manage.

Addictions aren’t the only thing we compartmentalize to our detriment. Sometimes we also compartmentalize our recovery. Our recovery is boxed away in the meeting we go to on Tuesdays, or the medicine we take every morning, or the program we went to for 3 months. Our recovery is under control: it’s in a box. But unlike addiction, our recovery compartment doesn’t usually leak. It just sits there. It doesn’t become the central part of our daily life that the addiction was. In fact, with recovery, compartmentalization poses the opposite threat: the danger that it may dry up and disappear if left in its box.

Rather than compartmentalizing our recovery, we need to integrate it with the rest of our life if we want our addiction to shift. When we quit doing whatever we did, it leaves a very big hole that something else needs to fill. If nothing fills that hole, whatever it is we quit is going to come back. A compartmentalized approach to recovery is not enough to allow the strands of workable change, the tendrils of real transformation, to be established and maintained.

It doesn’t matter what you do, whether it’s HAT, MAT or Hazelden. It matters how you do it. It matters that you carry your recovery around with you like a precious jewel wherever you go, not leave it in a safety deposit box you visit on weekends. People say that spirituality shouldn’t be something you talk about in church every Sunday, then lose sight of the minute someone cuts you off pulling out of the parking lot. Neither should our recovery be. Recovery is about purposeful re-engagement and reintegration into this absurd enterprise we call life.

More effective treatment approaches actually fight the compartmentalization of recovery. They are integrative, and they fold treatment modalities that are effective for individuals into their daily life, their personal ecosystem. The community of caregivers, friends, family and fellow addicts are all connected and can troubleshoot and collaborate to solve problems as they arise. There is the feeling that we are all in this together, all on the same team. When we feel this way, alienation tends to dissolve, and the need to compartmentalize, to control, lightens up. It’s safe for our recovery to emerge from its box, like a butterfly from its cocoon.

How do you compartmentalize your addiction, and why? How do you compartmentalize your recovery, and why? What would help you take your recovery out of its box and integrate it into all parts of your life? If we can find the answers to these questions, we can learn new ways of being that will take us beyond our addictions. As we learn to dissolve these boxes, we can build new lives. As I once heard an old timer say, “This isn’t a fucking dress rehearsal. This is it.” When we have everything to lose, we have to be open to anything that makes a difference. And compartmentalizing our recovery, putting it in a box, is unlikely to take us where we need to go.