Understanding Addiction

…by Gina Murillo (comments by “Gina”)…  

So much of what we’re trying to hash out about drug courts here wouldn’t be an issue but for poor drug policy (the War on Drugs — as discussed in the comment section following the last post). The War on Drugs causes far more harm than good. I agree with Marc that Johann Hari makes that case more compellingly than just about anyone else, with the possible exception of Ethan Nadelmann, executive director of the Drug Policy Alliance. (I’m not a huge fan of TED talks, but highly recommend his powerful talk on why we need to end the War on Drugs.)

This really all comes down to how society has been conditioned to view different substances and behaviors. Alcohol and tobacco are far from harmless, but are not only socially acceptable, they’ve both been glamorized to one extent or another. They both kill many times more people each year than all illegal substances combined, even in the midst of the opiate “epidemic”. Yet, we manage to find (admittedly imperfect) ways to deal with the harms they cause as best we can. We do this because we recognize that the harms of prohibiting these substances would likely be significantly greater than simply finding more effective ways to live with them.

Imagine people being arrested for possessing cigarettes (one of the toughest addictions to quit and the #1 cause of preventable death in the U.S.) and facing a drug court judge with the threat of jail or a longer prison sentence for failing to quit smoking. Sure, probably fewer people would smoke and fewer would suffer debilitating disease as a result. But at what (and whose) cost? After all, if legal consequences are so effective at changing negative behaviors, why don’t we criminalize all behaviors we’d like to extinguish for society’s benefit? For another example, how about obesity courts? Health care costs attributed to obesity in the U.S. alone are staggering, with the number of deaths increasing steadily each year — making it the #2 cause of preventable death (behind good ole’ tobacco). And the data strongly suggest that households with just one obese parent are at least twice as likely to raise obese children who are doomed to a shorter life expectancy than their parents. Using drug war logic, this ought to be as good a reason as any to criminalize obesity or the behaviors (and foods) that “cause” it.

Sound crazy? That’s how crazy drug criminalization and drug courts seem to me now. Having dealt with my daughter’s heroin addiction for the past five years, it really hit me, after her most recent “relapse” (for lack of a better term) a little over a year ago, that it wasn’t so much her addiction that was causing the pain and trauma we were both experiencing as it was dealing with the woefully ineffective — and often counterproductive and EXPENSIVE — U.S. legal and treatment systems.

Whether to decriminalize or even legalize powerfully addictive drugs like heroin is a topic of ongoing heated debate. Decriminalization of the use and possession of all drugs is a no-brainer to me. Legalization is more tricky, but still requires an honest and intelligent discussion about the inherent risks and potential benefits. Because while we labor under the delusion that prohibiting a given substance outright is the ultimate form of control, it is in fact the mechanism by which we relinquish all control to criminals, who have in turn been empowered by such policies to build massive global organizations. The only way to undercut that power is to minimize the enormous profits that are generated by prohibitionist policies.

Those who have considered the idea of legalization in any serious way are quick to couple it with proposals for control, which should address, at the very least, protection of minors (who are, incidentally, not protected from heroin availability at present), and, especially in the case of opioids, prevention of leakage or diversion to others, policies for supervision and safety, and strict constraints on who might be eligible for prescriptions. One model of a successful quasi-legalization policy comes from Switzerland, which implemented heroin-assisted treatment (HAT) with great success to stem the tide of its own heroin epidemic in the late 1980s and early 1990s. Here is a brief description of the outcome from an article by Johann Hari in Huffington Post:

Switzerland also had a huge heroin crisis. Under a visionary president — Ruth Dreifuss — they decided to try an experiment. If you are a heroin addict, you are assigned to a clinic, and you are given your heroin there, for free, where you use it supervised by a doctor or nurse. You are given support to turn your life around, and find a job, and housing.

The result? Nobody has died of an overdose on legal heroin — literally nobody. Street crime fell significantly. The heroin epidemic ended. Most legal heroin users choose to reduce their dose and come off the program over time, because as they find work, and no longer feel stigmatized, they want to be present in their lives again.

I would clarify Hari’s description further by pointing out that (1) while Switzerland didn’t legalize heroin, per se, it did make it de facto legal for a very specific subset of the heroin-using population; (2) HAT is a treatment of last resort offered only to those for whom all other methods of treatment have failed; and (3) most HAT patients actually become re-engaged in their lives once stabilized on HAT, regardless of whether they ultimately choose to taper off.

HAT has been so effective in Switzerland that it’s no longer even controversial there, and HAT trials have been implemented in a growing number of European countries and Canada. Very recently, a couple of forward-thinking lawmakers have even made attempts to introduce legislation that would authorize HAT trials in Nevada and Maryland.

I dream of the day our society can, in the inimitable words of Ethan Nadelmann, learn how to live with drugs sensibly, so that they cause the least possible harm and produce the greatest possible benefit to all. Because if there’s one thing we need to recognize, it’s that drugs aren’t ever going to go away, no matter how many laws we pass or how many people we put in jail.

Just finished day 1 at the Mind and Life conference. What a beautiful building this is for a conference. The corridors seem to echo with the shuffling feet of Christian monks. But now, in our modern age, there are a lot of shaven-headed guys with orange robes walking around. It’s strange to see them in the washroom with everyone else, shaving, brushing their teeth. Very corporeal. But most people here are young scientist types, assistant profs or post-docs in psychology or neuroscience, but incredibly friendly and warm-hearted. And a few old guys, like me, except that they look like they’ve known each other for decades. It’s weird to meet a guy with a name like Saul Weinstein who turns out to be an expert on meditation.

Today the talks were on heady Buddhist topics, loaded with Sanskrit and Tibetan words for different traditions. I had to struggle to focus. I’m still a bit jet-lagged and my mind is buzzing with worldly things. In fact today’s meditation session was a total write-off.  Tomorrow’s talks will be on neuroscience. That should wake me up.

What’s most strange about this event is that I’m staying in a small room with another guy. Two beds side by side, and four tiny shelves for our stuff. I haven’t shared a room with a stranger since boarding school. He’s a prof in religious studies at a university in Pennsylvania. A nice guy, actually. Still, he’s very close.

Anyway, not much more to say for now, so what I’ll do is post the second half of an article I just wrote for the Mind & Life newsletter.

To prepare for the meeting [with the Dalai Lama], I’ve been trying to think like a Buddhist for the last few months. And what strikes me most is that the Buddhist perspective on personal suffering, based as it is on desire and attachment, captures addiction surprisingly well. So well, in fact, that addiction comes off looking like a fundamental aspect of the human condition.

Buddhism sees attachment, craving, and loss as a cycle — a self-perpetuating cycle — in which we chase our own tails and lose sight of everything else. What Buddhists describe as the lynchpin of human suffering, the one thing that keeps us mired in our attachments, is exactly what keeps addicts addicted. The culprit is craving and its relentless progression to grasping. First comes emptiness or loss, then we see something attractive outside ourselves, something that promises to fill that loss, and we crave it. And the next thing we do is grasp — reach for it. Grasping leads to getting: a brief moment of pleasure or relief that reinforces the attachment. But it’s never enough, we crave more, and that’s what keeps the wheel going round. Whether the goal is success, material comfort, prestige — the more respectable human pursuits — or whether it’s heroin, cocaine, booze, or porn, hardly seems to matter. Either way, you’ve locked your sites on an antidote to uncertainty, a guarantee of completeness, when in fact we never become complete by chasing after what we don’t have. And, incredibly, the pursuit itself is the condition for more suffering. Because we inevitably come up empty, disappointed, and betrayed by our own desires.

Now that sounds a lot like addiction to me. Yet the Buddhists are talking about normal seeking and suffering. Isn’t addiction something abnormal? What about all those brain changes I mentioned? [which took up the first half of the paper.] Those brain changes suggest to most scientists and practitioners that addiction is a disease — an unnatural state. But a Buddhist perspective might cast it quite differently, as a particularly onerous outcome of a very normal process, a sadly normal process: our sometimes desperate attempts to seek fulfillment outside ourselves.

So what about those brain changes?

It turns out that the brain is designed to change.  Every advance in child and adolescent development requires the brain to change. The condensation of value and meaning in adolescence corresponds with the loss of about 30% of the synapses in some regions of the cortex. As with addiction, normal development involves a lasting commitment to a small set of goals: I’m going to make money, I’m going to live in a secure neighborhood, I’m going to find a life partner. And that involves the formation and consolidation of new neural networks at the expense of older ones. In fact, every episode of learning, whether to play a violin, move in a wheelchair, or see with your fingers after going blind, requires the growth of new synaptic networks. Such cortical changes ride on waves of dopamine, in normal development as in addiction. Gouts of dopamine, with its potency to narrow attention and grow synapses, are highly familiar to lovers and learners alike. That palpable lurch for sex, admiration, or knowledge is always dopamine driven. The brains of starving animals are transformed by dopamine, when, as in addiction, there’s just one goal worth pursuing. And successful politicians achieve dopamine levels that would make an addict swoon. The brain evolved to connect desire and acquisition, wanting and getting, and that connection depends on the tuning of synaptic networks to a narrow range of goals with the help of dopamine.

For both normal development and addiction, desire acts as a carving tool, collapsing neural flexbility in favor of fixed goals. So our understanding of addiction may benefit more from a Buddhist-style perspective on normal development — with its tendency to become fixated on attractive goals — than the disease model favored by Western scientists and doctors. Yet the Buddhist perspective offers another advantage: an emphasis on the value of mindfulness and self-control to free ourselves from unnecessary attachments.

On that note, I’ll end by touching on a provocative experiment recently published in PLOS1, a prominent scientific journal [and brought to my attention by Shaun Shelly on this blog]. It’s well known that cocaine addiction causes reduced grey matter (GM) volume — thought to represent a loss of synapses — in certain regions of the cortex. But these researchers found increasing synaptic thickness in cocaine addicts who had abstained for several months: and the longer the period of abstention, the greater the growth. Most striking of all, the new growth wasn’t simply a reversal of what was lost, like a pruned bush growing back its leaves. Rather, synaptic growth was observed in new areas — areas known to underlie reflectivity and self-control. In fact, this growth surpassed levels reached by “normal” (never-addicted) people after a period of 8-9 months, indicating the emergence of more advanced mental skills. If these results are replicated, they’ll provide solid evidence that recovery, like addiction, is a developmental process, which may benefit from the advanced cognitive capacities facilitated by mindfulness training.

Based on studies such as these, and filling in the blanks with subjective accounts, addicts, scientists, and contemplatives have a lot to learn from each other. I hope that this theme will help guide the discussion with the Dalai Lama in October. Ater all, addicts and meditators make use of the same brain, with all its vulnerabilities and strengths. It makes sense that the brain changes underlying suffering and healing have much in common, whatever their source.

Our sponsor is the brain, of course. So, before getting to Part 2, here’s an important message, also excerpted from the final chapter:

The term neuroplasticity has been bandied around a lot in recent years, but it’s been understood for at least a century. In Donald Hebb’s (1940s) memorable words: What fires together wires together — neurons that activate each other become more strongly connected — through adjustments (increased efficiency) in their synapses. Neuroplasticity is the brain’s natural starting point for any learning process. This includes the development of addiction. But is it also the springboard to recovery?

Neuroplasticity is strongly amplified when people are highly motivated. Which is why all learning requires some emotional charge, and entrenched habits like addiction grow from intense desire. Clearly, the desire to recapture a potent experience of pleasure or relief is the motivational on-ramp to addiction. But does desire also cultivate recovery?

In The Woman who Changed her Brain, Barbara Arrowsmith Young describes the many cognitive exercises she devised for herself, in order to overcome her very severe learning disabilities. She practiced these exercises prodigiously. As a result, she went from a high-school student who could not comprehend history, who even had a hard time understanding simple sentences, to a writer and teacher who has set up roughly 70 schools for learning-disabled children across North America. I met this remarkable woman in Australia, at a book fair, and I became convinced that her intuition, creativity, and determination to triumph over her learning disabilities were precisely the means by which addicts recover. I also learned her delightful phrase for the neuroplasticity needed to replace bad habits with good ones: What fires together wires together, and what fires apart wires apart. In other words, new mental patterns can fashion new and divergent synaptic avenues.

In 1993, Mogilner and colleagues looked at the brains of people plagued with webbed fingers. That means that some of their fingers were connected and could not operate separately – they functioned in total unison. After surgery was performed to allow the fingers to move on their own, these authors looked at changes in the (somatosensory) cortex. What they found was that clusters of neurons that had always fired together now fired partially independently.

The presurgical maps displayed shrunken and nonsomatotopic hand representations. Within weeks following surgery, cortical reorganization occurring over distances of 3-9 mm was evident, correlating with the new functional status of their separated digits.

So the brain adjusted its wiring, breaking down the coherent habit it had assumed, based on the details of repeated action patterns, and replacing it with new habits, based on novel action patterns. In fact these changes were observable just weeks after the change in action patterns took place! Might recovery work the same way?

Just in case you think the webbed-finger analogy is far fetched, you should know that it’s not an analogy. That’s exactly how neuroplasticity works, whether dealing with severe learning problems (which no doubt involve the prefrontal cortex) or reversing a physical anomaly that took hold during prenatal development (involving the sensorimotor cortex).

When people recover from strokes or concussions, the same sort of rewiring takes place in many regions of the cortex. Even language, one of the most basic human functions, can be relearned after it has been demolished by brain damage, through the synaptic rewiring of cortical regions that previously took care of other business. Thus, neuroplastic change can and does occur, in real life, with a speed and vigor we rarely imagine.

Back to addiction. People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of that plasticity. As if their fingers had become attached together, they can no longer separate their desire for wellbeing from their desire for drugs, booze, or whatever they rely on. Then, when they recover, whether in AA, NA, SMART Recovery, or standing naked on the 33rd-floor balcony of the Chicago Sheraton in February, their neuroplasticity returns. Their brains start changing again—perhaps radically. Just as in Mogilner’s study, their brains begin to grow new synaptic patterns to allow for those distinctions, to hold onto them over time, and thereby acquire new vistas of personal freedom and extended wellbeing.

The take-home message here is simple: Recovery involves a major change in thought and behavior, and such changes require ongoing neural development. Without developmental adjustments in synaptic patterns, we would stay exactly the way we are. Which raises the question: If the high-beam of desire is what drives the synaptic shaping of addiction, is it also the necessary ingredient for finding the road out?

Teeter-totters go through a tipping point when no one is in control

There is something terribly interesting about the moment of giving in. That moment when the teeter-totter crosses that invisible threshold, when the momentum shifts, when you know you’re going to do it, despite the hours of telling yourself you won’t. It’s a very distinct feeling, says a recent reader. It’s a lot different from thinking about getting high. It’s not thinking at all, really. It’s not imagining what it will be like. Rather, it’s a feeling of free fall, a release from the incessant gravity of your own rule book. It’s a massive change: from control to freedom, from responsibility to neglect, from wisdom to foolishness, from security to doom — all at the same time.

We’ve just come through the holiday season, most of us intact, I hope. And yet many of us may have slipped in one way or another. If you’re a recovering alcoholic, you may have buckled and started drinking. Maybe for a night, maybe for a week, or maybe you’re still drinking. If you’re a chipper (a sometimes addict), maybe you chipped at something a lot bigger and a lot more dangerous than you thought you would. If you live on the clean side of the line of self-indulgence for most of the days of your life, maybe you crossed the line — for an hour, a night, or a week — with a bottle, with your neighbour’s spouse, with a reckless ride through the dark side of the internet… What I’m interested in is that moment when you actually cross the line. When it’s no longer a choice that you continue to make or that you’re always about to make, but a choice (if you still want to call it that) you’ve already made. That’s when the free-fall starts…that pitch away from your centre of gravity to a new orbit, a new star, much brighter in that moment than the dull planet you’ve been calling home.

Sometimes the moment of giving in is barely conscious, and sometimes it comes long before there’s a full recognition that you’ve already changed orbits, irrevocably, and the crash landing is coming next. Just the other night I read of the “fall” of a reader/fellow blogger whom I respect very much. She’s a recovering alcoholic who gave in to a couple of drinks, and she wrote about it before, during, and after crossing the line. In one post she describes the moment when (I’d say) her intention shifted trajectories, though that moment was still embedded in the chatter of a familiar self-dialogue:

Today I was at the market and managed to talk myself into buying wine — for taking to a friend’s house for dinner tonight, of course, but the truth is  we don’t have to take wine. We’re bringing other things, so wine is probably a bit too much. But I talked myself into buying it anyway, “just in case”. Just in case WHAT, I now ask myself. I tell myself, you know. Who are you trying to kid, you know exactly just in case WHAT. What was I thinking? Ohhhh, I’m so far out on the limb I’m not sure I can get back.

At a certain point she warned herself, “One sip is too many…the dangers are huge…but the desire is chipping away at my resolve.”

Once you’ve said that to yourself, it’s pretty much game over.

In my years of addiction, I told myself many many times that my resolve was weakening. Like that terrible weekend in Thunder Bay when it became inevitable that I would steal more drugs. I had lost the belief that I was capable of self-control. And I was so fed up with the whole process that I took absurd chances that night and managed, finally, to get caught in the act and carted off to jail. To say “my resolve is weakening” is code for “I can’t stop myself anymore.”

But luckily, this blogger — someone I now consider a friend even though we’ve never met — stopped herself, just an hour or two later. Check out her second post. It’s a happy ending. Relapse is part of recovery, so they say.

Where am I going with this? I want to spend the next couple of posts thinking about loss of control – a major theme in the psychology and neuroscience of addiction. Psychologists have been studying a phenomenon known as “ego fatigue” for roughly ten years. That’s when you’ve been trying to suppress or inhibit an impulse continuously, for an hour or more, and the result is a breakdown in the self-regulatory function – which we think is housed in the anterior cingulate cortex (ACC: see my book for details). After excessive use (think of a car that’s been going uphill in first gear for an hour), that part of the brain literally runs out of its fuel supply (glutamate and/or GABA), and like an over-used muscle it just caves in. Recovering addicts have the unfortunate mission of maintaining active, effortful – sometimes tremendously effortful — self-control. Not just for an hour but for a day, several days, a week, maybe a month or more. Our neural machinery wasn’t made to take that kind of strain.

But that first pivotal moment of giving in doesn’t just feel like a branch breaking under too much weight. There is also excitement, tingling anticipation, hope, freedom, relief — and something a lot like pride — for some of us — a sense of triumph, just for that brief window of time. Now you are no longer ensnared in a tug-of-war between two ideal selves. Now you are wholly and completely you. Or so it seems.

In my next post I’ll get into some details, looking at people’s experience of the loss of control and the brain processes behind those experiences. Stay tuned.

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

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

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

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

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

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

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

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

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

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

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

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

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