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.

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.

This guest post by friend, colleague, and contributor, Matt Robert has a five-star rating. Check it out…..

A meditation “practice” isn’t called a practice just because it’s something you’re supposed to do every day, like brush your teeth. It’s practice for a performance, like that of a concert pianist or a pro basketball player. What’s the performance? It’s that moment that occurs in the real world when you’re not meditating— the moment after a stressful encounter at work when you start to visualize hitting the liquor store on your way home. The performance is making a choice, a decision under stress: will you be able to not react reflexively out of fear or anger?  Mindfulness practice is training to be more open to all the possibilities a given situation presents—not just those possibilities we see from our own habitual frame of reference, with our own personal blinders on. It’s practice to take a look at what we’re telling ourselves. It’s practice to act mindfully in real life.

In the beginning, meditation is useful just to relax the mind and body. In a busy world, we seldom spend time just sitting quietly.  We’re always on the go. In meditation we bring the physical activity down, and consequently let the mind rest more in its natural state—closer to being free of judgment, opinion and the restless activity of the stories we constantly tell ourselves. This can come about just by focusing the mind on an object of attention, like the breath or a mantra, or a point in space.  It’s simple, but not easy.

The more time one spends doing it, the more thoughts and emotions become recognizable as discrete objects instead of part of an amorphous blob of cognitive gobbledygook. In CBT-based recovery approaches, one technique is to name your “addictive voice” or disturbing urge. It becomes a thing, a person, a tangible adversary—the thing that gets triggered in you and seemingly drives your car to the liquor store without your permission. Mindfulness practice helps us recognize that adversary at the early stages of its waking up and entering the room.

People in recovery meetings who engage in some kind of meditation or mindfulness practice frequently report examples of becoming more mindful of problematic behaviors and being able to sidestep them. One person got into a terrible fight with his wife that involved throwing dishes. His anger got to a level where he just put on his coat and headed for the door knowing full well where he was going. But this time his practice paid off.  At this “performance” time, he just paused for a moment and looked at what he was doing, noted his feelings, and realized it was not what he wanted to do in the long run.  He took off his coat and sat back down.

Another person was experiencing alternating episodes of fear, anger and resignation whenever she had to use her sober-lock device to start the car. Every time she had to blow into it, it reminded her how badly she had screwed up. Every now and then the device also gave her a false positive, which led to tremendous anxiety. Her anger and fear caused her to imagine going down the road to relapse on the F-it express, with a string of false positives as the catalyst. So she began meditating a few minutes before she had to start the car, took some deep breaths, and this fearful, resentful reaction began to dissipate.

Every time people can maneuver through one of these episodes, whether it is spawned by high emotion or a passing thought, another brick is laid in the foundation of their recovery.

Addendum by Marc: The neuroscientific research on meditation is a bit of a hodge-podge, but two brain changes keep showing up. There is a network of brain regions called the default mode network, which includes some posterior regions not involved in paying attention. We spend our time lazing about these regions when we are day-dreaming, fantasizing, wondering or worrying about the past or the future, imagining ourselves in different scenarios, but not paying attention to the present moment. When people meditate, and especially when they start to get good at it, the default mode network turns off more readily, and regions of the prefrontal cortex (especially the left) turn on. The left prefrontal cortex is where we go when we are paying attention. But the brain changes in another way. With meditation, there is increased communication between the prefrontal cortex and many other regions. That means that our increased focus on “now” can alter our habits, redirect our memories, and clarify perception and action — seeing and doing.

Most important to people fighting addictions, meditation increases self-control. The perspective and insight provided by the left prefrontal cortex organizes thoughts and actions, so that we can act in our own best interests because we see things more clearly. Behaviors that get us in trouble show up on the larger map of possibilities as trouble spots. That doesn’t fit! Going to that party in this mood is a recipe for disaster. Hanging out with Dave does not fit with an overall game plan to stay clean. Your left prefrontal cortex knows all this. With meditation, it develops the skills to bring that information to bear whenever you need it. We learn to bring focus together with experience and action — and that’s a powerful arsenal for people who are trying to remain safe from their demons.

The paper I recently published in the New England Journal of Medicine (linked here, summary linked here) detailed my best arguments against the disease model of addiction. But it also explored new territory, and that’s the topic of today’s post.

I emphasized (as I have for years) that addiction is learned. It is not a pathology but a learned package of desires, actions and expectancies that keep leading back to the same reward. We call it a reward, but most of us who’ve been through it know that the experience itself gets less rewarding even as the desires and expectancies continue to strengthen. Is that pathological? No more than being in love with a hurtful partner, or praying to an unresponsive god, or being devoted to a sports team despite their string of losses. When the power of a reward arises from strong emotions and needs, the tendency to pursue it isn’t rational. When we seek and find that thing again and again, then, through learning, the synapses of our brain form into dense networks (pathways of connected neurons) that become very difficult to circumvent. Learning on overdrive, through repetitive need-satisfaction, is habit formation — addiction is a deep and insidious habit.

Well, you’ve heard me go on about this before, and my second addiction book, The Biology of Desire, makes the point pretty well. But my recent article came out in a journal read by more doctors than any other journal in the world. To convince that audience, I tried (with the help of Shaun Shelly, who co-wrote or edited much of it) to show that each of the brain changes highlighted by the disease model are not pathological. They’re the sorts of brain changes you’d expect when expectancies and emotions become attached to a specific goal, leading to behaviours that are partly automatic — and partly not. Habit formation results in automaticity,  sensitization to some rewards, and desensitization to others. The brain changes seen in addiction are just the biological underpinnings of this natural learning progression. And…they can continue to update; they’re not carved in stone.

The new territory I wanted to explore sits outside the brain, in the world, in the environment of the addict (I use that term without disdain or judgement, having been one myself). Our environment, especially our social environment, consists of the people we care about, many of whom care about us, and of opportunities for care, for sharing, for pleasure, for relief, for a sense of fulfillment. These opportunities require certain resources, such as social skills, knowledge, self-esteem (at least a little), financial stability, the capacity to understand others. Opportunities are bridges between our needs and their satisfaction. Resources are the capital we use to pursue them.

When people fall into addiction, their environments shrink around them. Good friends, stable romantic partners, available, loving family members, physical comforts such as a safe place to live, job opportunities, and all the rest of it, gradually become less available. The opportunities for getting them back also become less available. Our attention and motivation, riveted now to just one source of satisfaction, lose their connection with the other sources of satisfaction that “normal” people enjoy. I see this as a literal narrowing or shrinking of the environment. Because of what I’ve called “now appeal” — or simply habit strength or deeply learned habitual behaviour patterns — we focus only on what’s in front of us and forget how to go after other rewards. So other rewards fade in availability. They evaporate. They get lost.

When I was an addict, I lost close friends, I lost a woman I loved, I lost the opportunity to communicate honestly with my parents, I lost money, I lost a sense of social and physical safety, I got kicked out of school and lost that opportunity (for a while) and all the rest of it. This picture is typical, one way or another.

But what blows me away conceptually is how this narrowing of the available, reachable, usable social environment precisely parallels the narrowing going on in one’s brain. My synapses fell in line, in pathways and networks that had a single purpose, so to speak, rather than multiple pathways supporting multiple purposes. This “narrowing” in the brain corresponded with a shrinking or narrowing in my available environment. Neither is pathological. Both, especially both together, create a kind of prison.

Perhaps of interest to those into philosophy or psychology, this tendency has been studied as a universal feature of living organisms. The sensory and behavioural specialties of a species get synchronized with aspects of that species’ environment. Both change together. This can happen over evolutionary time. But it can also happen at the scale of human development, as I’m talking about here. The study of this process is called “embodied cognition.” Google it.

One more point made in the article that Shaun and I thought was crucially important: people who study addiction know that there are massive correlations between early adversity (e.g., neglect, abuse, poverty, racial segregation, parental depression, parental alcoholism — in childhood or adolescence) and the probability of becoming addicted later in life. When thinking about how the narrowing environment corresponds with the narrowing of brain function, we can see that the addict’s environment starts off narrow! Kids with happy, healthy social-emotional worlds, who have not experienced trauma, rarely become addicts.

It’s really so simple. The narrowing begins early, sometimes even before birth — look to the family of origin. (Gabor Maté has emphasized the impact of adversity in early childhood. Bruce Alexander targets sociocultural adversity.) This helps us understand how environments and brains influence each other all the way along. If your childhood is hampered by obstacles and dead-ends, whether emotional, social, financial, or some combination of these, the narrowing has already begun.

By Margôt Tesch…

A note from me (Marc):

This self-trust thing….it’s like a hardy weed. It keeps spreading, and now it’s bursting out in all kinds of places. Margôt Tesch, a member of this blog community, trusted her future self to help her curb her drinking. And it worked. This post is her description of the process she used and the impact it’s having on her life. The only thing I can add is that it makes me very happy…that an idea that emerged from my reflections on my own life can become a method for helping others. The rest is Margôt’s account:

I read Marc’s blog on Self Trust some weeks ago. At the time I read it, it resonated profoundly and sparked some immediate actions and changes in my life. Marc talked about the need to let the future self take control. It seemed to be exactly what I needed to hear at just the right time.

I have been aware of my addiction to alcohol for many years now. I try to be honest in my self-talk, i.e. acknowledge that I do have an addiction even though I manage it by constraining my indulgence so that I do not behave anti-socially. But drinking is something I do every day. That’s an addiction.

I have wanted to change my dependence on alcohol for a very long time and had even been thinking recently about my lack of self-trust in this area. You know, how you have a big night and a hangover and you decide “That’s it” … until about 5 the next day. Many of you will know the cycle. It’s ridiculous, but we act it out over and over again. Just as Marc points out, it erodes our self-trust.

I lead quite a disciplined life. I eat well, exercise regularly etc. As well, I have created a habit of goal setting and know how to push myself through to achieve things; for example, challenging adventure hikes, long distance running — the list goes on. Further, many years ago I overcame a serious food addiction which lasted over a decade. I also gave up smoking, though that was some 30 years ago now. So I have reason to trust myself. I have a sense of confidence that I can do difficult things if I set my mind to it.

I’ve always known that I could stop drinking and actually believed that I would stop. I’ve just been waiting for the right impetus, the right motivation to give me the reason to stop. Knowing that drinking habitually has health implications has not been enough. I guess I’ve been waiting for the health crisis. But when you stop and think about it, that’s pretty crazy. Why wait for the health impact to eventuate. Why not stop now and prevent it?

These thoughts had been going around and around in my head, but still I persisted to drink daily. When I read Marc’s blog in preparation for his TED talk, all this thinking came together in a moment of clarity. Suddenly I perceived “my future self” as an identity that could take control…now! I had always believed that this was possible, that my “future self” would one day do it, but Marc’s words made me realise I didn’t need to wait. My future self was actually inside me. I already believed in her. So I was able to merge the perception of my future self with the perception of who I am now, today. I/we became one. This simple shift in thinking gave me the sense of self-trust I needed to take control in a matter-of-fact way.

It worked. I had my first drink-free night for a long time. My husband even poured me a drink; I accepted it but couldn’t drink it. My future self was in control and was able to think clearly about the benefits of stopping (short term pain for long term gain).

In a way it was a relief — no more cognitive dissonance.

It’s been several weeks now. My husband also read the post and decided to join me, and I have to admit, that’s made it easier. We have achieved what we set out to do so far, no drinking during the week, and we are working to limit our weekend consumption to “reasonable” amounts (which means no hangover). So far that has probably been the greatest challenge. The first night after a period of abstinence is high risk as there is some compulsion in giving yourself permission to drink again, to over-indulge. But we are working on it.

My plan is to make this behaviour part of our routine so that it just feels “normal” not to drink every day; let a new set of habits and behaviours emerge. Already we have noticed we are more alert in the early evening and able to use the regained time for more cognitive activities, rather than just watching the TV.

We aren’t there yet and a trip overseas visiting family has set us back a bit. But now that we are home, the work begins anew.

Here are some notes that I refer to when I need to regain the initial impetus:

• Future health gets sacrificed for immediate gratification (i.e. too much dopamine production).
• Believe in my capacity for self-control (reduces ego depletion).
• Maintain a dialogue between my future self and me.
• Things will get better.

I really appreciate Marc’s thinking and theory in this area. It has helped to change my life.

Note (from Marc): Please see the new blog by Ken Anderson in Psychology Today. Ken is the founder of HAMS, a group that supports “Harm Reduction” approaches. Margot’s self-styled method is a great example of Harm Reduction.