Understanding Addiction

…by Nick Jaworski…

After nearly 80 years, addiction treatment in America is slowly warming to the idea of multiple pathways to recovery, after viewing the 12 steps as the only “real” way to recover. MAT (medication-assisted treatment) is among the most promising.

This is a guest-post by Nick Jaworski, owner of Circle Social Inc., a marketing and consulting firm specializing in addiction treatment. (See bio information at bottom)

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Quite recently, MAT has gained recognition as the gold standard for care in treating opioid use disorder (OUD) among researchers, legislators, and even the general populace. But the acceptance of MAT by the professional treatment community has not been nearly as fast.

Many providers I speak with are still very reluctant to accept MAT in their centers or as a viable component of treatment within the field in general. Even if facility leadership is on board, there’s a good chance staff or referral partners won’t be.

Other providers, such as Hazelden, were also reluctant at first but looked at the  research and made their own determination that they had to change their approach (other providers, even today, still look down upon them for it).

Congress and many States have also recognized the efficacy of MAT and so have begun to pump serious money into programs that offer it (like this large grant from SAMHSA). Insurance providers often prefer MAT as well.

Cost is a very significant factor for legislators and insurance providers. MAT protocols can be provided to those struggling with opioid addictions at a fraction of the cost of a residential program ($4,000 or less a year versus $28,000 a month for your average residential program).

Since the majority of those struggling with addiction lack resources or are on Medicaid, MAT also opens the doors for the demographic with the greatest need to access care.

There are two additional drivers of the increase in the use of MAT in the US — Wall Street and parents.

Wall Street has seen great opportunities because the opioid crisis is constantly in the news and the addiction treatment industry has an estimated market cap of at least $35 billion per year. These investors come from outside the field and do not have the same biases. They look at the data and see what’s effective and where trends are going.

And then there are the parents referring their adult children into treatment. Many parents, especially mothers, have become completely disenchanted with the addiction treatment industry as it has existed since the late 1990’s.

Their Children Are Dying from Overdoses, and Parents Aren’t Taking It Lying Down

The bottom-line is that length of care is one of the highest predictors of success for treatment, so any 28- to 90-day program has very slim chances of success for the first round or two of treatment, regardless of what model they are using. To move away from abusive substance use requires extensive development of new neural pathways that drive new habits and patterns of thought.

As outlined in my article on a Brief History of Addiction Treatment Marketing, it was not uncommon for these young adults to go through 10-plus rounds of treatment. My team and I actually just interviewed a client who was currently on his 27th round of treatment!

As you can imagine some parents have become extremely skeptical after 10-plus rounds of failed treatment (not to mention that they’re paying as much as $30,000 a pop). But, more importantly, many parents have lost children to opioid overdose. The 18-26-year-old age demographic has always had the highest prevalence of drug and alcohol abuse. Most of the time, this is alcohol or marijuana, with smaller percentages using meth, cocaine, and other substances.

However, with the rise in availability of opioid-derived prescription pills, more young adults were switching to these painkillers, which have a high potential for overdose when mixed with other drugs. A subset of these users would go on to heroin, especially when prescription regulations reduced the availability of legal drugs. As most readers know, the extremely high overdose rates of the last few years have been driven primarily by fentanyl-laced (or -replaced) heroin. Unlike in the past, when young adults using drugs or alcohol mostly survived to go on and live normal lives (probably like most of those reading this blog), these kids were dying instead.

So parents were sending their children to multiple rounds of rehab, paying tens of thousands of dollars, and then losing their children to overdose anyway. As you can imagine, this created a lot of anger and resentment.

But that was nothing compared to the anger many parents felt when they learned there was this option called MAT that decreased overdose deaths by roughly 40-60% and they had never heard about it! It’s not uncommon for parents who have lost a child to overdose to tell me that the first time they’d heard about MAT was after their child’s death.

Imagine how you would feel if you sent your child to the hospital and you weren’t even told of a readily available and cost-effective method of preventing your child’s death because the doctor personally didn’t care for the treatment.

This is the kind of anger we see from parents such as Gary Mendell, who created Shatterproof, or Justin Phillips, who created Overdose Lifeline. Parents are simply giving up on the traditional rehab industry as a whole because they feel lied to.

American Addiction Treatment Perspectives Are Shifting, But in What Direction?

All of this has started to open the window to different conversations surrounding effective addiction treatment. Programs relying solely on 12-step and abstinence-based models are regularly being called into question.

However, I am not yet seeing an attendant shift in the disease model of addiction. Conferences premised on non-disease models are still small, and advocates of this approach are still few and far between.

I am on the board of Above and Beyond Family Recovery Center in Chicago, one of the most innovative treatment programs in the country. We focus on providing free, high-level outpatient treatment to Chicago’s homeless and disadvantaged, but we have had a hard time gaining the support of other treatment programs in the city because we do not focus solely on 12-step programming or disease models of treatment (although these are offered alongside our other programs).

Americans have a long history of deterministic thinking when it comes to human behavior. Starting with Calvinistic predeterminism in colonial America and then evolving into Eugenics, the American view of genetic influences rarely goes beyond a limited and simplistic notion of Mendel’s pea experiments (perhaps a topic for a future blog post).

With this misconception, most Americans still view addiction as some kind of genetically predetermined disease, one that is chronic, progressive and incurable.

In the context of our conversation here, MAT is seen as some kind of fix for an ingrained defect, one that perhaps rebalances out-of-whack or deficient neurochemicals in the brain. What most Americans have not yet grasped is that MAT, or any other substance that alters the brain’s neurochemicals, simply combats symptoms, which is not so different from how cold medicines alleviate symptoms rather than cure the actual cold. The key difference here is that OUD symptoms induce so much suffering that users are often driven to continue using. Opioids are of course the best (if not only) way to control opioid withdrawal symptoms. In this respect, relieving symptoms, though not a cure, can change behavior patterns that exacerbate the underlying problem.

In order to truly find recovery, you must rewire the neurological pathways in the brain, which will, in turn, drive changes in neurochemical balances. Just as one cannot lose weight or get fit by taking a diet pill, individuals cannot overcome addiction by taking a prescription. The pill can help, but lasting behavioral change requires focused effort over extended periods of time, as Dr. Lewis has often pointed out.

It is only through an accurate understanding of the interplay between genes, environment, and human experience that we can create effective solutions which help individuals and communities. It’s a goal I strive towards every day and I hope others reading this will do the same. For a much more in-depth discussion on how unconscious processes involved in learning and development (rather than genes or choice) drive addictive behaviors, see my article You’re Thinking about Addiction and Choice All  Wrong.

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Nick Jaworski is an internationally recognized executive in the field of behavioral health marketing and operational consulting, with experience building organizations world-wide. As the owner of Circle Social Inc., he has helped healthcare organizations perform turnarounds and accelerate growth. He and his team spend most of their days in and out of treatment programs across the country. They do extensive analysis of trends, observe programs, interview patients and families, and analyze data from marketing campaigns. Nick is an advisor to the board for The Behavioral Health Association of Providers, and is also on the board for one of the most innovative treatment programs in the country – Above and Beyond Recovery.

If you read my blog you know that I try to post smooth, polished pieces. I try to produce something coherent, even conclusive. This one’s different: a bunch of notes that I recently found in a forgotten file from five years ago. The notes pose questions that intrigue and trouble me as much now as they did back then. I don’t even remember writing this stuff. Probably much of it landed in previous posts and articles. But anyway, here are the questions. Still without clear answers.

I’ve annotated the text and filled in a few spots that would be completely incomprehensible otherwise. I’ve also added tips to more recent work and inserted several links. But the text I started with remains relevant, at least to me. Things don’t change very fast, and I think these are hard questions.

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My drug use began with psychedelics. Then came heroin. They’ve always seemed like diametrical opposites. This is where I get my intuitive feel for whether drugs are good or bad. Psychedelics open you up, heroin shuts you down. But I dropped acid roughly 300 times in my late teens and early twenties. I shot heroin about 30-40 times. Why do l assume that heroin is addictive and LSD is pure sunshine?

The one wedge nearly everyone agrees on is whether a drug is addictive or not. If only it were that simple. Is addictiveness really a feature of the drug? Or a feature of the person and the social surround (Rat Park)? When you take the addict as the unit of analysis, you place him in a cage, and then analyze his interaction with this or that drug. How stupid. How is it that scientists and doctors have become the priests of such stark distinctions?

The boiled-down argument re drugs and addiction: think about Percy Menzies [see his guest-post here] and the idea of chemical hooks (in Percy’s view, the only real cure for heroin addiction is OST, opiate substitution therapy, and he especially likes naltrexone: kill the good feeling and they’ll stop). [The idea of opiates as chemical hooks is also pitched in Dreamland, by Sam Quinones.] Then along comes Carl Hart (High Price) who says “addiction” is just a label used to badmouth drugs, and our only responsibility is to educate drug users. [In his new book, Drug Use for Grown-ups, Hart argues that all drugs, including heroin, can be taken recreationally, and  it’s repressive for governments to ban any drug for personal use by normal, sane adults.] And along comes Johann Hari (Chasing the Scream), who says that the opposite of addiction isn’t sobriety, it’s human connection. All very liberating. But what about addiction?

Addictive drugs: are they neurochemically distinct? Do addictive drugs mimic natural neuromodulation (opioids, dopamine, etc)….vs nonaddictive drugs (like LSD, psilocybin?) that effect perspective change? [But let me add this: last year I went to a neuroscience conference and learned that baby zebrafish will swim toward water laced with Vicodan, an opiate painkiller. I doubt they’d swim toward an LSD solution.] Mind-altering vs. mood-enhancing. Is that what decides? (Though SSRIs are mood-enhancing…and guess what, they’re addictive…sort of.) But behavioural addictions are just as serious, aren’t they? (Gambling addicts can destroy their lives as effectively as any crack-head) Can behaviour also be divided into mood-enhancing vs mind-altering? Probably not. Maybe there are just good and bad addictions…in life, love, and drugs. Oh, and in products. Where do we stop?

Why do we value control so much? Is control the wedge? Or is harm the crucial marker? Control vs harm and the history of antipsychotics…that increase control and kill the soul. Drugs that harm: don’t they require harm reduction? Or is it happiness, well-being, that’s key? Then why prescribe SSRIs when you could prescribe opiates for emotional pain? If you value control, then get this: drugs are a way to control our thoughts and feelings. Yet self-medication often leads to self-harm. How do we weigh the goodness of drugs when control, well-being, creativity, awareness and harm are all simultaneously changing variables?

Drugs and therapeutics…. Psilocybin vs. depression and anxiety. If that’s okay, why not prescribe opiates for those who crave them? The duplicity built into psychiatry: we want what’s best for you. Oh really?

Patches to move us from moralism to relativism:

Individual differences  — genetics are the simplest exemplar, but different life experiences matter hugely. Trauma leads to drug-use, not the reverse. Yet, the research shows that kids who never try drugs do worse than kids who do. How do we explain that?

Developmental differences  — the wrong drug at the wrong age might become the right drug at the right age.

Societal differences  — my undergrads at Nijmegen [a rural region of the Netherlands] still see addicts as a different species; in Amsterdam students don’t see it like that. Let’s send Mr Hazelden to an ayahuasca ceremony and see how/whether he evolves.

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A sort of summary:

Why would anyone put ayahuasca in the same category as heroin…isn’t there something intrinsically valuable about perspective change, for its own sake? And what’s the difference between methadone and SSRIs when it comes to allaying depression (yet one is for disgusting addicts and the other is for normal healthy people, like Aunt Mary). But I so disagree with Carl Hart when he says that when your teenage kid wants to try meth your only duty (and your only right) is to educate him/her about safety issues. Are the distinctions between good and bad drugs in the drugs themselves (as we often think reflexively) or in the relation between the drug and the user? We have to really get individual differences. And developmental differences. Binge drinking at 16, not so good…social drinking at age 28 can really help people connect. And what I learned from [my good friend and courageous colleague] Shaun Shelly: Isabel and I often reflect on his description of the unemployable/sidelined teens in Capetown smoking (not shooting) heroin…for social cohesion and a little pleasure. So, put it all together: look at the relationship between the person (of a certain age) and the drug, in the context of the social group and the society at large.

Coda: What makes drugs bad? Is there something simple and primitive like the idea of being too attracted?

Conclusion: I don’t know.

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A number of you posted very helpful comments about what you’d like to see in future posts. We’re working on it. Next, Eric Nada, a past contributor to the blog, will post a piece on psychedelic therapy for addiction. Given the above, I’m aware of possible ironies.

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.

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.

A reader recently brought up the fascinating connections between Buddhist meditation and neuroscience. There has been a lot of work in the last two decades, trying to develop a scientific foundation for meditation and also teaching science a thing or two, like how meditation changes the brain. In this post I want to suggest how meditation can reduce craving, thus potentially aiding recovery, and I want to briefly describe how this might work in the brain.

Last post, I suggested that “free will” or at least deliberate choice could be facilitated by slowing, down, relaxing, seeing the bigger perspective, and…even meditating. I was following Nico Frijda’s ideas about the importance of reflectivity in overcoming impulsive action. But how on earth do you slow down, relax, and reflect (let alone meditate) when craving is erupting throughout your consciousness. The craving for drugs (or booze, or other substances and activities) can be enormously powerful. As noted recently in a response by Mike Johnson, the dACC (dorsal anterior cingulate cortex), which is the seat of deliberate self-control, can be a leaf tossed around by a cyclone when the impulse to take drugs gets too strong.

Indeed, addicts are often caught in the cross-fire between two warring brain systems. The dACC, and its connections to the (probably left) dorsolateral prefrontal cortex, try to set up a long-range forecast, a bigger picture, a more reasoned perspective, and then use that perspective to inhibit behaviours that surely lead to failure and misery. Meanwhile, connections between the ventral striatum, which is the seat of goal-seeking, and the orbitofrontal cortex, another ventral system that anticipates the pleasure and relief of taking the drug or drinking the drink, get increasingly activated by dopamine, as the possibility, no, likelihood, no, GIVE IT TO ME NOW! gets closer and closer. The craving builds on itself in a self-reinforcing feedback loop in the ventral (lower) regions of the prefrontal cortex. While efforts to control the craving activate the dorsal (upper) regions of the prefrontal cortex, trying their best to hold the feedback in check. What’s a poor brain to do?! Or in human terms, how do you slow down enough to choose tomorrow, and the day after tomorrow, instead of the few hours’ relief promised by the drug?

Research into the neuroscience of meditation often uses practiced meditators, or else they compare people following a course of meditation against those who’ve taken some other form of instruction (the control group). These people are placed in an fMRI scanner or other brain-imaging system, and their brain activity is recorded, either while they are meditating or while they are engaged in other activities (such as looking at pictures designed to induce empathy). It’s difficult to sum up this entire branch of research in a few sentences, and results are not always consistent. But one finding from several studies (here’s an example) is that meditation causes increased activation in the dACC and/or in the (left) dorsolateral prefrontal cortex—the exact regions that support insight, reflection, and long-range perspective.

So it looks like meditation builds muscle, so to speak, in brain regions that can win against impulsive (e.g., addictive) thoughts and actions. How can addicts, recovering or not, use this information to their advantage? I’m no expert on treatment and recovery. But maybe we can think of these insight-generating brain regions as muscles, that are weakened by excessive use (trying, trying, trying not to give in) and strengthened by meditation. Then meditate whenever you can! And do it even if you’re still using. In fact, do it especially if you’re still using, or if you’ve recently stopped. Try it for 5 or 10 minutes, if that’s as long as you can last, even if you’re still thinking about getting high later in the day. But do it the next day as well. And the day after that. You can learn how in twenty minutes. Or check out this link to a talk by Jon Kabat-Zinn. As I said, I’m no expert, but meditation really helped me in the weeks and months following my last relapse. A little bit of meditation, spread over days and weeks, can gradually shift the balance between brain systems that dance to the music of craving and those that turn down the volume.