Understanding Addiction

…by Shaun Shelly…

Percy Menzies’ post has stirred up a lot of controversy! Here, Shaun’s extensive rebuttal gathers some of these arguments, plus many of his own, and launches them in torpedo-like fashion. Shaun’s command of the research landscape is awesome, but let’s take care to keep a balanced perspective.

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In the previous post on this site Percy Menzies makes what appears to be a persuasive argument for naltrexone as a favourable intervention when addressing heroin use disorders. Where Dr. Menzies and I agree is that people who have a heroin use disorder should have a wide range of options for treatment, all the way from non-pharmaceutical to antagonist to agonist. Having said this, I have some major problems with his argument, and I believe that the promotion of naltrexone as a valid response to the heroin epidemic, compared to agonist and partial agonist therapies, is flawed.

The first thing we need to know is that opioid substitution therapy (OST) works. It is the gold standard recommended by the World Health Organisation, and for the last 50 years methadone has been proven to reduce mortality, reduce crime, improve health, improve retention in treatment and allow people the space to resolve many of the issues that have made drug use so meaningful to them. It also reduces the spread of HIV. Through robust head-to-head clinical trials, buprenorphine has also been shown to be effective, in some cases more so, in some cases less, but it is effective and has a better safety profile.

Dr. Menzies suggests that the treatment of heroin use disorders is “overwhelmingly dominated” by OST. This is simply not true. According to a 2015 SAMHSA report, only 22% of people between the ages of 22 and 34 accessing treatment for heroin use disorders received OST. Even judges playing doctor are ordering people to stop OST. Further, Dr. Menzies argues that if OST was made more available it would “exacerbate the existing problem, as the pool of opioids will greatly increase along with abuse and diversion.” The data simply do not support this: In Switzerland, where 92% of people in heroin use treatment are receiving agonist therapies, the number of people with a heroin use disorder is dropping by 4% per year and no one has died from a heroin overdose since the programme was started in the early 90s. Similarly in France, where buprenorphine is the norm, 70% of heroin users have access to OST and there has been an 80% reduction in heroin-related deaths and a 75% drop in HIV prevalence among injecting drug users. 20% of French physicians prescribe buprenorphine compared to 3% in the US.

As far as diversion is concerned, diversion is a function not of greater availability but of lack of availability. The diversion of methadone and buprenorphine occurs because they have a street value — because people cannot access these medications or because the services that offer them are not attractive to them. This is basic economics, and it has been proven throughout history. Increased access through appropriate services will reduce diversion!

The most concerning aspect of Dr. Menzies argument is his promotion of naltrexone in lieu of OST. Naltrexone has been available since 1984 in the oral form for treating opioid dependence and XR-NTX, the extended release injectable version, since 2010. Naltrexone is an opioid antagonist. In other words it has affinity with the opioid receptor but has no intrinsic value and therefore no efficacy. Theoretically this blockage causes the dissipation of Pavlovian learning over time. But for this to occur, the naltrexone needs to be taken over time, and retention and compliance are listed as a major problem in all the studies. The 28-day injection (XR-NTX) was developed, and this has improved compliance, but in many studies patients do not complete the course — in a phase four trial only 36% of participants completed the treatment. Dr. Menzies and his organisation, Assisted Recovery Centers of America (ARCA), also describe naltrexone as an anti-craving medication on their website. But what does the data say?

A Cochrane and other reviews have shown that naltrexone performs no better than placebo in reducing heroin use. Craving has only been shown to be reduced with the XR-NTX formulation, but studies suggest this is linked to period of abstinence independent of the drug. Further, due to the antagonist nature and subsequent upregulation of opioid receptors, once naltrexone is stopped it significantly increases the risk of overdose. Some studies have suggested that this risk can be 7 times higher than with methadone.

Further, the studies that were used to secure FDA approval for XR-NTX in the treatment of heroin use disorders were done in Russia, where OST is outlawed. It is a basic principle of clinical trial ethics that if there is an existing treatment option, placebo controlled trials are not ethical. There have been no head-to-head trials in the US for naltrexone vs. OST. A Malaysian trial ended prematurely because the difference between buprenorphine and naltrexone was so great that it would not have been ethical to continue!

Dr. Menzies is suggesting that we use a medication that has: not been through head-to-head clinical trials with a known effective treatment (OST); that performs no better than placebo unless autonomy is taken away and it is given in a 28-day formulation; and that has been shown to significantly increase the risk of mortality on termination. He further suggests that it may be especially useful for “patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.” This despite the recommendations of the World Health Organisation and the UK National Institute for Health and Care Excellence (NICE) guidelines recommending that only employed, fully informed, short-term users who want total abstinence and are well informed of the consequences of naltrexone would benefit. Studies looking at retention and efficacy have shown that people who are homeless, injectors, or have co-occurring disorders are not suited to naltrexone. At US$1000 a shot, I wonder how long the “not well-to-do” will be compliant.

In the interests of autonomy, disclosure and choice, naltrexone should be on the menu, as Dr. Menzies suggests. But based on the evidence, Dr. Menzies’ post promoting naltrexone as the most promising response to the heroin epidemic appears to be less of a reasoned argument and more of a biased stance that capitalises on the fear and stigma so many have towards opioids and those who use them.

For a more complete argument against the use of naltrexone, complete with references, please see my piece in The Influence.

I got back Saturday from a 3-week extravaganza: first the Nobel conference on Addiction, then two weeks as a visiting prof at Gustavus College, and then a week in Toronto, catching up with relatives and friends, hanging out with my daughter, and doing about one talk per day on…you know, addiction not being a disease, that sort of thing. We’ve got a lot to catch up on.

Let’s start with the conference. The Nobel Foundation (yes, the big guys, and no, I did not get a prize — they’re often awarded posthumously so I should be grateful) has been hosting this annual event at Gustavus Adolphus College. I’d never heard of it either, but it’s a high-ranking liberal arts college near Minneapolis. This year “addiction” was the topic. So I was pleased to be invited and especially glad that I’d be meeting Carl Hart.

He was easily the most dashing speaker at the conference — a tallish, slim black man with long dreads, handsome, friendly, cool, and collected. His book, High Price, is one of the most popular books on addiction of the past few years. Carl’s talk came on day 2 of the conference, and the crowd of 4,000 present (and supposedly another 10,000 online) were ready for some meat. Yesterday’s talks had generally tiptoed around what many considered the main issues.

So he gets up in front of an audience of rosy-cheeked, blonde midwesterners and proclaims that 80 – 90% of recreational drug users are not addicts and never will be. And most people who use drugs don’t need jail and they don’t need medical treatment. Even the addicts — especially the addicts — are the last people one would ever want to put in prison. Massive applause. The most important thing we can do for drug users, young or old, is to educate them. Just like with sex and driving — other activities that are potentially fun and potentially harmful — users need to know how to stay safe. The crowd likes this guy, and so do I. There’s laughter and applause. It makes sense.

He provided an example of drug education specifically targeted to this audience: when you eat cannabis it takes a long time to feel the effects. So don’t keep eating brownies until you know how strong they are! More laughter, more applause, some clearing of throats from the elders. Everyone is transfixed. Hart is deliberately opening a rift between the beliefs and sensibilities of young people who are presumably experimenting with drugs and the stodgy older generation who are starting to fidget in their seats. Fascinating to watch.

But things got a bit weird when he got onto methamphetamine. He showed some footage designed to scare people away from meth: a clip of a man writhing on the floor as though possessed by demons. He said he could not even imagine what symptoms this man was expressing — in other words, he was ridiculing the kind of “drug education” that has become status quo in the U.S. Good point.  But then he went on for a long time about meth being chemically similar to Adderall, a stimulant used for ADHD. He showed slides of two molecules that looked the same except for a methyl group and apologized for speaking over the heads of the less scientifically inclined. I thought that was a cheap trick. I wasn’t convinced that Hart knew much about methyl groups to begin with. He’s a psychologist, not a chemist. In fact, methamphetamine is not the same as Adderall, which is a mixture of dextroamphetamine and levoamphetamine. Meth is far more powerful, especially given its conventional modes of ingestion, and far more addictive. So what was the message here?

I’d read Hart’s book, cover to cover, in the month preceding the conference. What made him famous was his research program, conducted at Columbia University, showing that crack and meth addicts didn’t have to lunge for a hit of dope every time it became available, if they had other choices. He kept self-identified addicts in a residential setting for three weeks at a time, and he gave them choices between monetary (or other) rewards and various-sized hits of crack or meth. And since they didn’t get the money until they left the residence, they couldn’t go out and spend it on the street. Sure enough, meth and crack addicts often chose the money instead of the drug, especially when the money offered was at the high end of the scale and/or the dosage was at the low end. According to Hart, this demonstrated that addiction is a choice, not a disease. Addicts don’t lose their free will, as Nora Volkow might insist. They can make choices when choices are available.

I really like Hart’s argument in one respect. He is trying to show that inner-city kids who don’t have much to do except take drugs are more likely to take drugs — as a choice, not a compulsion. And I fully concur with his message about the disadvantages faced by minority members, both when it comes to choosing drugs and when it comes to the vastly disproportionate jail sentences they’re hit with — because of the built-in racial bias in laws that, for example, punish the use of crack (a “black drug”) 20 – 50 times more harshly than the use of powder cocaine (a “white drug”) despite their chemical similarity. Johann Hari gave us the same message, loud and clear. And it needs to be heard.

But I find other aspects of his message highly questionable.

First, does anyone, even Nora the Terrible, really believe that addicts cannot control their addictive impulses, even for a little while? I doubt it. That seems like a classic straw-man argument. It’s an exaggerated claim, so it’s not that hard to rebut. Second, how much crack or meth is he offering these guys? The dosage information is in the book and related papers, but if you are offering crack or meth addicts smallish doses many times a day, day after day, surely their tolerance will soon override the potential high. Mightn’t the drug offer become just a tease? Hart doesn’t seem to care about these issues. He does not use self-report to evaluate the level of the high. And he doesn’t show how the choices might change over time (within the residency period), potentially reflecting a day-by-day build-up of tolerance.

Carl Hart got the only standing ovation of any of the speakers. Hooting, whistling, on-your-feet cheering coursed around the auditorium for several minutes. Especially from the young people — the undergrads and high school students. Indeed his message was powerful, both courageous and outrageous: the middle-class, middle-of-the-road masses (young and old, expert and novice) needed to be confronted with the distortions, in fact the lies, that have been beamed at us through every conceivable media channel from the overlords of the War on Drugs.

I liked this Carl Hart. I stood up and applauded with the rest. But I wanted there to be another Carl Hart as well: one who addressed the 10 – 20%, the ones who suffer, the addicts.

When someone from the audience asked him what he would say to his kid, if the kid told him he was thinking of trying meth, Hart said he would try to educate the kid about how to stay safe, whatever drug he was taking. That’s not the answer I would have given. I would have said: smoke weed, try mushrooms, and here are some tips about doing it safely. But stay away from meth.

My last post was about neurodiversity, and it brought up some great discussion! Now I want to bring all this back to addiction.

I’m at this Writers’ Festival in Sydney Australia, extremely jet-lagged, flogging my book, doing radio interviews a couple of times a day, and the same question keeps coming up: Is addiction genetic? I mean, do you think you became an addict because of the way you were made? Not everyone is vulnerable to addiction, right? So there’s got to be something in the basic brain plan that makes you that way. Right?

I don’t think so.

There is simply no gene or combination of genes that is linked with addiction as a trait. That doesn’t mean that genes are not part of the enormously complex causal bouquet that does result in addiction. But the genes that are correlated with addiction are genes for traits like impulsivity. And even these correlations are often weak or inconsistent. Some traits – impulsivity, maybe neuroticism, maybe low frustration tolerance – do help describe an individual who will, when things get tough, tend toward addiction more than the next guy. But impulsivity also puts you “at risk” for bungee jumping. And nobody is saying that bungee jumping is genetic.

A lot of people are doing good research on genetic factors that predispose toward addiction, and I’m not saying this work is irrelevant. But so far, the result seems to be a lot of small pieces of a very large puzzle. So let’s go back to impulsivity, where the water is clearer.

Impulsivity, the opposite of inhibitory control, is known to be correlated with inherited (genetic) factors. And the lynchpin of this correlation is believed to be brain mechanics. Well, what else could it be? So a recent study, which claims to be the largest of its kind ever conducted, looked at the brain activation patterns underlying impulse control in early adolescence. The researchers identified multiple brain networks involved in impulse control…which of course means they’re involved with its opposite – impulsivity. But each network was associated with a different style or type of impulsivity. Moreover, activation in one of these networks correlated with early drug or alcohol use, while activation in a different network correlated with ADHD symptoms. Already this shows that an individual’s particular brand of impulsivity (and the hardware underlying it) lends itself to a different constellation of problems.

Of most interest, the pattern associated with early drug use (reduced activation in the lateral OFC) was not a result of drug-taking but a predisposing factor. Does that mean we are beginning to discover the neural recipe for addiction? No! It means that a particular style of impulsivity predisposes teens to experiment with drugs or alcohol. It probably predisposes them to experiment with a lot of other things, including sex, travel, maybe graffiti, maybe tree-climbing, and quite possibly bungee jumping. And notably, this particular brain pattern was not linked to any genetic variant. Again, not surprising. These are the brains of kids who have already grown up in their own particular environments, and brains rewire themselves with experience. These brain patterns were not preformed in the womb. So genetic links, which are often insubstantial to begin with, have to step aside to make room for the role of experience – no matter what.

In a nutshell: Genetic links? Yes. Genetic determinism? Not at all. The relations between genes and brain structures help – among many other factors – to build personality dispositions. They do not build addiction. Addiction is an outcome, a result of a particular set of life experiences, a learned pattern of thought and behaviour. There are many brands of misfortune, both inside and outside our bodies, that can move us toward this outcome.

Yesterday I was interviewed with another author in front of 200 people, and he and I were encouraged to take off from the questions and start our own conversation. I met this guy in the lobby, a half hour earlier. His name is Lemon Andersen – um yeah, his first name is Lemon – and he’s this short, slender, cool looking poet dude from Brooklyn, with a Hispanic accent that makes him even more cool. His style of oral performance is related to “slam poetry,” he’s been mentored by Spike Lee, and he won a Tony in his mid-twenties. Now he’s in his mid-thirties. His parents met at a methadone clinic in Brooklyn. They were both long-term junkies, and they both died of AIDS.

Lemon has never taken drugs. He sold them, to get by in an impoverished housing project, but he never took them himself.

We were in the same session because we both had a lot of addiction in our past lives. But when I first met this guy, I wondered if there’d be any rapport. The Beat poet and the dowdy professor? As it turned out, we practically fell in love with each other on-stage. Maybe because we’ve both struggled to get away from drugs. Maybe because we’ve both found a calling that helped keep us sane. Do you know why Lemon has never touched drugs? Because he was afraid to. Simple as that. With all that genetics working against him – so you might think – he took a different path. His own path.

That’s what we all do, whatever it is we’re made of and wherever it is we come from. Masters of our fate? No. But we create our own masterpiece – ourselves – from the multidimensional palette of genes and environment.

If you weren’t completely sold on the bicycle analogy. Try this one. The point is the same, and it’s not complicated: addiction is a mental habit, it grows, stabilizes, and gets difficult to reverse. But it’s not permanent. It can be reversed — with practice. Unfortunately, the good habits that replace it may not be permanent either.

Mental habits become stable and resilient, hard to switch out of, when they are practiced repeatedly. That’s the case with piano lessons, pizza night, bicycling, and heroin. (I don’t distinguish “cognitive” habits from motor habits like bicycling — they’re all grounded in the same brain.) It’s possible to switch out of one mental habit and settle into another incompatible habit; that’s all well and good. Except that you might switch back into the old habit if you’re not careful. Because the synaptic configuration that held that pattern in place isn’t gone. It’s just been “deactivated.” Synaptic patterns take a long time to fade — through a process known as synaptic pruning. And the only way that’s going to happen is if other habits are practiced in their place.

Until that occurs, you’ve got these two habitual mental frames, let’s call them drug-wanting and drug-shunning. I recently referred to them as “two you’s.” They’re incompatible. One disappears when the other takes over. And it’s not hard to switch from one to the other — either by accident or on purpose.

So here’s another example: the Necker cube. (I don’t know who Necker was….maybe the guy who discovered this cool optical illusion.)

Take a look at it:

Pretty, isn’t it? Now try seeing the face that includes the lower left corner as the outer face — the face facing you. Easy enough, right? Just stare for awhile. Get used to it. Then imagine a different orientation: imagine that that face is actually at the back, and the front face is the one pointing up and rightward (and including the top rightmost corner) rather than down and leftward. Can you do it? It might take a while, but if you blink a few times and/or move your head around, you should get it. But it’s delicate — like early recovery. Blink again…and your former interpretation might spring back to mind, making the second interpretation highly effortful once more.

Of course these two “interpretations” of the structure of the cube are incompatible. They can’t coexist.  Just like the you who eagerly anticipates getting high can’t exist at the same time as the you who is in control, centered, and connected to the future. These two you’s are incompatible! But they can switch. So watch out!

Now take a look at this diagram:

This represents, in a very simple way, that each version of the Necker cube can be represented by the same group of neurons. Here there are only six neurons involved — obviously an unrealistic number. But line (b) is showing us that a different pattern of activation on the same set of neurons projects a different interpretation of the cube.

Now imagine that you have one (much larger!) group of neurons representing the two interpretations you have of your drug of choice: let’s say cocaine-good and cocaine-bad are the two versions. A different pattern of activation on that same macroset of neurons will produce one or the other version. And the two versions can easily switch, as the activation of the neurons shifts, due to….well, due to the way you’re feeling, the way you’re thinking, how much you slept last night, whether or not your dealer just called, whether you had a coke dream recently, whether you just got a raise at work…or lost your job. I’m sure you know what I’m saying.

In some ways addiction is very complicated. But in other ways, it’s pretty simple. Mental habits can be considered, reflected on, worked with, played with….and they can ultimately be controlled — with practice — though perhaps not entirely.

If you’re a regular on this blog, you probably know that Peter Sheath and Matt Robert have enough knowledge, compassion, and common sense about addiction and recovery to lead us to a far far better world. I’ve grabbed these gems from their comments to a recent post. If you’ve already read them in context, well read them again. If not, now’s your chance.

Peter Sheath:

I feel like there is an amazing amount of synchronicity going down, especially between you [Marc], Matt and li’l ol’ me. I can almost guarantee that I will have had my interests stimulated by a client, book, lecture or simply talking to someone and, a few days later it will be there in your blog and Matt will have made one of his beautifully eloquent comments on it. This may not sound so apparent at first but please bear with me.

Over the past couple of years I’ve been doing a lot of thinking, talking and research around this whole co-occurring conditions/dual diagnoses thing. I think we, organisationally, have got astonishingly good at not dealing with it. We love to have these imaginary silos that we place people into, develop manuals and protocols to either keep them there or embargo them from going there. We’ve even developed competency/accountability frameworks, skill-sets and governance systems that ensure that, supposedly, the right person is working with the right person, at the right time, in the right place.

The trouble is that it mainly creates confusion, uncertainty, apartheid and exclusivity. Only the other day I received a phone call from a friend who is managing a substance misuse team for people with complex needs. He had been asked to develop a “criteria” for the people his team would be working with. I said that I’m very sorry but I really do not believe in having criteria for people we do or don’t work with and everybody who comes to substance misuse services for help will have complex needs. Turns out that he is of exactly the same mind but has to do it because that’s what he’s been instructed to do.

Doing things in this way means that we often screen more people out than we do in and I have real difficulties understanding why we continue to do it. Jordan Peterson’s 12 rules for life, motivational interviewing, open dialogue, ACT, CBT, person-centred counselling, narrative exposure, etc. are all transdiagnostic and probably work best under the collective umbrella of the therapeutic relationship.

I’m currently working with a paying client who has had a lifetime of psychiatric diagnoses and various dependencies. He came to me because he had approached his local alcohol service looking for a community alcohol detox. The detox would need to fit around his work, because he works for himself and is the only employee. He was drinking at least a 750-ml bottle of vodka every day and was getting increasingly desperate and depressed. The service said that, because of his underlying mental health problems, levels of alcohol use and not being able to take time off work they couldn’t help him! I know it beggars belief, doesn’t it? I negotiated a course of Librium with his GP, involved his mother and his local pharmacist in the plan (open dialogue), then did some motivational interviewing type interventions to boost his confidence and ensure that getting sober was the right thing to do. We arranged a daily telephone check-in and weekly face to face, with myself, and I taught his mum and him how to do blood pressure monitoring. He agreed to call in to the pharmacy if his BP raised or reduced by 10.

Got a phone call last night to say that his detox had finished a week ago and he is now 21 days sober. He has struggled a bit because the weather over here has been lovely and he has an association with sunny days and sitting outside the pub drinking beer. He has used some psychotropic meds sparingly, because he does get worried about his anxiety levels, panic attacks and past psychoses. I’ve also been teaching him mindfulness-based meditations, relapse prevention and managing his mental health. We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope. We’ve also focused on very small steps, although he is always wanting to make massive leaps. Fingers crossed.

Matt Robert:

Hey Peter!! It keeps coming back to this, doesn’t it? It takes a village…but a coordinated one that meets the needs of the individual as well as the tribe. Your sentence captures it all:

“We’ve developed a really good therapeutic relationship based on trust, autonomy, prosocial role modelling and hope.”

There has to be autonomy, agency… individuals need to feel in control or we don’t feel safe. I have to trust my fellow participants, the method, the goal, because I’m not going to stick with a process of arduous change if I don’t believe in it. And none of it is gonna work if I don’t feel like I’m in a sharing, connected, reciprocal relationship with the humans who are helping me. Something all effective recovery traditions have in common. All human endeavor, for that matter.

The thing about open dialogue that is so simple and compelling is that it is the same model humans have used to cooperate, help each other, and progress throughout history. It’s getting all the stakeholders, the people who care, in the same room, on the same page. It’s putting the puzzle that’s fallen apart back together.

We all know how to do this because it is a human thing, not an “addiction” thing. Addiction is a proxy for meaningful relationship.