Understanding Addiction

So I’m having this relatively uneventful week, doing a bit of homework for my Dutch lessons, preparing for a class I’ll be teaching next term, defrosting the freezer, debating with a publisher as to why she should accept my next book, driving the kids to soccer and always arriving late, though no one seems to care, and wondering during my few un-busy moments what I’m actually doing with my life. Do I seriously think there’s more I can contribute to the addiction literature – besides blogging, which I love? Or should I hang up my spurs and take up growing tulips?

When all of a sudden I spy an email from the Mind and Life Institute, a group started by the Dalai Lama and a few other notables, whose mission is to identify links between the contemplative arts (e.g., Buddhist meditation) and neuroscience. I figured it was a generic invitation to their yearly conference. I went a few years ago, and it was actually great. Each day I woke up early, did a lot of yoga, ate a lot of vegetables, and spent many hours with my eyes closed, making infinitesimal progress toward enlightenment but getting pretty relaxed.

No, it wasn’t that. It was a letter, addressed to me. I had to read it twice to believe it. It was an invitation to spend five days with the Dalai Lama at his residence in Dharamsala, all expenses paid. I would be one of fewer than ten scientists or scholars or addiction specialists, and we would be meeting with him throughout the five days to discuss craving and addiction. The Dalai Lama remains deeply interested in societal problems, especially those that might be addressed from both Buddhist and scientific perspectives. According to the letter, he sees addiction as a major source of suffering in today’s world. I have to agree with him there.

So…yeah…I’m blinking rapidly and checking the address to make sure it’s not a hoax. They “very much hope you are able to join us for this special conference …” and would I please let them know as soon as possible. So I thought about it – for approximately 2 ½ seconds. I would give my left arm, maybe my right arm, to meet this man and talk about addiction with him and a few other folks. I’d go just for the ride. Just to be in his presence. Besides, Dharamsala isn’t Rotterdam. It’s halfway up the Himalayas. It’s a beautiful place according to the pictures.  Just to be there would be an amazing trip, but to talk with this precious man about, let’s face it, my favourite subject. Yes, I accept!!!

I don’t know why I’m telling you all this. I guess just to share the most exciting moment in my life for the last couple of years. But this opportunity also brings to mind something I’ve thought about for awhile. When I argue my usual position, that addiction is not a disease, I often get a lot of flack. In particular, the disease advocates often argue that addiction must be a disease because it changes the brain, often irrevocably. And I argue back that I think addiction is an extreme form of normality, because normal learning also changes the brain, often irrevocably, especially when the learning concerns goals or intentions that are highly emotionally charged, such as falling in love, having a child, religious conversion, and, well, developing a serious fondness for coke, smack or booze. I haven’t yet been able to make my argument as articulate and convincing as I’d like to. In a recent post on a science blog, I tried to put it as succinctly as possible. And dozens of comments came back – most of which were not in agreement. So I’d counter that, if drug addiction was a disease, then so would gambling and other serious behavioural addictions be diseases, not to mention a passionate affair with the man or woman next door, and so on and so forth.

But how’s this for cutting to the chase: Just about everyone describes addiction as a continuous state of craving that can only be relieved by acquiring/doing the thing you crave. Whatever is going on in the brain, the psychology of it is pretty straightforward. So if I were a Buddhist, I’d probably say: hey, that’s human existence for you. Human existence is characterized by longing, by craving…and then being propelled by the craving into grasping – which means going after the thing you crave and getting it. Which always lets you down, since material things never satisfy the emptiness that’s at the core of craving. Which is why Buddhists recommend that you do some serious meditating and thereby give up your attachments. When that starts to happen, then you can watch yourself being in a state of craving without going to the next step, grasping. You can just watch it, see it for what it is, and let it go.

(Which may be why a lot of people find meditation extremely helpful for recovery.)

I wonder if the Dalai Lama will see addiction in a similar way. I suspect that he, of all people, will see it as an extreme form of attachment, which of course generates craving, which is why addicts suffer so much – until we’re able to watch the cravings come and go. I doubt I’d have to convince him than addiction is not a disease; it’s a highly focused state of longing – for something that glitters but isn’t even close to gold.

(Another reminder: Check out the Guest Memoir page, linked above. We’ve gotten a couple of new ones, and they’re really gripping. Please comment if you’ve got anything at all to add, or send us your own memoir.)

Isabel and I want to share this with you. We hear a lot of former and recovering addicts describe the grim and lonely hours waiting for them on the far side of their addiction. The loneliness and bleakness are real, but that’s not the end. It’s a stage in a transformation that can be breathtaking.

WILD GEESE

-by Mary Oliver

https://www.youtube.com/watch?v=lv_4xmh_WtE

Sorry I haven’t written much lately. My family and I just moved from the Netherlands back to Toronto for six months. Busy summer! But here’s a guest post that may be especially valuable for those of us who keep on keeping on.

…by Danielle Kunkle…

As a Medicare insurance broker, I’ve seen everything under the sun when it comes to healthcare. We’ve had clients who are who are 95 go to the gym every day and take not a single medication. We’ve also had people who are 45, on Medicare early due to disability, taking over 20 medications.

There are both acute and chronic health conditions, and of course, there are mental health conditions and substance use disorders.

Far more than you might think.

In fact, Medicare foots the bill for millions of dollars of substance use treatment every year. It also pays for treatment of depression in the elderly, which is very common. There are many aspects of depression in the elderly such as loneliness and isolation which can lead to addiction.

As we age, we have fewer opportunities. Our bodies and sometimes our brains aren’t as functional as they used to be. We might lose our sense of purpose once we retire. We start to lose people we’ve known and/or loved for a long time. Kids grow up and move away, creating a sense of emptiness. We also must shift from actively earning a living to stretching Social Security and savings to last the rest of our lives.

My grandmother used to say: “Growing old is for the birds, Dani.” She may have been right.

While grief or money woes can cause depression at any stage of life, there are specific factors that make older people who experience depression more vulnerable to addiction, which in turn may be harder to treat.

One factor is that it is particularly easy for elderly people to gain access to prescription medications that later become a problem. Medicare beneficiaries might begin using pain medication innocently enough, but they can easily become hooked on drugs like opioids for chronic pain or benzodiazepines to treat insomnia or anxiety.

Doctors are often willing to prescribe these potentially addictive drugs for sleep problems or for vague aches and pains. They also may not spot a developing addiction because it’s too easy to misdiagnose declining mental ability or a dishevelled appearance as being due to depression or dementia rather than substance use.

Because Medicare is not part of a health insurance network managed by an insurance carrier, it’s easier for elderly individuals to “doctor-shop” for more medication than they need. Physicians can’t easily see who else is prescribing the same or similar medications.

Drug addiction is especially dangerous because our metabolism slows as we age. Substances take longer to filter through the liver and may build up in the body. This puts older adults at greater risk of dangerous side effects or accidental overdoses.

Another factor is the limited social circles of many elderly individuals. Many older adults live in isolation after the death of their spouse, which makes addiction easier to fall into. What used to be a glass of wine after dinner can turn into an evening of drinking away one’s sorrows.

Not all of these individuals will have children or younger family members living nearby who see them often enough to spot the problem. Even if they do, they may dismiss the signs because they don’t really think of addiction as being a problem for elderly people.

Addicted people may also contribute to this oversight. They may be secretive in their drug or alcohol use. They may feel embarrassed or ashamed of their addiction and go to lengths to hide it. Because no one is aware of the problem, an elderly person may have a harder time climbing out of an addiction.

While all of these things point to a greater need to identify substance use disorders in the elderly, there seems to be less urgency to treat them, as if this would be a waste of resources. Indeed, not everyone considers an addiction to be entirely negative. Someone who is living out their last years may prefer to be addicted if this means they are free from physical pain.

Yet older adults deserve the option to seek treatment if they want help with a substance use disorder. Just like younger people, they can and do overcome addictions with proper counselling and support.

Treatment, as many readers here know, can be expensive and ineffective. However, Medicare does provide considerable benefits for available treatment modalities:

Medicare includes an annual screening for depression and substance misuse or addiction. Speak to the Medicare doctor and request a screening.

If risky behaviours are identified, you can ask a physician to make a referral to services. Medicare will cover therapy in an individual or group session as well as treatment in an outpatient clinic.

Some cases may require care in an inpatient psychiatric unit or residential treatment center, both of which would be covered by Medicare for up to 190 days in a person’s lifetime.

Part A hospital benefits may also cover methadone or Suboxone that you receive during an inpatient stay whereas these medications are unfortunately not covered when prescribed for addiction on an outpatient basis.

If the prescribed treatment plan calls for other types of outpatient medications, you’ll want to be enrolled in a Medicare Part D drug plan. All Medicare drug plans include some medications designed to treat addiction, withdrawal symptoms, and depression.

To take advantage of Medicare’s benefits for these services, you must receive treatment from healthcare providers who are in Medicare’s network. There are over 800,000 providers nationwide and programs covered by Medicare can be found online.

Be aware that Medicare requires the Medicare beneficiary to share in some of the costs of treatment. They are responsible for deductibles, coinsurance, and copays.  However, individuals with Medicare supplement coverage may find that their plan covers some or all of their cost-sharing responsibility.

Often, elderly clients are unaware of their Medicare benefits for mental health and substance use problems. Spreading the word might help someone near you find the support they need.

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Danielle Kunkle is the co-founder of Boomer Benefits and is a licensed Medicare insurance agent in 47 states. She and her team of Medicare experts can be found at https://boomerbenefits.com.

Addiction.com invited Nora Volkow to pit her “disease” argument against my (and others’) “learning”  model of addiction. She declined, or at least didn’t agree, but I’m happy to announce that we have finally sort of crossed swords in the Huffington Post Blog network.

Here’s her initial post and here’s my response. And I’m really pleased that my response appears on the front page…that column of posts on the left side of the page…next to all that nasty news of the world.

I’d love it if we had a chance to engage in this dialogue directly. But…I don’t fault her. She’s an amazingly prolific neuroscientist, as well as an NIH administrator, and she probably gets publicity requests of one kind or another  20 times per day.

I’m just glad that we anti-disease campaigners got our foot in that particular door…and I do mean we.

We usually talk about addictions to substances (opiates, alcohol, whatever) or behaviours (gambling, porn, etc). But that misses the point. Addiction is entirely psychological, and I think it describes an attachment to a symbol that goes with the feeling provided by the substance or behaviour. The feeling and the symbol are coupled, bonded, and that’s a big part of what makes addiction so hard to beat.

Forget about “physical” addiction for now. I mean the withdrawal symptoms you get when you quit opiates. That’s not addiction; it’s chemical dependency. You also get withdrawal symptoms going off antidepressants or blood-pressure meds. And you don’t get any withdrawal symptoms quitting coke, meth, alcohol (unless you drink a huge amount) or, obviously, porn, sex, overeating, etc. You get psychological rebound, sure, but that’s not the same thing. It surprises me that people continue to confuse these different (but often overlapping) phenomena.

Once we see that addiction is purely psychological, we can break it down, and the categories most valued by psychologists are “cognition” (perceptions, thoughts, images) and “emotion” (feelings, urges, etc).

For some time now I’ve been thinking that the cognitive aspect of addiction is symbolic — entirely — it’s a representation of something. And the reason that symbol is so attractive, so strongly entrenched, is that it’s coupled with emotions like desire, excitement, pleasure, and relief (relief isn’t really an emotion; rather it’s the reduction of an emotion — generally anxiety). It is ALWAYS the case that cognitions and emotions hold each other in place. You think someone is blocking your goals, you feel anger: the anger highlights the image of this goal-blocking person, this shithead, and that image holds the anger in place. I’ve been writing about cognition-emotion coupling for decades….literally dozens of journal articles. But for now, let’s leave the academic abstractions behind and get down to lived experience.

With addiction, you think this thing, this substance (let’s say a few lines of coke) is valuable and special. And you feel the excitement of anticipation — soon I’m gonna have some. Then you feel the buzz, and doesn’t that feel great? Which strengthens the image, the conception, that coke is valuable and special. See how the thought/image and the feeling (both before and during) fuel each other? Which is why it’s so hard to say No thanks, not tonight.

So what does the addictive substance or act symbolize? To me, that’s the big question. The longer I practice psychotherapy with people in addiction, the more convinced I am that each person constructs his or her own scenario, vignette, drama, diorama — I don’t know what to call it — based on what went wrong or what went missing in childhood or adolescence. I introduced this idea last post, in terms of diving into the child self-narrative. Here I want to get into the details: what’s the narrative about?

Example: Helen says she can’t stop snorting coke. What does the coke mean to her? Through talking and remembering in therapy, we discovered that it means something similar to what cutting meant when she was about 12 years old. Her parents weren’t interested in her as a person. They wanted her to perform, be this charming, cute girl, be quiet and unobtrusive because Mom is trying to sleep — because she’s depressed, as usual. So they dismissed and scorned her spirited, creative, and needy self. Helen submitted to the good-girl role…and she was achingly lonely. But when she went into her closet and cut little red lines in her forearm, she felt free, she felt vital, she was unobserved, she didn’t need or seek permission, she felt defiant, and most of all she felt in control of her own feelings. That’s what the cutting meant to her then. And that’s almost exactly what coke means to her now, decades later. She scampers into the bathroom, leaving the other ladies chatting over wine or coffee, and does a couple of lines. Again, she’s on her own, released, free, defiant, and in control of what she’s feeling. Now take that symbolic scenario she’s created, and graft it onto the feeling of the anticipation and then the feeling of the rush itself. That cognition-emotion linkage has been reinforced thousands of times. It’s not going to go away easily.

Behavioural addictions like gambling and porn are no different. I’m the cocky guy who just might win big tonight, and won’t everyone be impressed. They’ll look at me with boundless envy and admiration (like they should have back in high school) as I strut down the corrdior with my armful of chips. Now couple that image with the sheer excitement of not knowing how the next hand will turn out. (That’s a big deal for gamblers.) The image and the feeling fuse — possibly forever.

By the way: the feelings of excitement, defiance, energy, etc, that I’ve described so far have everything to do with dopamine. Maia Szalavitz calls it the thrill of the hunt. And what’s going on at the brain level is this: your nucleus accumbens and amygdala are stoked up on dopamine, so their connections with “association cortex,” where memories converge into vignettes and fantasies, form deep ruts…and those connections get strengthened every single time they get reactivated.

A couple of my clients have combined drugs, sex or sexting, and/or porn into this incredibly artful (what else to call it?) ritual — a scenario in which they are desirable, desired, potent, free, and safe. The experience they’re addicted to is basically a fantasy of being both very good and very bad, nasty and safe at the same time — the dream fantasy of a child or young teenager. But here’s the thing: the components — the coke and the porn for example — are only valuable in how they contribute to this symbolic amalgam. What each offers, without that symbolic currency, is almost nothing at all.

I’ll end with one last example: my own. I recently developed a painful condition called sciatica, and I’ll probably need lumbar spine surgery in a couple of months to carve away the bone that’s squeezing my sciatic nerve. Don’t worry about me: this surgery is extremely low-risk and has very high success rates. I look forward to getting it done. But meanwhile the pain is…well…painful.

So I’ve got a prescription for some pretty powerful opioids. And as soon as I pop one or two, the whole symbolic vignette from my days of addiction returns. I get to make myself warm and safe, I get to be taken care of, like when I was sick as a child — come here, Mommy, I need you — and I get to control all that with these little objects — the pills — which are mine! (particularly handy if Mom isn’t feeling very connected). That symbolism is so much more powerful than the feeling the drug provides. Yet the drug does provide a feeling…a warmth in my stomach, a vague but familiar sense of pleasure. What I’m saying is that this feeling is pretty nice (though I know it will collapse into boredom soon enough), but its power lies in how it holds the symbolic scenario in place.

I’m not worried about becoming addicted again. I’ve had three surgeries in the last decade (I’m actually incredibly old and held together by screws and picture wire). I went on and then off painkillers each time. I recognize the childhood fantasy, tailored, perfected, by years of efficient drug use. I recognize the feeling. Nice, but, as feelings go, if there were nothing else to it, I might prefer a back rub or foot massage. And I’m pretty much past being a slave to my attractions. I’ve had nearly forty years free of addiction.

But man, do I ever get what it’s like, for my addicted clients, and for almost anyone fighting that so-powerful amalgam of thought and feeling: the fabricated scene, the sense of completeness, the revised reality, and the control you take (or at least hope for) — an entrenched (but fantasized) improvement over what it was really like to be young and scared, alone and helpless.

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Please think of attending this one-day conference on novel and progressive ways to conceptualize addiction, highlighting harm reduction (and, in general, compassionate) approaches. It’s called Shifting the Addiction Paradigm. It will be presented by The Center for Optimal Living and partners, at the New School, New York City, June 7th. I’ll be a keynote speaker.

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ALSO PLEASE NOTE: The bug that was trashing some of your comments is now fixed. Please comment!