Understanding Addiction

Here’s an article I wrote for The Guardian a few weeks ago. This link will take you right there. And while you’re there, check out some of its neighbours in The Guardian’s Autocomplete series. These articles try to provide quick, neat answers to the deep questions we often pose to Google. Or, in their words:

Every day, millions of internet users ask Google some of life’s most difficult questions, big and small. Our writers answer some of the most common queries.

I  especially like David Shariatmadari’s piece on depression. And another that might be of interest is David Nutt’s attempt to answer the question Why are drugs illegal?

This reposting is an easy way out of sitting at my desk and pounding out something original. Instead of being productive, I’m supposed to lie on my back on the sofa, which sounds very appealing, because…

I just went to Geneva to attend a conference on Behavioral Addictions. But something very painful happened to my hip soon after I arrived. No, it’s not serious…according to the X-rays and CT scan, but to find that out I spent roughly 15 hours in a hospital in Geneva, moaning, squirming, with a bit of writhing thrown in. The best part of the story has something to do with the irony of lying on a cot, pleading for more morphine, while skipping these cutting-edge talks on addiction. More on that next week.

Sofa, here I come.

The following is a guest post, composed by Julia Hammid. I’m grateful to Julia for her thoughtful and sensitive reflections…..

Judging by the volume and intensity of the discussion around Harm Reduction (HR), both here and in many other venues, it seems to be a flashpoint for identifying some of the core issues driving policy, research and personal opinion in regards to addiction (even as the term addiction is still being defined). In the spirit of promoting an illuminating and productive conversation around addiction, recovery and treatment, here are some of my thoughts on HR. Just for the record, I am in favor of HR as a concept, though I may not agree with every version of how it’s provided.

So, why the brouhaha around HR? Doesn’t it just describe a broad variety of strategies to counteract the damage of addiction, short of complete abstinence? The question is not so much whether HR should exist. It’s going to exist no matter what we say. The question is whether or not we like it and support it. For example, we dispute whether the powers that be should fund programs that provide clean syringes, safe spaces to use, and even the (uncontaminated) substances themselves.  In my mind, HR includes a lot more. In fact, I would claim that most, if not all, recovery includes some form of HR, even if complete abstinence is the goal.

While addiction includes a vast array of substances and behaviors, abstinence can only be applied to selected substances, mostly illegal ones. How are we to define abstinence from addictions that are not measurable with a blood test? And even where abstinence is the only goal, where HR is most controversial, those who are abstinent from the identified substance often end up substituting or relying on (dare I say becoming addicted to?) other substances or behaviors, which fly under the radar. For instance, there’s a joke around AA about being addicted to the donuts and coffee that are ubiquitous at meetings.

I am not saying that addiction cannot be overcome or that one thing is always replaced by another or that any of the above is bad. I am just saying that I think, with few exceptions, recovery is always a continuum and always includes some form of HR, in the fullest sense of that term. More often than not, there is a period of shifting of dependence from the target bad thing to other less harmful (or simply legal and more easily obtained) things. Even seemingly positive things can be pursued with some of the same desperation that the original addiction carried, including socially approved addictions such as, coffee, sugar, TV, running, the internet, or even “dependence” on therapeutic treatment, religion, etc. I  know some people who are so immersed in their 12-step community that their whole lives revolve around meetings, the literature and the people they know in that community. I’m not saying that’s a bad thing. I’m just saying that it should be recognized as a form of HR.

To some, HR connotes state-supported addiction. But that is nothing like the actual goals of HR proponents. The controversy is kept alive by discrepancies such as these. In contrast, I think the word “abstinence” carries its own social and psychological baggage and may misrepresent what the opponents of HR are arguing for. Abstinence is not a term I personally find appealing. For me it connotes ascetic monks trying to rise above earthly existence by denying themselves much of what makes life worth living. Abstinence puts the focus on what one is not doing, rather than looking forward to what is truly worthwhile. In some ways, full blown addicts are abstinent from life, foregoing all its richness in pursuit of their addiction. Most agree that abstinence from a particular drug or behavior is far more precious.

A story was shared in response to a post on this blog, about a relative being instructed to just apply a cool cloth  to the addict’s forehead and in a few weeks they would “be good as new.” As any recovering addict will tell you, it takes a lot more! And much of what it does take I would classify as HR. Even if you quit the identified addiction, there are still a mountain of other issues that need to be addressed, such as recovery from the trauma that may have been driving the addiction, employment, reputation, how to create/repair a life, a family, a community. From the addict’s point of view, support for those tasks is as essential as stopping using.  And much of that work can begin while engaging in “official” HR services.

Society sees addiction as a drain on its resources (unproductive individuals sucking up services) and a source of harm to others (crime, disease, embarrassment, etc.). So, from society’s perspective, fully abstaining from the addiction removes all the above negative consequences. But from the perspective of addicts (and those who are able to step into their shoes, whether family or treatment providers) it’s not at all that simple.

Abstinence and recovery are not one and the same. As opposed to simply stopping using the target substance, “complete” recovery is as varied as are humans. Life is, by its very nature, imperfect, and applying definitions of things such as addiction, abstinence, sobriety, and recovery to real people will always be approximate.

The core arguments I’m hearing are about who pays for what services and strategies, what the authorities endorse, and what is socially and ethically acceptable.  We can, and should, argue about specific programs, policies and laws, but trying to agree on one “correct” way to recover from addiction ignores the valiant struggles and triumphs of so many who have recovered, one way or the other. I was bulimic for over 15 years (many years ago), which was as intractable, self-abusive and life threatening as addiction to any drug. And I am quite certain it would have killed me had I continued. As with other less clear-cut addictions, recovery for me is a continuum, one which involved plenty of what I would certainly call Harm Reduction.

Julia Hammid

PS. I (Marc) highly recommend this Time article by Maia Szalavitz.  It is just excellent, and it provides some very dependable statistics that argue for the value of various Harm Reduction programs and policies.

Two posts ago I promised to follow up on “what is addiction?” by supplying the missing piece. Anyone who has experienced addiction or  studied it knows that compulsion is that piece — the elephant in the living room.

Here’s a quick review:

A key aspect of addiction, as we experience it, is the urge to complete the act, scratch the itch, etc. You’ve probably heard a dozen phrases that try to capture that feeling, that moment. We know we’re not going to feel any better, maybe worse, or if we are going to feel better it won’t last long. We’ve gone through all the arguments and counterarguments as to why we should not, cannot, do it one last time. We have done all we can to steer a path home that avoids the liquor store, to wait until our dealer is out, to provide a context that makes it unattractive or even impossible, like going to a meeting even. And then we lunge for it. The behavioural switch has been switched on — so it seems. And the alternatives and obstacles fade into the background. Just do it. Get it over with. There’s still 15 minutes before the liquor store closes. We can still find our dealer if we try.

This compulsive aspect of addiction arises over time. It’s not there for the first few weeks, or months, or maybe even years. And then it’s the main act. It’s the Achilles’ heal that resists every effort at mindful self-control.  So it seems. And resisting the urge just wears us down — as per my descriptions of ego fatigue, in my book and other writings. The anxiety that mushrooms as we continue to resist becomes agonizing.

We can trace this psychological and behavioural sequence in ourselves or others. Both at the minute-by-minute scale — the way it builds over the course of an afternoon — and the month-by-month scale, the way it gets stronger the longer we continue using. But what’s going on  with the brain in parallel?

The launching of an action (toward a goal) is governed by the striatum (or basal ganglia), a large structure with connections both “downward” to the amygdala and other parts important for emotion and “upward” to the prefrontal cortex, where expectations, plans and choices are activated. The striatum has a ventral (“southern”) terminal, which we often refer to as the nucleus accumbens. That’s considered the hot spot for addictive cravings. But it’s also got a dorsal (“northern”) region. While the ventral striatum evokes anticipation, longing, and zeroing in on potential rewards (e.g., drugs, booze, porn), the dorsal striatum seems to be involved in automatic behaviours — what psychologists call Pavlovian conditioning, or stimulus-response (S-R) events.

I’ve written about all this stuff previously, so I won’t get into more detail here. The main point is that only the ventral striatum (southern region: nucleus accumbens) becomes activated (bright yellow spots on the MRI) in early addiction — e.g., the first few months. But in later-stage addiction, activation increases in the dorsal striatum. For a while addiction neuroscientists thought that the addictive trigger got passed along, so to speak, from the ventral to the dorsal striatum. That could explain how addiction seems to evolve from being an active desire, motivated by an expected good feeling, to a habit, beyond conscious control and motivated by nothing at all — purely automatic. In fact, the disease model of addiction — the idea that drugs hijack the brain and destroy the will — got a lot of traction from this kind of neural model. See, folks, addiction means no more choice — it’s simply a compulsive act that can’t be stopped.

That turns out to be inaccurate. Recent studies, both with addicts and with those suffering from OCD (which has lots in common with addiction), show that the ventral hot spot, the nucleus accumbens, remains part of the flow of activity that moves us from a stimulus (a rumbling in the gut, a vodka ad, a phone call from a buddy) to a response. The response. The data suggest that the ventral and dorsal striatum both get involved in the kind of compulsive actions that characterize addiction. But they seem to take up different phases of the moment-to-moment sequence, with the dorsal striatum staying active longer, holding the action “at ready” until it’s executed, and the ventral striatum contributing to the earlier phase, the blush of wanting and seeking.

So the habitual nature of addiction is nothing like the habit of wiping your hands on a napkin or brushing your teeth. It’s not automatic in the same way. Addictive urges are far more complex. Even after years of addiction, those compulsive moments are packaged together with an emotional surge, a bouquet of emotions that are probably both positive and negative, a conscious sense of moving toward an expected reward, AND, finally, a more automatic sense of “must.”

What’s the point?

If the compulsive aspect of addiction remains part of a conscious stream of anticipation and preparation, then we have far more choice than we might have thought. Choice and will don’t just disappear with years of use.

Certainly the compulsive “just do it” urge increases over time, both over months and years and over minutes and hours. But the compulsion never replaces the impulse, the wish, the want, the conscious anticipation that we associate with the nucleus accumbens. Rather, the compulsion might be the final springboard to action, coming at the tail end of a series of thoughts and feelings that are conscious — and therefore controllable.

Hello all. I have to admit I’m becoming addicted (again!) — this time to addiction memoirs. I’ve read four in the last four months, all written by alcoholics:

Drinking: A Love Story — Caroline Knapp.

Drunk Mom — Jowita Bydlowska.

Drunkard: A Hard-Drinking Life — Neil Steinberg.

The Couch of Willingness — Michael Pond & Maureen Palmer.

I’m still finishing the last two. I pick them up in my spare time, packed up on my Kindle for train rides and class breaks, or late at night when I’ve got time to myself. I really like them. I find them delightful, suspenseful, fascinating, epochal, and redemptive — redemption seems to be a big word in this genre.

But really, why do I like them so much? First, I’ve written one of my own. I know how the story goes from inside out. Second…okay, let me reconsider the list of adjectives I just used:

Delightful. Really? These are without exception intimate portrayals of people who are living horrific lives, cutting out hunks of flesh and soul without knowing how to stop, committing reprehensible acts and then choking on shame, guilt, and remorse. Why is that delightful?

Suspenseful. I already know that they are going to keep drinking until they finally quit. And then they’re going to feel better. Where’s the suspense?

Fascinating. Ditto. The stories are remarkably similar, as though they are simply variations on a theme — sitcom formulas. I mean, right down to the details. They hide bottles all over the house. They get rid of empty bottles in the neighbours’ trash cans. They feel embarrassed going back to the same liquor store day after day. Then they go to another store. How is this fascinating?

Epochal. That’s a word used to describe Greek myths, classic tragedies, and so forth. These folks just get drunk a lot. How epochal is that?

Redemptive. Well, they do finally quit. (I’m still not sure about Neil Steinberg, having not gotten to the end. But I’d be surprised if he didn’t). But “redemption” seems like a pretty strong word for finally behaving in your own best interests rather than continuing to torment yourself and everyone around you.

So here are my best guesses at why those words came to mind:

Delightful. They are such human beings. Such an unpredictable, ever-changing mixture of strengths, weaknesses, suffering, defeat, pride, shame, and even humour. A fair bit of humour in the last three for sure. Because you have to laugh if you’re not going to cry. Or at least get some of each. These memoirs epitomize the complexities and virtues of humans facing and eventually overcoming astonishing challenges.

Suspenseful. When are you going to quit?! How are you going to do it?! You have tried so many times without success (often), I just can’t see how you’re going to pull it off, and I’m waiting for it with every page turned.

Fascinating. See “delightful”. But let me add that these are war stories, dramas, tragedies, and they describe unimaginable extremes of human desperation, depravity, creative problem-solving, and determination. So you really held an airplane bottle of vodka to one nostril, blocking the other, to inhale the fumes?  Snorting booze? You poured your wine into baby bottles as camouflage? You really grabbed that bottle off the bar counter while the bartender turned her back? Unbelievable!

Epochal. But they really are epochs. Each and every one. Just as Shakespeare’s tragedies all followed the same formula, and yet each came across as unique, profound, one of a kind. Each one (at least each good one) carries us effortlessly along classic story lines constructed from the basic components of suffering, self-deception, and the inexplicable capacity — the heroic capacity — to come back from the jaws of defeat with your dukes up. Or to reshape your personality until that becomes possible. Addiction memoirs seem an obvious extension of classical drama into our modern age.

Redemptive. Well, what is redemption, anyway? I think it must presuppose the idea of sin, moral failing, finally overcome through some sort of penance that one endures voluntarily to become clean or whole once again. In his recent book, Lance Dodes mentions this assumption as built into the AA-inspired notion that you have to hit bottom before you’re ready to quit. But very often, you do. People fight like crazy to quit. And the most agonizing part of that fight is turning your back on the one thing that provided relief, support, and comfort. As Steinberg puts it, “attending the autopsy of someone you love.” That’s pretty damn courageous.

Addiction memoirs seem to tell the same tortuous story, often starting in the same place and ending in the same place, but with the incredible diversity, the unexpected creativity and novelty, the unanticipated twists and turns, partial victories, temporary failures, redoubts and stupidly courageous counterattacks, that derive from being one of an infinite variety of suffering humans. We are so different. And though addiction pulls us through roughly the same line-up of torture instruments, like those tours you can take through torture chambers in medieval castles — adults, 18 euros; kids, 8 euros — it does so in ways that never cease to surprise me, mesmerize me, and make me proud.

Last week I was trying to think like a Buddhist, in preparation… I thought about the self-reinforcing nature of “attachment” (à la Buddhism) and the self-reinforcing nature of addiction (which we all know about from our, ahem, independent research). What Buddhists describe as the lynchpin of human suffering, the one thing that keeps us mired in our attachments, unable to free ourselves, is exactly the same thing that keeps us addicted. The culprit is craving and its relentless progression to grasping.

The cycle of human attachment is represented in Buddhism by a wheel that keeps on turning. First comes emptiness or loss, then we see something attractive outside ourselves that promises to fill that loss, then we crave — a state we all know and love. Craving seems to be a universal form of anxiety, focused on a goal rather than a threat. So we crave and crave, and here comes the clincher: the next thing we do is grasp — reach for it. That’s what keeps the whole wheel spinning, like a merry-go-round you can’t stop. Grasping of course leads to getting. Getting leads to more attachment. Attachment leads to more emptiness and loss, because the thing we’ve attached ourselves to is never enough to fill the void. And so we’re embarked on the next revolution of the wheel — searching for something outside ourselves.

The parallels with addiction are so obvious, I won’t bother to list them. I guess the only thing that’s special about addiction is that we keep grasping for the same thing again and again. There are good neural reasons for that — reasons the Buddhists may not have appreciated. Each cycle of craving, grasping, and loss leaves its trace on the synaptic architecture of our brain. The synapses that represent the addictive substance or behaviour, the getting or doing it, and the expected relief become increasingly reinforced each time they are activated. “What fires together wires together.”

As far as I know, Buddhist common sense recommends breaking the cycle between craving and grasping. Is it possible to remain in a state of craving without going after it — the thing you so badly want? Of course it’s possible, but it ain’t easy.

A paper published by Kuhn, Gevers, and Brass (2009, Journal of Neurophysiology) reports on a neat experiment. These guys measured electrical activity in the area of the dorsal anterior cingulate cortex (the dACC: the region responsible for effortful self-control), using brain wave signatures called event-related potentials. On most trials, the subjects were instructed to press one or two buttons in response to a pattern on the screen (called the “instructed Go” condition). But on some trials they were told not press the button (to withhold the action, called “instructed NoGo”). And on other trials, they were free to press or not press, according to their own whims (called “free Go” and “free NoGo”). Given this design, the researchers were able to compare the level of brain activity (in the region of the dACC) between instructed actions, free actions, instructed non-actions, and free non-actions.

The point is that instructed non-actions (“instructed NoGo’s”) are exactly what we face when we tell ourselves NOT to grasp, not to go for another drink, another bite, another pill or whatever. When you hold in mind the “instruction” not to do something, and you successfully obey your own instruction, then you’ve broken the cycle, at least for now. You’ve refrained from doing something you were just about to do: that’s craving without grasping.

The diagram showing the results of the experiment gives voltage values for different brain regions in each of the four conditions. In the second row, the “N2” tells the whole story. The N2 is considered a measure of self-control, and the N2 shows the maximum voltage (blue colour, because the voltage is negative rather than positive) in the “instructed NoGo” condition, not the “instructed Go” condition or either of the “free” conditions. So your brain, and specifically your dACC, is working hardest when it’s trying to refrain from doing something — harder than when it’s trying to do something. In Buddhist terms, it’s a lot easier to grasp than to refrain from grasping. And if you’ve been following my previous posts, you know where that self-restraint can lead: ego fatigue! Your dACC can’t take the strain and sooner or later gives up.

So here’s an instance where neuroscience and Buddhism tell us complementary aspects of the same story. Neuroscience tells us how hard it is to intentionally refrain from something you’re about to do. Buddhism tells us: Yes, it’s hard, but do it anyway! And you’ll be glad you did… That makes sense to me. If you can let yourself crave without grasping, even a few times, then you start to break down that automatic progression — that compelling momentum — that keeps the wheel going round and round. And after a while craving itself begins to diminish, because it’s got nowhere to go.

My family and I are going back to Toronto for two weeks to meet up with friends and family. So I may take a break from blogging — unless something really interesting comes along. Meanwhile, Happy Holidays to all of you! And thanks again for your warm good wishes last week — That’s the best present I could have wished for.