Understanding Addiction

The heroin “epidemic” is a major concern all over the world right now. What are the various philosophies for dealing with it? In today’s post I’ll share some impressions from my recent visit to a harm reduction/methadone clinic in Belgium. Then I’ll post a piece by Percy Menzes who is dedicated to the use of naltrexone and policies that minimize access. Then we’ll see what Sally Satel has to say about programs that use punishments and rewards to get people to quit — so called incentives. That should keep us busy.

Last Thursday I took a train to a town in Belgium called Diest. It was two or three days after the attack on Brussels…so there were quite a few military guys standing around in the train stations with machine guns in their hands, ready for action. Not exactly reassuring.

But with all the chaos and pain that seem to infest the world right now, I felt a warm, cocoon-like embrace when I entered the Wit Huis  (The White House), a harm reduction clinic that provides prescriptions for methadone, counselling, and a place to hang out for a little while.

The waiting room was a pleasant lounge where people (mostly addicts) could relax with tea and cookies (and baked goods such as Easter cakes) and chat with their fellow travellers. It was clean, bright, and there was an air of positive energy: care, concern, and understanding. There were leaflets everywhere, outlining the dangers associated with different drugs. And there was always a staff person present, just being friendly, chatting, offering snacks. The staff consists of two social workers, two MA level psychologists, a criminologist (to help with charges, probation, as so forth), and the doctor, Carl, who wrote the methadone prescriptions. Carl was my host.

After being shown around — rooms for counselling, a play area for people with kids, a laundry room, showers, a medical area where wounds and infections were treated and clean needles and accessories were handed out (in exchange for used needles) — I mostly sat in a chair next to Carl in an office/interview room, while one client after another came for their methadone script. It was sort of fascinating.

Most were heroin addicts of course, but many also used meth and/or coke. Many of the heroin users balanced their methadone dose with heroin obtained on the street. And this was no secret. There wasn’t much lying or sneaking going on, according to Carl and the others. It was a tacit assumption that opioid addicts would fluctuate in when, whether, and how much heroin they used to spice up their diet. And there was no confrontation. There was no scolding, no pep talks, no condescension, no sense of a parent figure keeping tabs on the naughty children. Yet Carl was careful to balance the dosage of methadone against simultaneous heroin use: less methadone with more heroin, naturally, to minimize the odds of overdose. And overdose was rare with this population. So how did they manage that?

The clients seemed content to report honestly on what drugs they were taking, mostly because there was no censure or disapproval, either explicit or implicit, in the attitudes and behaviour of the staff — including Carl. But just to make sure, unanticipated urine tests were requested when people said they’d stopped using heroin and wanted to increase their dose of methadone to compensate. Again, it was the warmth and camaraderie that flowed between staff and clients that neutralized the temptation to lie. The smiles and hand-shakes, the invitations to chat about how things were going, the absence of demands. These people were leading lives that to some extent they were choosing and to some extent they were stuck in…and nobody was judging them. The purpose of the clinic was to keep users safe, healthy, and out of jail.

Nevertheless, despite all this sweetness and light, these folks were seriously addicted, both physically and psychologically, to a very powerful drug. They weren’t anywhere close to safe and stable in the big picture. About half were homeless, which generally meant they slept in different homes night by night, or in abandoned houses, or with relatives. They were not the happiest of campers.

And where I saw this most clearly wasn’t in the statistics — re homelessness, unemployment, co-occurring psychiatric disorders — but in the posture and facial expressions of the people sitting in the chair across from the doc. They often looked defeated and helpless. While some expressed enthusiasm, plans for the future, many looked dreamy or blank. Quite a few had the hunched over posture that expresses shame or remorse. Their eye contact might be sparse and fleeting, looking down a lot — the gaze pattern of people who live with a chronic level of shame or sense of inferiority. A sense of personal failure they’ve grown deeply accustomed to.

That part was sad. That aspect made me think that harm reduction and methadone provide a solution to the heroin epidemic, but it’s not a great solution. Something is still seriously wrong here, and this form of treatment, connection, and care can make it livable. But only just.

Clinics of this sort have sprung up in towns and cities throughout Belgium and other European countries. As always, I’d love to hear your opinions.

A while back I promised to survey the three most common models of addiction – disease, choice, and self-medication – and say something about the advantages and weaknesses of each. I got hung up on the choice model for a few posts: there’s so much there to think about. But now let’s look at self-medication as the essence of addiction.

The self-medication model seems to be the kindest of the three. It has the advantage of the disease model, in absolving the addict of excessive blame, but it has the additional advantage of avoiding the stigma of “disease” and all that goes with it. In fact, it gives control (agency) back to the addict, who is, after all, acting as his or her own physician. Whereas the disease model places agency in the hands of others and casts the addict as a passive victim. Furthermore, the self-medication model just might be the most accurate of the three.

The idea is simple: trauma is the root cause. Trauma includes abuse, neglect, medical emergencies, and other familiar categories, but it also includes emotional abuse, and above all loss. Loss of a parent during childhood or adolescence can take many forms, including divorce, being sent away from home (in my case) or the shutting down of one or both parents due to depression or other psychiatric problems. Trauma is often followed by post-traumatic stress disorder (PTSD), which includes partial memory loss, intrusive thoughts, anxiety and panic attacks, avoidance of particular places, people, or contexts, emotional numbing or a sense of deadness, and overwhelming feelings of guilt or shame. But if that’s not bad enough, PTSD is about 80% comorbid with other psychiatric conditions – depression and anxiety disorders being chief among them.

A famous study using a huge sample (17,000) looked at Adverse Childhood Experiences (ACEs) in relation to subsequent physical and mental problems. The results of the study are nicely summarized in the Sept. 25/2011 issue of The Fix. Take-home message: the relationship between trauma and addiction is unquestionable. An ACE score was calculated for each participant, based on the number of types of adverse experience they endured during childhood or adolescence. The higher the ACE score, the more likely people were to end up an alcoholic, drug-user, food-addict, or smoker (among other things). Here are two graphic examples:

These figures, which are likely to be low estimates, show a 500% increase in the incidence of adult alcoholism, and a 4,600% increase in the incidence of IV drug use, predicted by early adverse experiences. Wow!!

So how does self-medication work? There must be something about PTSD, depression, and anxiety that gets soothed by drugs, booze, binge-eating, and other addictive hobbies. Again, it’s not complicated. PTSD, depression, and anxiety disorders all hinge on an overactive amygdala – one that is not controlled or “re-oriented” by more sophisticated (and realistic) appraisals coming from the prefrontal cortex and ACC. That traumatized amygdala keeps signalling the likelihood of harm, threat, rejection, or disapproval, even when there is nothing in the environment of immediate concern. In fact, this gyrating amygdala lassos the prefrontal cortex, foisting its interpretation on the orbitofrontal cortex (and ventral ACC) rather than the other way around. The whole brain is dominated by limbic imperialism — making it a less-than-optimal neighbourhood in which to reside.

At the very least, drugs, booze, gambling and so forth take you out of yourself. They focus your attention elsewhere. They may rev up your excitement and anticipation of reward (in the case of speed, coke, or gambling) or they may quell anxiety directly by lowering amygdala activation (in the case of downers, opiates, booze, and maybe food). The mechanisms by which this happens are various and complex. But we all know what it feels like. If we find something that relieves the gnawing sense of wrongness, we take it, we do it, and then we do it again.

So, according to the self-medication model, addictive behaviours “medicate” depression, anxiety, and related feelings. But is that the whole story? I don’t think so, and I’ll get into why in my next post.

PS: I have just installed new anti-spam software. If you write a reply that does not appear immediately on the blog site, please let me know!

So I got the manuscript back from my main editor (who works for the publisher), and to my horror the right margin was swarming with little purple boxes containing suggested revisions. This was only for Chapter 9, mind you. Everything else was pristine by now. Still, I really thought there would be little left to do…and I was just starting to sink into a warm pool of mindless oblivion. (yes, I know how that sounds)

Besides little phrasing issues, there was one serious omission, in her eyes: I had not identified the implications of “my model” for treatment. Duh. She had a point. Shouldn’t that have been the grand finale?

So I dragged my ass back to my computer and immediately sent cries of distress to Matt and Cathy, my two informal (but brilliant) editors, and then thought about it for awhile, and this is what I came up with. No, this is what we came up with —

(I’ll quote the relevant sections in two installments. Here’s the first:)

Part 1. What’s wrong with conventional treatment — i.e., treatment that fits the accepted definition of addiction as a disease?

The medicalization of addiction has provided certain benefits. Foremost among them has been the development of pharmaceutical agents that can diminish withdrawal symptoms and ease cravings. Even if these are temporary measures, they can make a real difference during the darkest of times. The disease model has also led Medicine and society to a more enlightened view of addiction, as a very human phenomenon with clear biological underpinnings, while encouraging humane treatment for those who suffer. But treatment approaches based on the disease model are too often ineffective. Addicts continue to suffer. Medicines that help people cope with symptoms do not ignite the desire to change or light up new pathways for life beyond addiction. And worse, rigid, cookie-cutter methods and institutional and monetary self-interests too often turn “treatment” into a dead end or a revolving door for people who seek help. The premise of this book is that medicalization and the disease model have outlived their usefulness.

To bring the drawbacks of medicalization to a point, consider my claim that addiction can only be beaten by the alignment of desire with personally derived future goals. Does medically-based treatment help with that agenda? On the contrary, such treatment is almost always institutional treatment, and institutions are famous for eroding the self-direction that addicts may have mustered to get them to the door. Typically, those seeking treatment are told to call back, unless they are ordered into treatment by the legal system, which obviously trounces self-direction from the outset. Then they are given a date to come in for an assessment. And any delay can be easily justified: “We want to make sure you’re really ready.” Finally they’re scheduled to begin treatment, weeks later. That is, if they’re lucky enough to bypass the notoriously-long waiting lists for state-sponsored care or afford the swank offerings of a private setting. They are assigned a bed. Ironically, their beds are the hallmark of their claim for help, but beds are where people sleep and where sick people lie when they can’t walk around; they are hardly platforms for initiative and empowerment. Then, if the waiting time for service delivery hasn’t completely undermined their incentive to change, the philosophy of medical care may do so. Addicts become patients, and patients do not participate in decisions about their care. Patients follow the regimens of authority figures who understand the workings of their disease far better than they do. So personal intention has no place in the cure.

If you think this depiction is too extreme, you need only listen to addicts who have been through institutional care (or read Inside Rehab by Anne Fletcher). They often feel overwhelmed by the weight of depersonalization, passivity, and submission to authority, the disinterest of staff in their personal views, and their exclusion from evaluations of how they’re doing, what they’re doing, and when they’ve had enough. At the outset they are told, “We’ll have to break you down so we can build you back up again”—a phrase commonly heard in institutional settings, according to Matt Robert, a friend, former addict, and group facilitator in both institutional and community-based programs. It’s not that such policies are borne of ill intent. It’s just that they’re wrong-headed. Disease model advocates like David Sack despair that “a large portion of addicts continue to use in the years following treatment regardless of the particular drug involved.” They view this as evidence that the disease of addiction is terribly serious and needs all the ammunition society can muster—which often translates to more money and more institutional beds. Yet the obvious conclusion is that mainstream treatment for addiction just doesn’t work. And since it is founded on the disease model, that model is likely to be flawed.

Note that many of these conclusions derive from the sincere and sometimes devastating stories shared by you, dear readers.

Part 2 — what’s the alternative? — coming up next post.

Hi you guys!!!!! Okay, I give up. I was seriously considering ending the blog, at least for a while. It’s time consuming! Especially trying to reply to your thoughtful and heart-felt comments. (I know I don’t have to, but I usually just feel like it.) I have two courses to teach in the next four months, and then there’s that book that’s supposed to be completed by June. Although my publishers may be somewhat flexible, I do want to finish by June. It’s a hot topic now. It may not be so hot in a couple of years.

The fact is, I miss you. I miss my blog, which means I miss communicating with you, my readers. It feels like a chunk removed from my life. And although there are a lot of other things I can attend to, I have learned a tremendous amount from this blog. About addiction and treatment and recovery and suffering and courage and being human and hurting deep down and soothing that hurt…and finding other ways to soothe it, other ways to feel. I don’t want to lose that incomparable source of knowledge, wisdom, compassion…whatever it is. I continue to study, write, and give talks about addiction and recovery. I’d better keep learning what I can about how it works. But beyond that, I just want to stay in touch. Whether you’re a frequent commenter or a hovering spook, I’ve become attached. You’re a second family to me.

So…New Year’s Resolution: I’ll try to keep my posts shorter — each one doesn’t have to be an award-winning essay — and just send you tidbits of stuff that seem new and important to me and that you might appreciate learning about too. Since I seem to be a blogging addict, I can at least try some form of harm reduction.

So here’s the connection. Last week I went to Toronto to give a keynote talk at the annual conference of the Ontario Harm Reduction Distribution Program.   What an eye-opener! I thought I knew something about harm reduction. That’s when nice people try to keep addicts alive and relatively healthy until they can quit, right? Not exactly. Here’s a cool radio piece about a harm reduction initiative in Amsterdam: supplying beer to serious alcoholics as partial payment for cleaning up the park they trashed the night before.  Maybe this tells an important part of the story.

Well yes, harm reduction includes all that. But it’s also an entirely different approach to addiction, maybe you’d even call it a distinct philosophy. It doesn’t seem to have much to do with abstinence, for a start. Well, here’s how it came across to me. There were a couple of hundred people at this conference, and they make their living caring about people who most of society would prefer to write off. They seem to have unusually big hearts, and weird ideas to go with them. For example, teaching methamphetamine addicts to inject safely. How can you inject meth safely? The few times I shot meth, back in my chaotic twenties, I had no doubt that I was playing with death. One woman, a harm-reducer from London, Ontario, said, during her presentation: “We’ve distributed two million, one hundred and something thousand syringes this year. And we’re very proud of that.” Proud? I was shell-shocked. Proud? And when I passed the registration desk on day one, I was asked to try on the tourniquet. Arm-band, you mean, right? Isn’t it a nice navy blue color? And see how snugly it fits….velcro, you know.

I happened to be with my 25-year-old daughter that day. Still, as instructed, I pulled the thing around my upper arm, and sure enough those nearly-forgotten habits popped up to the surface of my consciousness, just as my veins popped up to the surface of my forearm. Besides being incredibly embarrassed in front of my daughter, who knows something of my history, I was simply grossed out. I haven’t shot drugs for over thirty years. Like is this some clever version of a registration tag, a door prize, or what? I couldn’t do it. Not that they were offering anything to go with it. But…it’s been too long. It was just yucck.

In keeping with my Resolution, I’ll end here. More on the conference, and some very interesting individuals I met there, next post.

Meanwhile, welcome back. And thanks for sticking around.

Hi all. I’ve been low on energy for a couple of weeks, which is why I haven’t posted anything. Actually, depressed is the word. I have this whole world of opportunity waiting for me — a visit with the Dalai Lama! And yet I’m completely nonfunctional. I’ve been trying to start Book 2 for over a month, and it just seems like too much effort. At the same time, Isabel is highly stressed at work, and she brings it home with her (of course), so we argue more, which depletes my energy further.

The working title for my new book is: The Biology of Desire: Why Addiction is Not a Disease. You probably know my stance on that one. But the problem is: how to frame it in the current debate? The way I see it, most of the medical community, most if not all of the psychiatric community, most of the treatment community, and most of the scientists who study addiction (either behaviorally or neurally) do in fact see addiction as a disease. Nora Volkow, the head of NIDA (one of the nine branches of NIH) describes addiction as a disease every chance she gets. A chronic brain disease. So it’s important to refute that definition — if in fact it’s wrong. But the trouble is, you then get bogged down in this dichotomy: that if addiction is not a disease, it must be a choice.

The current spokesperson for that position is Carl Hart. Here’s the latest: a write-up and video, care of the New York Times.

Hart brings crack addicts into the clinic, they stay there for awhile, and they are offered crack to smoke on a regular basis. But they are also offered a certain amount of money each time they forego the crack. And often they make that choice: they take the money instead. Sometimes for as little as $5, and almost always when offered $20. In other words, addicts can choose not to partake of a highly addictive substance if they have alternative choices that are attractive. Hart deserves the credit he’s been getting for this research. He is showing that addiction is not a result of some property of a drug; it is the result of some property of the environment, namely the absence of opportunities to get rewards elsewhere. Hart compares his crack addicts to the poor, young, black, marginalized men he grew up with. He argues, very convincingly, that there were no other rewards (e.g., financial stability, steady interpersonal relationships, respectable jobs) available to them. So they chose to get high. According to Hart, it was a rational choice, given the available options.

And by the way, Hart talks about the impact of environmental impoverishment on rats too. He reviews the famous “Rat Park” studies by Bruce Alexander, which I have written about elsewhere. Here is Alexander’s own commentary on what he found out about addiction and environment.

But I don’t agree that addiction is a rational choice. Just yesterday I got an email from a meth addict who’s in big trouble. Someone I don’t know. I had answered a desperate query from this person a couple of months ago, then again a couple of days ago, saying there wasn’t much I could do to help. Then I got this email yesterday:

I am unsure of what to do or where to turn next. I tried rehab once for a few days before my body became toxic and I ended up in the hospital for a week. It was only after I tried quitting that i fell ill close to death with a high fever,failing kidneys and toxemia. Now three years later I am that much more addicted and afraid that this is what will kill me ,and it wont be long. I dont know what I am more afraid of, being sick physically and dying or  staying high, falling apart mentally ,and for things to never change. Maybe this is how it was meant to be? In which case life isnt worth living and my children might be better off without me. I wish there was an antidote.

That doesn’t sound like rational choice. And I get emails like that, more or less, once every week or two.

I want to get into this debate, but where? The problem with the “choice” approach is that it completely ignores the brain. It relies on economic reasoning, not biological reasoning. But we are our biology, Our brains are not computers. They are inscribed with biases, attractions, associations, and habitual pathways of thought. Their fundamental modality is emotion — attraction and repulsion — not logic. And they really do change with addiction (as with other forms of learning). The evidence is indisputable. So, do we have to ignore the brain to oppose the disease model?

I don’t think so. I want to talk about “choice” as a highly irrational mechanism. And there’s lots of research to back that up. See Kahneman’s recent book, for example. In fact, research shows that people think that they’ve made a deliberate choice after their brains have already decided what to do. Much of this literature is quite technical, but here’s an example. I want to model addiction as a biased choice, a choice that is not inevitable but is highly probable, given the attractions that are already engraved in our synapses.

I’ve got the book mapped out, of course. I just need the momentum to get over the hump of page one. But writing this post helps. Maybe today’s the day.