Understanding Addiction

I have not posted anything on this blog for over three months. I sometimes feel I’ve said all I have to say about addiction, and now is one of those times. But new ideas come in clusters. It’s hard to know whether and when a new cluster is about to pop up. Maybe it’s now. Anyway, if any of you were concerned, my family and I are fine. Radio silence doesn’t mean I’ve disappeared.

For now I’ve got a couple of guest posts ready to go, and I think they’ll be of interest to you. The first is from our old friend Shaun Shelly, whose March 6th post stirred a fair amount of controversy. Here’s Part 2. Get ready for more controversy — and directions for how to clear the air.

…By Shaun Shelly…

Previously I argued that “drugs” are essentially a construct that defies any straightforward, objective designation or referent.  Some felt that my point was mere semantics and that the drugs I referred to were indeed harmful. To minimize confusion, let me clarify that I was pointing to drugs that are often (not always) illicit or unregulated and thought to be addictive. I quoted Derrida who said “the concept of drugs is not a scientific concept, but is rather instituted on the basis of moral or political evaluations: it carries in itself both norm and prohibition…it is a decree, a buzzword.” Here I’ll use the term drugs in italics to refer to this hard-to-define category.

So, onward: If there is no empirical definition of drugs, what are we hoping to achieve when treating “drug addiction”? In this post, I argue that a value-neutral and rational understanding of drugs would save lives and change our response to the use of drugs for the better.

The opioid crisis in the USA gives an excellent example of how the impact of a moral and disease-laden framing of opioids plays out. The combination of an economic crisis, the loss of jobs, increasing inequity, the housing crisis, the increased cost of education and little chance for resolution made people vulnerable to anything that gave them some relief from the pain of their existence, lack of hope and sense of impending failure.

Widespread emotional and physical pain combined with direct end-user advertising of opioids and increased prescribing made the rise in opioid use predictable.  Opioids filled the gap, as did Trump. Another critical contributing factor was the message that opioids are highly addictive. People believed that using an opioid would make you addicted and, once addicted, your life would spiral out of control. The narrative became a self-fulfilling prophecy. People prescribed opioids started overdosing, by exceeding the correct dose or mixing their opioids with other medications and/or alcohol.  Then heroin began to be contaminated with fentanyl. Fentanyl is many times stronger than heroin and was often undetected. People who used heroin began to die from drug poisoning due to fentanyl contamination.

The response, informed by the prohibitionist narrative, was predictable: the aim was to eradicate the drug, cure the disease, get people ‘clean’. The CDC placed restrictions on prescribing opioids. Doctors cut people off from their essential pain medications, and the DEA increased inspections of doctors prescribing opioids. Information about the addictiveness of opioids and the consequences of the disease of addiction dominated the headlines. Predictably, people began to access pharmaceutical drugs from the street. When those ran out, they did the previously unthinkable and started to use heroin. When cut off from opioids, some pain patients could not live with unbearable pain and committed suicide.

If the response had been value-neutral, we would have had a very different outcome. Many deaths would have been prevented. The rational response, in a world without the rhetoric of drugs would have been:

With the increase in prescribing and dependence, the CDC would:

• Not reduce the supply of regulated opioids.
• Ensure additional training of physicians.
• Ban all direct-to-consumer advertising.
• Ensure the marketing of drugs to doctors was not incentivised but based on data.
• Ensure that people dependent on opioids have an uninterrupted supply of regulated opioids so they would not have to switch to unregulated opioids.

With the increase in fentanyl-related poisonings, policy-makers would:

• Lower the threshold for agonist-prescribing services (methadone programs).
• Ensure that people dependent on heroin (diamorphine) have a regulated, unadulterated supply of diamorphine via community services or retailers.
• Make fentanyl tests widely available to all drug sellers and consumers.
• Analyse heroin samples contaminated with fentanyl and identify the source.

1. To ensure immediate broad access to naloxone.
2. To promote the passage of federal Good Samaritan laws.
3. To distribute factual information and data.
4. To access networks of people who use drugs, social media and first-responder reports to map contaminated drugs and distribute information about risk areas.
5. To divert funding used for the DEA and supply reduction to community-based services and support for all community members.
6. To decriminalise the use and possession of drugs for personal use.

Tragically, the ‘opioid crisis’ has not motivated policy-makers to take logical measures to prevent further death and suffering. By thinking that drugs like opioids are ‘bad drugs’ and must be prohibited, rational options are beyond consideration. In a rational world, we would realise that the opioid crisis, most addictions and the negative consequences of drugs are not caused by the drugs themselves. Instead, they are the symptoms of our society’s misguided beliefs and policies.

Trying to stop drug use and eradicate drugs are futile pursuits. Instead, we must modify or eliminate the policies, practices and beliefs that cause harm and suffering for certain people who use certain drugs. I long for a world where people can, most of the time, make informed decisions about the what, where, when and how of using or not using drugs, especially drugs, without the threat of arrest, pathologisation, medical maltreatment and social or economic isolation.

Hello, my lovely blogites. It seems you are among the few recognizable lifeforms left on my computer — my computer whom I now love, hate, and mostly mourn. I had the most terrible “accident” — or maybe it was an act of God — the sort of biblical God who goes around punishing people for being too proud or too successful, eating from the Tree of Knowledge or something.

The good stuff:

It has been an amazing week, and I wanted to share it with you. The book is doing fantastically well. (Here comes the boasty part, but I don’t have to worry about being struck down by lighting because it’s already struck.) The sales rank on Amazon.com hovered between 1,000 and 2,000 for a week or two. That’s out of ALL books. I mean, all the books in the world. (They’re all for sale on Amazon, right?) Including Tolstoy and, I don’t know, Daniel Dennett and Malcolm Gladwell and… And (get this) this week The Biology of Desire got up to #13 in sales of ALL books on Amazon.ca (I’m Canadian — that’s got to count). Move over Margaret Atwood (just kidding, God. Joking…) And it was #1 in substance abuse AND neuroscience on Amazon.ca. It’s # 82 today — still in the top 100 for all books. And, okay, it’s now #2 in neuroscience. But still. AND it was selected as a best book of the month.

The tour:

The week started in New York City: three days of radio interviews. They mostly went just fine, which is one of the main reasons why the book is selling well. By the last one, NPR New York, I was on a roll. Many interviews started off with questions like “Why do you say addiction is not a disease?” There were times I felt like saying and even times when I did say “Whyever would you think it is a disease?” But mostly I behaved well and answered the questions sensibly. It was an experience: going over my own reasoning time and time again, thoroughly convincing myself that I was right.

After a quick visit to California to see family, I ended up in Vancouver. Russell Maynard is the person actively running the Portland Hotel Society, the group that established the famous INSITE supervised injection site in Vancouver’s Downtown Eastside. That and quite a few residences for the impoverished and fragile community of addicts who call these few square blocks their home. Russell took me to many of their facilities. I watched people shooting up without shame or fear….and I met a lot of caring and dedicated young people who help to make sure they stay safe. I’ll share my impressions of that strange tour in another day or two. I’ve never seen anything like it.

The bad stuff:

That evening, my computer had an out-of-body experience. Unfortunately it never came back. All my meticulously saved and organized files within folders within folders within folders — hundreds or thousands of articles on addiction and such, many drafts of things I’ve written or partly written, a huge collection of Firefox bookmarks, the couple of dozen passwords I’ve saved — all gone. Except for the 10% of stuff (luckily including most talks) that I backed up on Dropbox.

The guy at the data recovery store here in Toronto (I arrived on Wednesday) said he’d never seen this particular disappearing act before. But luckily, as he wrote me the next day, most of my data had been recovered. I eagerly got to the store and opened my computer, went to the folder named “Recovered Data,” and indeed there were hundreds, maybe thousands of files there. They all had names like PDF-00162.PDF or D00148.doc. Well, these seemed not very useful, but I would deal. Except that most of the files had bits of text or weird graphics or they just refused to open. My pdf files had degenerated from the latest findings in the neuroscience of addiction to stuff like this.

Have you ever seen these images? Some came with Russian or Chinese text. It was sort of like being laughed at by a coterie of drunken computer deities. Here’s your information bud: don’t lose it this time. Hah hah!

I keep thinking, the book is out, I don’t really have to keep most of this stuff…maybe it’s time to find a cave in the Himalayas and take some time off. Other times I just feel incredibly pissed off. Or stupid. Or…maybe slightly relieved.

But today is Saturday: no interviews or anything else for a couple of days. That’s a good thing. I’ll wait until Monday before I worry about what’s next.

Hi all.

Shaun Shelly (a frequent contributor to this blog) and I are co-hosting a series of four “salons” webcast (if that’s the word) by a splendid organization called Interintellect. These salons are Zoom-based meetings of people from various disciplines: IT, mental health, consciousness, culture, art and literature, drug use, philosophy, neuroscience, and science more generally. A broad array. It is a forum for discussion more than a lecture series, and the participants tend to be progressive and humanist as well as intelligent, thoughtful, and knowledgeable. The cost for participation is minimal.

I hope you will check out other salons on Interintellect as well. Many of them are just fascinating, many are hosted by key thinkers on various topics (e.g., TED-type folks) and it’s a great way to get up to date on current thinking. It’s also an opportunity to voice your own thoughts and see how others respond to them, and to connect with individuals who may become colleagues or friends. Shaun’s and my salon series will be a vehicle for connecting with researchers, clinicians, and policy people who are up to date on current approaches to addiction and drug use.

So please join us to listen and share perspectives on addiction and related issues: https://interintellect.com/salon/understanding-addiction-how-addiction-works/

The first of the four salons is to be on 25 February, 1pm EST, 6pm in the UK, and 7pm in Europe.

Best wishes,

Marc and Shaun

Hi all—

Here’s an announcement before the main act: Please look at the Guest Memoirs page if you haven’t already. The first four memoirs are terrific, and hugely different. I hope that we’ll soon get more, and I hope people will leave comments on those already posted. It may seem hard to “comment” on something autobiographical….but just saying “I get how you must have felt,” one way or another, can mean a lot to someone who has just exposed themselves so openly.

The main act:

I haven’t published a post in a few weeks. I’ve had one part-written since the day after Persephone’s amazing post (see previous), but it remained in note form while I was busy with other things. Those things included my twin 6-year olds. Mama (my wife, Isabel) was in the States for 10 days, doing research (and staying in fancy hotels) while I slaved away here. It was more work than I’d expected, because the boys now go to an after-school daycare, where I need to pick them up, but I never seem to get there without getting lost and ending up in farm country.  So that’s an hour out of my day, getting them to school in traffic is another 45 minutes, Dutch lessons plus practice – 4-6 hours per week, showing up for work at the university once in a while, cleaning up an amazing amount of trash left over from the intense Halloween party we had a couple of weeks ago (fabulous costumes, lots of food and wine, even a fire juggler) but did we have to buy 30 rolls of toilet paper so the kids could have a dress-the-mummy contest? Yet the main time drain was none of the above: it was keeping a lid on the kids. With Mama gone that long, they were bouncing off walls, ignoring my commands, arguing more, breaking rules. So I spent a lot of time disciplining these adorable little buggers…not my favorite parental duty.

Which brings me back to Persephone’s post. The main problem with the 12-step approach, she says, is the freeze on emotional development they seem to demand, intentionally or not. So recovery becomes a way of not moving – it’s static. According to Persephone, the epitome of successful recovery in NA/AA is to sit around with the same people, year after year, sharing stories about how shitty it was being an addict, so that you can REMAIN clean or sober. It’s all about remaining a certain way rather than growing. As Persephone saw it, they tell you that your addiction is doing push-ups in the parking lot, or waiting to leap on you, so the only safe course is to stay here with us – stay being the operative word. And the result is that you continue to define yourself as an addict. In other words, not only the way you govern your life but your whole self-image is frozen in place. This is what you are, and if any change occurs, be warned: it’s going to be a change backward – back to being an addict who’s no longer in control.

Persephone proposed the following: With your behavior, your choices, your capacity to explore, and your self-image all frozen in this way, and with the horror stories of your addiction constantly resurfacing, you are in the same condition as someone with PTSD – post-traumatic stress disorder. What a concept! People with PTSD live with continuous anxiety, denial and avoidance mechanisms, intrusive thoughts, and more, about what happened to them, whether it was a serious accident, a mugging, physical or sexual abuse, rape, getting wounded in a war… And the therapeutic principle for recovery is pretty simple: you have to free yourself from those fears, from the anxiety that it’s still happening or will happen again, by reprocessing the event, with some sense of acceptance. Yes, it happened, but it’s over now. You have to do that before you can move on. Then you shift from a static state to a fluid state, let down your defenses, allow for the unexpected, and find the confidence that you can handle whatever comes.

So here are my kids in a state of anxiety. They’re not old enough to conceptualize how long 10 days will last. As far as they’re concerned, Mama is just plain gone. They love me a lot, and we sure got closer during this period. But their anxiety changed everything! They regressed, they became more moody, aggressive, shut-down, or simply unregulated. And to continue the analogy with NA/AA, I became like their sponsor. Come to Papa when you start to lose it, and then do exactly as I say. Because the thing/person you really want is missing from your life, and you’re in danger of going from bad to worse. My style of parenting changed. Everything became more rule-bound, there were a lot more time-outs, consequences dished out, time deducted from weekend TV… In brief, living with anxiety takes its toll. I knew this as a psychologist anyway – I just got reminded: anxiety diminishes cognitive flexibility and creativity, and it draws attention to the negatives – whether you’re a motherless 6-year old or a boozeless 60-year old.

My kids became dry drunks for over a week.

One of the coolest (but still experimental) treatments for PTSD is to relive the traumatic event while you’re taking beta blockers, drugs that reduce sympathetic arousal. This article describes the approach. So why should that work? Are you just relieving anxiety over time? No, the theory says you are interfering with the maintenance of traumatic memories. Memory strength and endurance depend on a kind of rehearsal process. You have to keep on reliving the memory (at least some version of it) while feeling the emotions that came with it – e.g., the fear unleashed when a trauma occurs, or maybe that stew of shame, anger, and horror that comes with addiction. (I still vividly remember the time I shot the heroin left in “the cotton” from a junkie with yellow eyeballs, broadcasting hepatitis – and I get a jolt of disgust and shame each and every time.) Without that emotional charge, the memory fades…just like other memories.

Memories are encoded in the connections (synapses) between brain cells. You have to reinforce those connections (keep strengthening those synapses) to keep vivid memories vivid. Strong emotions like anxiety activate or facilitate synaptic cascades (e.g., in the amygdala). Anxiety also does the job of connecting novel events to that ball of fear at the core of the trauma, thus extending the synaptic network still further. With beta blockers in your blood, you can relive the memories without the anxiety, allowing the memories to become diluted or dissipated. They start to dissolve and lose their hold on you. Then you can spread your wings and fly, rather than remain frozen with your wings permanently clipped (Persephone’s words, with a nod to Lennon & McCartney). That’s when your emotional world starts to grow again.

According to Persephone, many/most 12-step groups intentionally reinforce a PTSD-like state: Be afraid…be very afraid… Sort of like the opposite of trauma treatment using beta blockers, many 12-step groups seem to kindle the very emotions that cement your already vivid memories of when you were seriously fucked up. Almost like telling scary stories to keep little kids in line.

But sometimes it works: because living with PTSD is one way to keep away from danger. After getting mugged or raped, you won’t go strolling through city parks at night, you’ll stay inside when the parade comes by, you’ll avoid people of a certain type, you might avoid eye-contact with strangers altogether, and you’ll continue to see yourself as a victim or a loser. Not only is that a static state; it’s also an unhealthy state. It maintains anxiety rather than relieving it. You stay clean because you stay scared.

If that’s the solution offered by many 12-step programs – to plug yourself into a static state of PTSD in order to avoid the dangers of relapse – then I can sure see why a lot of people don’t sign on, or stay for a while and then get out. I can see why the notion of a lifetime addict can be a self-fulfilling prophecy. And I can see how people get hurt, sometimes badly hurt, when they try to break free: because they may actually get chastised for wanting to leave their PTSD behind — and that hurts.

For the most serious, interminable addictions, this might well be worth the price. We’ve heard a number of claims to that effect. But for those who do have the capacity to continue growing, leaving their addictions behind and moving on, it doesn’t sound like an ideal solution.

Please note! I’m not trying to rekindle the debate as to the pro’s and cons of AA/NA. Been there, done that. I’m just trying to build a clinical and neural extension onto the perspective of one person – who seemingly reflects the experiences of many others (judging from comments received!) – people who didn’t find what they needed.

Next post, coming in a few days, I’m going to zoom in on the relation between anxiety, memory, and habit formation – both in the development of addiction and in recovery seen as a developmental process — by looking more closely at what’s happening in the brain.

This is an extremely relevant and useful guest post. I have come across many different formulas for a step-wise approach to recovery, but this is the most coherent and sensible one I’ve seen. The middle step is often our downfall, and Fred helps clarify the problem.

…by Fred…

In a recent post, Marc fleshed out the idea that addicts need to shift their perception of the tradeoff between their addictive behavior and the potential consequences of that behavior.  It is well known that addicts tend to overvalue the current rewards of using, and undervalue the potential rewards that might come from staying sober.  One definition of addiction is “emotional immaturity and lack of discipline,” and it is this difficulty in seeing the big picture that trumps everything else when an addict tries to revalue the tradeoff between using and not using.

In his book “In the Realm of Hungry Ghosts”, Gabor Maté builds on the work of Jeffrey Schwartz in laying out an approach to resisting relapse called “The 5 Rs”.  When the urge to use occurs, the addict is encouraged to “Relabel” the thought (it’s just a thought, not a command), “Reattribute” the thought (it’s my old addictive pattern again – my brain’s old behavior), “Refocus” (distract and turn one’s mind to healthy activities), “Revalue” (play the tape forward and clarify all the negative consequences that could occur because of relapse), and finally “Recreate”, where the addict focuses attention on his or her dreams for a new sober life.

1. Relabel

2. Reattribute

3. Refocus

4. Revalue

5. Recreate

The 4th and 5th Rs, Revalue and Recreate, are explicitly about addressing the addict’s distorted thinking when weighing short-term payoffs against long-term chaos.  But first, the addict needs to have enough mindfulness to consciously intervene in his or her own addictive cycle (the first 2 Rs).  See the recent post by Matt Robert for more about how this works.  At that point, it’s important to give the mind something else to do — to interrupt the cycle. This is where the third R comes in — Refocus.  This is a process that combines distraction and substitution to stop the addictive thought process and ritual, and, ideally, to address the deeper needs underlying the urge to use.

Addicts use, in part, as a form of mood regulation.  The addictive ritual and behavior releases nature’s mood enhancers — endorphins, dopamine, serotonin, noradrenaline and adrenaline.  Stress, boredom, loneliness, grief, resentment and other uncomfortable feelings can all create a desire for refuge and an urge to use.  Sometimes, simply being exposed to a certain place, or image, or a particular person, can start the cycle.  Revaluing and Recreating in that scenario are probably not going to be strong enough, especially in early recovery, to interrupt the cycle and protect the addict from relapse.  That’s because the unpleasant mood state that the addict is in (which is often accompanied by negative physical sensations) is difficult to tolerate, and the future benefits of staying sober are merely conceptual.  They alone won’t shift the mood.  This is where Refocusing (i.e., distraction and substitution) is critical.  By getting away from the immediate stimulus and unsafe environment, and focusing the body and mind on a healthy substitute activity, the addict has a better chance of riding out the urge to use, and sometimes directly address the underlying stressor and associated emotions.

When confronted with stress, a young child seeks comfort in the arms of a caregiver.  The endorphins released by the loving touch and soothing presence of the attachment figure help to calm the child.  Adults also experience endorphin release as a result of intimate touch and connection with others.  But, for the addict, this source of endorphins is typically unavailable — the addiction makes safe intimate relationships impossible.  Similarly, the elevated dopamine levels that accompany craving make it difficult for the addict to focus on anything but the anticipated high, thereby ignoring everyday activities that might otherwise be rewarding and satisfying.  The addict’s artificial mood regulation strategy cuts off the ability to regulate in healthy ways — through close relationships and meaningful activities.

Refocusing not only helps the addict stay sober until the urge to use passes, it can actually start inculcating new mood regulation habits.  Instead of relapsing in response to a trigger, the addict might develop the habit of picking up the phone and calling a friend in recovery, or going to a 12-step meeting, or exercising, or reading a novel, or doing a kindness for someone in need.  These types of activities will not only provide a distraction, they will substitute a behavior that reduces stress in a healthy way and helps to alleviate negative moods.

Faced with pain from life, our addictions temporarily soothe us, but they leave us more alone, and even more vulnerable to pain.  It’s suicide on the installment plan.  In recovery, faced with pain from life, we replace the mood-regulation strategy of addiction with caring for ourselves and connecting with others.  Consoled, we begin to believe in, and create, a future free from addiction and filled with the blessings of a life worth living.