Understanding Addiction

Hi again. Well, I started writing. What a relief! I’ll say more about that in a sec, but to make it slightly relevant to this blog, let me tell you what I just learned about “choice.” Last post there was a great dialogue about the “choice” model of addiction. I ended my post arguing that the choices addicts make are highly irrational, based on biases and attractions already inscribed in the brain. Thus….we need to think about making choices in a new way, a way that has nothing to do with logic.

So writing is an intentional act, right? Sitting down to write something, whether a book or an email, is a choice people make. It’s clearly not a disease, it doesn’t happen unconsciously, and it involves deliberation, planning, and so forth.

In that way, writing is something like the decision to take a drug or a drink. And it’s also something like the decision to quit — choosing not to take a drug or drink. (though it’s always harder to choose not to do something than to do something — because the goal is not right there in front of you)

My choice to sit down and write involved a great deal of anxiety, self-scolding, reflection, and many many attempts before I actually pulled it off. Sound familiar?

I had to sneak up on myself. And that’s very often the way addicts manage to quit. I had to wait until I wasn’t concentrating. It was too difficult to sit down and force myself to write, to stare myself in the face. Rather, I was en route to doing something else, making dinner or something, when I stopped at my computer and wrote a few sentences on the fly. Very little deliberation, actually, in the moment of doing it.

But that was enough. An hour later I stopped by my computer and started to revise the….ONE PARAGRAPH. There’s already one paragraph on the screen! I wrote that. And it’s not too bad. Paragraph 2 flowed from paragraph 1, as you’d hope, and since then it’s been easier and easier.

So here was a deliberate and important (to me) choice that changed the direction of my life, the way I spend my time. And I had to be clever, resourceful, sneaky (toward myself), not staring myself in the face — in order to make it. The parallels with quitting are obvious. And the choice to take drugs is not unlike the choice to quit, in that it can happen on the fly, without really focusing on what you’re doing.

The coolest thing I noticed is how the activity of writing grew on itself. Once I had one paragraph on the screen, I felt that I could do it. I felt that I was finally moving. Then the second paragraph was so much easier. And thirty years ago, my second week of recovery was a lot easier than my first.

By the way, this is all about the emergence of self-trust, a topic we discussed in some detail several posts ago.

To say that addiction is a choice is to say very little. The same goes for recovery. Choices come in many shapes and sizes. The crucial thing to remember about making choices is that they usually involve a mixture of deliberate intention, situational factors, unconscious processes (like biases), emotional readiness, and momentum — that sense of moving forward. Some choices, including the choice to quit drugs, depend a lot on momentum. Which is why it’s so hard to get started, and why it’s so useful to sneak up on yourself, don’t think too much, just do it, then let nature take its course (with a little help).

In a recent post I brought up the age-old debate as to whether addiction is a disease or not. In response, Alese raised the bigger issue of neurodiversity. Many scientists believe that a certain amount of individual diversity is built into human behaviour, because it provides an evolutionary advantage for all of us. It may be that our social groupings work best when a small percentage of us are highly detail oriented (autism spectrum), a small percentage are fearlessly aggressive, some tend toward extreme caution. And perhaps some are born with the tendency to seek immediate rewards over long-term gains – those most at-risk for addiction.

This built-in diversity in psychological styles would have to be based on diversity in brain plans. And this neurodiversity would then be considered a survival benefit for the species. That would mean that the psychological syndromes we like to classify as disorders or diseases don’t fit those categories. Not at all. (Even if they don’t make life pleasant for those who “have” them.) Instead, they may be outcomes of adapative variations in the human genome.

When I was in Toronto last month, Jim Kennedy (a highly-renowned research psychiatrist at CAMH) told me an amazing story over dinner. It concerned some research in which he’d participated, examining ADHD (attention deficit hyperactivity disorder), genetics, and migration. I’ll make that long story short:

ADHD is a disorder, if not a disease. Right? Not right? It depends on your perspective. According to Dr. Kennedy, the study of genetically pure (no intermarriage) native populations in the Americas reveals a fascinating pattern of geographically distributed genetics. A gene variant related to ADHD (a certain number of repeats in the part of the DNA linked to dopamine metabolism) shows up at a very low rate in native groups living in northern Canada: 2-3%. The incidence of this variant increases, to something like 10-20% in native groups living in the southern U.S. In Central America, incidence of this variant increases up to 50%, and it exceeds 50% in parts of South America.

What could this possibly mean? Does sunburn cause a genetic predisposition to ADHD?!

According to accepted theory, the Americas were first settled by migration waves from Asia, across a land bridge connecting Siberia with Alaska, at least 12,000 years ago and possibly much earlier. That bridge has since disappeared. This model implies a gateway for migration, starting in northwestern North America and moving south, over many thousands of years.

But why would there be a greater hereditary risk for ADHD as the original settlers of America moved south? ADHD describes a syndrome in which people are more distractible, their attention wanders off target (which means it goes to new targets), and they are more attracted to novelty than to routine. In North American and European classrooms, this is bad news. You’re supposed to be facing the board, listening to the teacher, and doing your assigned work. If a certain proportion of people don’t do this, if they have a “problem” with their attention, and if this problem is related to distinct neural mechanisms AND to genetic predispositions, then the problem gets classed as a mental disorder or disease.

But if this “problem” only arises in certain social contexts – if it can be an advantage in other contexts – then the disease label starts to peel off. Imagine that you are a North American native, it’s 10-15,000 years ago, you live somewhere in northern Canada, and there is nowhere nearby to buy a Gortex jacket or even long underwear. It’s awfully cold for many months of the year. But you happen to have a predispositon to wander off into the woods, peak over the next hill, and to lose attention to the normal duties of hunting and trapping. One fine day, while on your explorations, you look over the crest of a hill and find a long valley extending off to the south. The lands north of you are already settled, so they’re not very interesting to explore. But this valley to the south is completely uninhabited. You let the elders know, and within a generation half your tribe is living there. Your children have a greater likelihood of having the same attraction to novelty, the same low tolerance for routine. After all, they carry many of your genes. When they grow up, they are also more likely to discover greener pastures, and  your descendants  will continue to migrate southward.

By this process, the genetic makeup that confers an attraction to novelty and a disdain for routine will become correlated with geography. Tribes — or groups within tribes — who have a higher proportion of that genetic variant will be more likely to migrate, and will show up further and further south. Thus, a certain genetic pattern is linked to a certain pattern of migration. In fact, it is the adaptiveness of this pattern that EXPLAINS the migration.

Today, in North America and Europe, we associate that genetic pattern with ADHD – a “disorder”. But for those aboriginal people, it facilitated adaptive waves of migration, moving them further and further away from the frozen North and opening up new possibilities for hunting, farming, and building civilizations.

Conclusion: the psychological qualities of a genetic distinction can’t be defined or labeled in a vacuum. The advantages or disadvantages of that distinction can only be described in context.

Research points to genetic patterns that are correlated with addiction. I’ll get into that topic next post. For now, I want to leave you with the thought that addiction may arise from a predisposition that’s not unhealthy or bad in itself. Its goodness or badness may depend entirely on what our society values and on where and how it fits in.

Two posts ago I sent you a few paragraphs from the introduction to my new book. In that draft I said:

This book makes the case that addiction results from the motivated repetition of certain thoughts and behaviors until they become self-perpetuating habits. Thus, addiction develops, and it can develop quickly, through a process I call accelerated learning.

I woke up at 5:30 today and couldn’t get back to sleep because I realized that this portrayal is flawed. Of the five people whose biographies I include in the book, two of them make it very clear that addiction can have a slow or  delayed onset. The man I call Brian was using coke and then methamphetamine for about two years before he became really addicted. At first he just wanted to stay awake and energetic. But then he slid deeply into addiction, to the point of smoking meth every few hours and missing many nights of sleep in a row. The woman I call Donna was on Vicodan for a year to treat back pain caused by a bicycle injury. Only then did she start doubling her dose and liking how it felt. She ended up forging prescriptions and stealing pills from just about everyone she knew. It blew apart her marriage and her life.

Both these people eventually recovered, as most addicts do. The point is, though, that the learning spiral leading to addiction need not cycle quickly. At least not at first.

So I lay there till the alarm went off, thinking, okay, what the hell is it? What makes it different from other learning trajectories — other bad habits? The phrase “overlearning” popped into my head from undergrad psychology. Here’s the definition — which highlights extended practice that results in “escalated persistence of the learning over time.” But that was an idea that faded with the decades, because it simply described the use (especially in classroom settings) of a greater number of learning trials to get a longer period of retention. Not all that interesting after all. Unless you bring in the power of motivation and start thinking about dopamine.

So how am I going to resolve this? As mentioned last post, I am still doing final edits. But I have to figure out a concise description of the psychological process leading to addiction, a particular twist to the more general mechanism of learning, or the book will have a big hole in it. It’s there in the stories. It’s there in the neurobiological details. I think I show very clearly that drug addiction is no different from falling (deeply) in love — both in its psychology and its biology — or from behavioral addictions, etc. Still… I have to find that phrase.

By the time the alarm went off, I was pretty set on “deep learning.” As long as that’s fully explained, I think it works. And it will be fully explained, if it isn’t already. So now I have to make a new set of revisions.

I know some people get addicted very quickly, once they’ve found their substance (or activity) of choice. But that’s not universal — or mandatory. I want to explore this in some detail next post.

Now back to the grindstone.

I just got back from a two-day meeting on animal models of addiction. And here’s what I learned: animals way way down the evolutionary ladder also like opioids and psychostimulants. And flies like alcohol. That should make us feel less lonesome.

I was asked to be the keynote speaker for the meeting, because the organizers thought that animal researchers should learn more about human addiction. Well, it was a nice idea, I got a free trip to Chicago, but my work may just be too distant from what these folks think about. They study “addiction” — or more simply drug seeking — in, for example, crayfish, sea-slugs, something called zebrafish, and the common fruit fly (drosophila). Seriously. They listened to what I said about human addiction. I stressed cognitive-emotional factors like “now appeal” and “ego fatigue”, I stressed how difficult it is to make good decisions in stressful environments, especially when memory serves up powerful associations between getting high and relief. I talked about the symbolic appeal that intensifies addiction for us humans. How we’re addicted to what the drug means to us more than to the physiological change it produces. They listened, but I don’t think they got it. And when it came to my spiel about the internal dialogue, the “addict self” and so on, it’s like we were on different planets.

Regardless, I learned a lot from them. For example, I learned that zebrafish larvae (baby fish that look like seahorses) like opioids. These little guys will swim up near the surface of their tank — which is intrinsically aversive to them — to get Vicodan. Yes, Vicodan…through their feeding tube. And I learned that fruit flies will endure 120 volts of electricity to get a nip of alcohol. Yet they won’t do it for sugar. Crayfish get stoked on cocaine and race around recklessly with their claws outstretched. Like, seriously! I also learned that dopamine is the neurochemical by which lower animals identify and pursue rewards. They may even get a dopamine burst when they acquire drug rewards. I could give you more details, but in sum, it’s pretty simple: opioids and psychostimulants cause physiological changes that we interpret as “good” or “rewarding” — “we” being animals from flies and fish to humans. And we do this using the same neurotransmitters — dopamine and serotonin — across species that evolved hundreds of millions of years apart! It’s no accident that heroin and meth are the most addictive drugs we know of. We’re in good company.

But how do we make sense of the fact that gambling, porn, internet use and sports can also be highly addictive? It seems we somehow have to draw a line from the physiological changes that opioids and stimulants provide, up to the level of “I like this — I want more!” and then back to all kinds of addictive behaviours as well as drugs themselves. Then maybe we can figure out how behavioural addictions — in fact all addictions — really work.

What about the genetics of addiction?

I also learned more about the genetics of addiction. For years I’ve been arguing, much like Maia Szalavitz, that the oft-cited 50% heritability of addiction is mostly due to personality traits. There’s certainly no gene or gene cluster that predicts addiction, though there are genes that can make one more or less sensitive to specific substances, like opioids (the dynorphin receptor gene) and alcohol (which is more complicated). Yet personality traits, which can be genetically shared, predict addiction itself. The most clear-cut example is impulsive personality. More impulsive people are more likely to try drugs, or drink (or drink more) at younger ages, than others. So they and their identical twins (the basis for computing genetic effects) are more likely to become addicted. An introverted or anxious disposition also predicts addiction, for obvious reasons. And, as Maia Szalavitz says about herself, I think I score pretty high on both of these (seemingly opposite) traits. So…my odds started off a little higher than average.

Yet I’ve always emphasized environmental effects. They are so huge and so obvious. From Gabor Maté’s oppressed native populations, to Rat Park, to the ACE studies…yeah, it’s pretty obvious that difficult or stressful or oppressive environments predict addiction. And most of my clients who’ve struggled with addiction have had really shitty times during their childhood or adolescent years. Young people adapt to abuse (physical, emotional, or sexual) or neglect (like rejection by  a parent or step-parent) by trying to make themselves feel better with substances. It’s called “self-medication.” It’s not rocket science.

But here’s what I learned about genetics. Over the history of genetic research, labs could only look at gene-outcome effects one by one. That’s not the way genetics operates. With the huge explosion of computer technology in the last few years, scientists can now look at complex interaction effects. These include, not only genes, but the parts of the DNA that regulate networks of genes. Now things get complicated. I already knew that trauma or early adversity can “set” changes in motion which last a lifetime — called “epigenetic” effects. For example, punitive parenting can set your amygdala on high alert for the rest of your life — i.e., induce trait anxiety. These changes take place at the DNA level, but — and it’s a huge “but” — they are driven by environmental impacts. So, again, environment wins out over inheritance. What I didn’t get until last week is the complexity of the interactions between these environmental impacts and the genes we inherit.

One of the scientists speaking at the conference, Daniel Jacobson, showed us that he can predict fine gradations of autistic behaviour, by data crunching (on the world’s fastest supercomputer!) hundreds of thousands of genetic variables interacting with each other and with thousands of environmental variables. So — once we get better at quantifying environmental impacts (like isolation, abuse, bullying) we may indeed be able to predict addiction, not from genes themselves but from the interplay between gene networks and environmental challenges.

Still, even with all the fancy computing power in the world, I think that environmental challenges will remain impossible to quantify. As I argued with this dedicated scientist at the reception, isolation in Sweden and isolation in New Jersey are entirely different things. The gradations in environmental impact are close to infinite. He disagreed, said it’s a matter of time, but I guess the jury’s still out.

How to conclude? Two things. First, addictive drugs are addictive because of what they do to the nervous system of animals, lots of kinds of animals, not just us. But we humans build all this symbolic stuff — like need fulfillment, warmth, the sense of being in control — on top of that primal impact. Second, we may never be able to accurately compute who becomes addicted, but your chances surely derive from what you were born with (inheritance) interacting in hugely complex ways (development) with the sting of environmental misfortune.

Addendum: I realize this post covers two seemingly different topics. Yet they’re deeply connected. Our genes are the basis of our humanity, but we still carry these mechanisms of reward-seeking that go back hundreds of millions of years. After all these aeons of evolution, we still haven’t been able to discard the code for these mechanisms. We still need them. They’re that basic. Think about it.

This morning I woke up before the rest of my family. We’re in a hotel in Switzerland, on a ski holiday. Switzerland isn’t that far from our home in Holland, but I know that I’m a lucky guy. My life has improved substantially since sitting in a cell in Thunder Bay, Ontario, waiting to get bailed out (after raiding a pharmacy with a motion detector). So I snuck out of the room, trying not to wake anybody else. But of course one kid started coughing and the other went to pee, by which time Isabel was frowning at me in her first moments of wakefulness. Was I being too noisy?

Anyway, I’m feeling a bit disoriented. Vacations are nice, but I find it hard to just….um….relax. So I get to the lobby and boot up my computer and the first thing I read is a comment on one of the memoirs, by “jaqueline” (about 15 comments down this page).  Now suddenly I’m not bored anymore, or preoccupied with petty things like wondering when the grandparents will come down for breakfast and whether I’m supposed to get back to the room to help the kids dress. Suddenly I’m with this person in the freezing cold – cold attacking her body from the outside and her soul from the inside – trying to figure out what she can sell to get a bit of heroin. Her mother offers to get her a hotel room but refuses to give her any money. And she thinks: what good is a hotel room without drugs?

I remember that feeling so clearly. Viscerally. Even though it’s been a long time for me. The need for drugs that attaches itself to you so thoroughly that every movement of your body, even turning over in bed, feels like you’re pulling against a second skin. There’s this dark sticky second skin that’s stretched around you, irritated, pulling away patches of your own skin with every move you make. I’m here. I want drugs. What are you going to do about it?

That old expression, “monkey on your back,” isn’t far off. But it feels bigger than a monkey and so much darker. And there’s really nothing else to do. That’s the point: there’s only one thing to do and no other action has any point to it.

So you lurch out into the cold of early morning or late night, seeking, searching, there’s got to be a way. There’s got to be a sequence of steps. If I can only figure out where the path starts, I know, I just know, that there will be drugs at the far end.

That’s called compulsion. The drive to act, to do something, without thought or reason.

I promised last post to continue the model of addictive behaviour I was working on.  I’ve been reading more neuroscience papers, and there is a final state in the sequence of states I outlined. A final stage that I think is applicable to most people and most addictions: When addiction tightens its grasp, impulse turns to compulsion, and that’s when you just can’t stop – or so it seems.

There’s a distinct neurobiological change when this happens. I have focused a lot of attention on the ventral striatum or nucleus accumbens. That’s where attraction and focus suddenly converge to create the impulse to go after the thing you crave. But the striatum has another whole subsystem within it, higher up in the brain, which we can call the dorsal striatum. When impulsive drug-seeking behaviour turns to compulsive drug-seeking behaviour, it’s the dorsal striatum that gets activated. This is a definite change in how the brain processes cues – and when I say cues I mean the thoughts, memories, withdrawal symptoms, or reminders out there in the world that call your attention to the thing you’re addicted to. Now, the action sequence, the set of steps, the behavioural response, whatever you want to call it, is suddenly resonating, vibrating with life. You are plunged into action, forced into action by the wiring of your dorsal striatum. Much like Pavlov’s dog, who starts to salivate when he hears the bell. There’s nothing to think about, no more reflection on whether it’s worth it or not. You just have to act. Which means: you just have to get some.

I’ll say more about compulsive addictive behaviour next post. For many experts in addiction neuroscience, compulsive drug-seeking is the definition of addiction, and it’s worth our attention. For now, I feel a bit compelled to get this post up. (I’ll probably revise it more later). Jaqueline’s story, so resonant with Janet’s memoir and so searing a reminder of my own crazy drug days, got my fingers going until this post was done.

Now I’ll go see what’s up with the family.