Understanding Addiction

Not to be confused with the 12 steps, but read on.

Two posts ago I said I’d suggest practical applications for some of Jordan Peterson’s self-help recommendations, as they might apply to people struggling with addiction. I hesitate to put Peterson’s name in the title of this post, as there has been such a fantastic degree of controversy surrounding this man.

Many thousands have thanked him for live-saving advice, women as well as men. Many love him, I’d say for good reasons. And many hate him. Despite my admiration for most of Peterson’s proposals, I also find myself turned off by some of the things he says in public. These seem careless, absent-minded, maybe provocative, sometimes angry, but certainly not intended to harm vulnerable individuals. But again, I want to avoid the political shit storm. It just doesn’t interest me as much as the content of Peterson’s proposals and their capacity to help those in need.

The first recommendation I want to explore is the theme of taking small, manageable steps out of addiction. To paraphrase from my previous post:

People in addiction often want to make a massive change in their lives, but the change is so massive that it overwhelms their capacity for self-direction. So they fail, again and again.

As noted previously, Peterson’s approach to the problem comes to the surface in this talk, about 33 minutes in:

You need a goal, but we don’t want your distance from the goal to crush you…Set a high aim, but differentiate it down so you know what the next step is. And then make the next step difficult enough so that you have to push yourself past where you are, but also provide yourself with a reasonable probability of success.

Nothing particularly new about this idea? Except that Peterson urges a balance between idealized progress and the capacity to succeed even minimally. People in addiction know the price of repeated failures. Each time we set a goal (e.g., never again, not tonight, not this weekend, not shooting it, stopping after two drinks, sticking to wine) and fail to follow through, there’s a dash of salt in the already-gaping wound to our self-respect. More evidence for that critical inner voice (which I’ll get to next post) and confirmation of the belief that we’ll never succeed or we’re not worth the effort (and pain) of repeated attempts.

These outcomes are both familiar and devastating. When I was taking drugs, each and every time I promised myself to stop — and didn’t — deepened the pit of hopelessness and self-contempt. Stopping was just too difficult…at first. “Never again” felt like being cast on the shore of a desert island, naked, alone, and lacking the one source of safety I could have brought with me.

Little steps — cutting down, controlled use — will be far more manageable for most people in active addiction. Call it harm reduction, if you like, because it certainly reduces harm. But, as Peterson emphasizes, this isn’t a rationale for falling short of complete success. Getting your life exactly where you want it to be is possible, in fact necessary, but it might not be possible this week. So, he advises, be really practical, identify a goal that’s in reach. And make sure you stick to it. If your house is a veritable pig sty, set yourself the goal of gathering the laundry off the bedroom floor — just that — and tomorrow you’ll feel capable of tackling the sock drawer.

One of my clients is a man I’ll call Jason, a sixty-plus year-old who lives in a large European city, having left his home in the U.S. more than twenty years ago. We have a psychotherapy session usually once a week via live chat on the net. Jason would  score a gram of heroin almost every Friday afternoon, because the weekend stretching out ahead of him felt like a wasteland of boredom and loneliness. When he got home from work Friday he’d get high. Then he’d use the rest on Saturday. There might be enough for a small hit on Sunday, but by then things were already looking pretty grim. Every Monday came the crashing depression of going without, compounded by exhaustion (not sleeping well) and savage self-recrimination. This generally went on until Wednesday morning.

The habit was entrenched. He did this every week. The emotional vulnerability, combined with habit strength, sunk him every Friday. So we set a goal that he felt he could manage. This week, just this week, he was to make a plan to go out with a friend on Friday evening. I helped by calling him Friday morning to make sure he was on track. By Friday at dinnertime his dealer was off duty. All he had to do was to make it till then.

We did not try to resolve whether he would use later that weekend, or the following week. He’d cross that bridge when he came to it. (The one-day-at-a-time idea is certainly familiar in the 12-step world, though it comes with spring-loaded rebuke for failing.)

This goal was in range. It was possible. And he succeeded. Saturday happened to be a sunny day and he spent it well. By Sunday there was no intense longing. Tomorrow would be a workday. Work organized Jason’s life. He wouldn’t feel tempted to use again until next Friday.

A good start.

Obviously this isn’t rocket science. But it is powerful. Jason felt good about himself. By Sunday, and through the week, his mood was brighter than it had been in months. And he had the beginnings of a defense, a bulwark, against the self-denigrating voice that made him feel like shit most of the time.

As Peterson recognizes, as any good psychologist practicing CBT ought to know, small changes build momentum, allowing for a lot more progress than can be envisioned from Square One.

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Check out this cute Medium post showing how small changes to bad habits can generate a chain reaction. Just as good habits lead to the strengthening of additional good habits, indulging in addictive acts leads to more addictive acts. It’s that simple.

I find it impossible to reflect on these cognitive calculations without considering the internal dialogue. See next post.

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By the way, here is a positive and constructive website/blog from a recovered heroin addict — now a neuroscientist. No, not a cousin.

Those of you who remember record players probably recall the infamous “broken record” — which kept repeating the same sounds over and over. Maybe that’s me, but I thought I’d share a few more words of thanks. I finally finished editing the copy-edited manuscript of my book, a horrific chore that took three weeks, nearly full time. Now the book is really, really, really finished — entirely in the hands of the publishers And my last task was to compose the dedication, which goes at the front, and the Acknowledgements, which go at the end. Here they are…

Dedication

For the members of my blog community, who have generously shared their experiences and insights, and for the five who trusted me to tell their stories here.

Acknowledgements

After writing a book about my own passage through addiction, I needed to learn what my experiences had in common with those of others. So I began a regular blog that attracted a bright, boisterous, and empathic community populated by former and recovering addicts. The many comments following my posts and the guest posts contributed by members provided a wealth of insights and information that I could not have hoped to find elsewhere. I want to thank each and every one of the people who’ve engaged in this conversation with me. You inspired me to write the present book, and you helped me understand addiction well enough to feel I could make a worthwhile contribution.

The five former addicts whose stories I tell deserve the gratitude of everyone attempting to comprehend addiction by combining private experience with other forms of knowledge. The people who volunteered for this project donated many hours to respond to my questions, and they did so with unstinting energy and honesty, dredging up details from experiences they might have preferred to forget. When wearing my interviewer’s hat, I often felt like a dentist drilling deeply, painfully, until I unearthed every chunk of my respondent’s past. They bore up bravely, shining the beam of self-examination wherever I asked them to look. I am deeply grateful.

Lisa Kaufman, my editor at PublicAffairs, helped me upgrade my understanding of the rehab world, past and present, until I’d acquired the perspective I needed to portray it sensitively and accurately. But I’m most grateful to Lisa for encouraging me to follow the implications of my own model from theoretical abstractions to concrete directions for practice. She convinced me that, for many readers, that’s where the book had to land. And she was right.

Tim Rostron, my editor at Doubleday Canada, has now been my writing guru through two books, and I continue to celebrate my good fortune. Tim’s mastery of the deep and subtle currents of English and his dedication to transparency and flow have nursed my growth from scientist to writer.

I benefited hugely from the seasoned perspective of two unpaid editors, Matt Robert and Cathy O’Connor. As a pioneer in the rehab community and a sparkling commentator on current trends, Matt took me behind the scenes of the rehab/recovery world. He read most if not all of these chapters, showed me what I was missing in both form and substance, and helped me smooth out terms and concepts that might otherwise get caught in the reader’s throat. Cathy generously dipped into her editorial talents to guide me through the no-man’s-land between what I thought I was explaining clearly and what readers were likely to grasp. There were jagged craters everywhere, most in places I would not have checked. Cathy pointed them out with patience and precision and helped me figure out how to fill them. I am so very grateful to both of you.

Other treatment experts came to my aid. I am particularly indebted to Shaun Shelly, who kept pace with every conceptual step I took, in the book and in the blog, and harvested examples to help support our shared understanding of addiction. And my thanks to Peter Sheath, who spearheaded the Birmingham Model described in the last chapter and infected me with the courage, creativity, and optimism he has brought to the treatment world. [Both of these men have been frequent contributors to this blog.]

My most generous and dependable editor remains Isabela Granic, my partner for eighteen years. Your steady supply of gist was the mortar by which my details could cohere and settle. You continued pointing me toward what I’m good at and reminding me of its worth. And you stoked the fires whenever I got discouraged or just tired. This book could not have existed without you.

Finally, Ruben and Julian, thank you for letting me work all those hours when I should have been playing with you. Ruben, thanks for adjusting my chair. Julian, thanks for the cuddles. I’ll try to make it up to you both now that the book is finished.

To Matt, Shaun, Peter, my five interviewees, and all the rest of you — Thank You!

Last post I shared a conundrum with you. I’d written a chapter for a book for addiction doctors. But when I learned the title of the book I decided (after all that work!) to withdraw it. Was that the right thing to do? Your comments convinced me it wasn’t.

My chapter urged practitioners to view addiction as a learned habit, not a disease, and showed show how the brain changes corresponding with addiction fit our understanding of learning rather than pathology. And it seemed compatible with a book that was supposed to “create space for clinicians to go beyond narrow guidelines….to reflect more of the ‘art’ of working within addiction medicine.” I thought my chapter would fit right in.

Until I read the proposed title: A prescriber’s guide to methadone and buprenorphine for opioid use disorder. How could a “prescriber’s guide” advocate moving beyond conventional guidelines? At best I’d have to rewrite the thing. And even then, my whole argument for moving beyond the “disease label” starts to unravel when it comes to the prescription pad. (see last post for details) In sum, my chapter in this book would be a sellout! Not just a poor fit but a surrender to the opposition!

That’s where you guys came in. I asked commenters to give me the benefit of your perspectives, and that’s what you did. There were good arguments on both sides, but a majority of you articulated good reasons why I should have left the chapter in.

For example, Matt had this to say:  “I don’t quite understand why you would not offer your unique perspective to anyone, especially physicians, and especially since they asked for the chapter to begin with. There are so many physicians who would be exposed to your ideas who may have had no idea they existed.”

For “my ideas,” read “progressive conceptualizations of addiction that step around medicalization.”

Annette wrote that “your role is, undoubtedly, to EDUCATE. The world is shifting…Mental health advocates are talking openly about the impact of social, economic and political structures on our (fragile) mental health, so those of us who understand this need to keep educating.”

But Shaun came up with the coup de gras: “I imagine two scenarios,” he wrote. “ONE: a well-meaning doctor who has learned it all from the book of NIDA, Chapter Volkow, TIP63: Patient has life-long disease of brain that compromises free-will. They will manipulate and lie. I will insist that they pee in a cup [and] have medication discontinued if they test positive… Chance of getting on with life, zero.

“TWO: Having read Marc’s chapter, start by seeing a person who, for whatever reason, has learned to use heroin as a valid way dealing with life. Through collaboration and honest dialogue, with voluntary additional services that they may or may not request, I will prescribe their methadone without fuss and making them seem like I’m doing them the world’s biggest favour. I will…not wield [my] autonomy like a weapon…I would…’provide a scaffolding’ of methadone ‘to support a vision of future self,’ rather than use methadone as a straight jacket to constrict their right to breathe.”

(I suggest you to read these comments in their entirety.)

When I read Shaun’s comment I was still reeling from a psychotherapy session I’d had with Sally (fictitious name) a few hours earlier. I’d been meeting (online) with this fortiesh English woman for psychotherapy every week or two for about eight months, during which time I’ve tried to help her get on with her life, make peace with her demons and self-doubts, and keep her codeine habit within safe limits. This session she talked about her years of heroin addiction and hooking. It wasn’t the first time, but the level of detail, the pain she expressed so vividly, made me more aware than ever of the grinding inhumanity of the life she’d lived.

How did Sally get into heroin? When she was 14, a teacher at the children’s home began touching her genitals. She wasn’t angry at the time, she says, but her perception of adults changed entirely from that point on. A couple of months later, a math teacher–she remembers him as being very old, with bad teeth–started making advances. This time, she threw a chair at him. She got kicked out of school for her troubles, and that’s when she got to know Mike, who introduced her to heroin.

Sally had a pattern of running out of one children’s home and landing in another. She hated them all, she told me. Her parents came to visit her often enough, but they didn’t take her home with them. Maybe that was the problem. Her mom had told her she couldn’t handle her tom-boy ways. Sally liked looking for bugs under rocks rather than dressing nicely. That’s just Sally being Sally, the family concluded. And she became an outsider in her own home. By adolescence she’d often end up swearing at her mom, sniffing glue and hanging out with the wrong kids on the corner.

So it was the usual culprits: inadequate parenting, child abuse, growing up without any real protection…Sally’s credentials for drug use would include a pretty high ACE score. But Mike was the catalyst.

He started off as her friend, someone to love her and listen to her. Then he became her pimp, demanding that she go out and find money to score more dope. Her young body was all that stood between his well-being and withdrawal symptoms. He’d beat her up if she refused–broken ribs, a couple of teeth knocked out– except when he got worried about damaging the merchandise.

Sally’s life stabilized after all. She went out at night, looked for men, got the money up front, until she had enough to score. Then went back to Mike and shot up. This went on for years. Her mother saw her once, sitting at a street corner, head lolling back, almost unrecognizable because she was so thin. But she just kept driving. That’s just Sally being Sally. Skeletal and bruised, waiting for a man degraded enough to look past the bruises for 20 minutes of warmth. That’s who she became. Until she was rescued by a man who got her off dope, as long as she’d never look at another man again.

The real story of Sally’s addiction is so diametrically opposite anything resembling a disease. The web of social, economic, and familial factors, the absence of a social safety net, the play-it-safe inclination of child-welfare services that weren’t interested in the child’s version of events. That’s where the problem arose. So where was it to be solved? In a doctor’s office? In a methadone clinic?

At least once a year someone would demand sex without pay or else they’d hurt her, badly, they warned. And she’d have to “service” this man anyway, get it over with as soon as possible, because the night was wearing on. There weren’t many hours left to find a paying customer. And she needed to buy heroin. Her stomach was already knotting, her muscles cramping, the nausea rising. She couldn’t face it, not tonight. She couldn’t face Mike empty-handed and she had nowhere else to go.

Sally told me that she’d cry every day, even once her life had moved on. She just couldn’t process all she’d been through. Now, today, I couldn’t shake my own grief. That’s when I read Shaun’s comment. And that’s when I realized I should have submitted my chapter after all.

The horror of Sally’s circumstances could have been prevented if opiate substitutes had been available, without prohibitive costs, without further degradation. She would have left Mike, would have left the street, if she could have found a way out.

I’m not beating myself up about it, but I made a mistake. My reluctance wasn’t wrong. The “prescriber’s” shingle unfortunately strengthens the inclination to make OST (opioid substitution therapy) the goal of addiction treatment. It was my decision to withhold the chapter that was wrong.

I should have contributed the chapter to help doctors see OST as scaffolding, a means to an end, rather than an end in itself. That way, the social-developmental roots of (psychological) addiction and the doggedness of physiological dependency could have been specified as parallel aspects of an opioid habit, distinct but convergent, making it all the more insidious. Both are real. Both may need to be challenged head-on. And there’s no universal formula for which should come first.

In the last 24 hours, a video clip of a Texas judge beating his teenage daughter (for the crime of downloading music) has gone viral on the internet and news media. It’s a horrendous video, involving not only brutal violence but also vicious humiliation of a child by a parent. What makes the story more provocative still is that the daughter, 16 years old at the time, has cerebral palsy, the father is a judge who presides over child welfare issues, and, oh yeah, he was apparently addicted to opiates.

There’s little doubt that, as the story spins out in various directions, the issue of opiate addiction will hit the spotlight. While thousands clamour for the judge’s dismissal or worse, even his daughter, the victim of the abuse, says he needs rehabilitation instead. Could opiate addiction possibly explain this kind of behaviour? Could it excuse it?

There are drug families that change the personality in fundamental ways, as a direct result of brain damage. But it’s pretty clear what those drugs are: methamphetamine and crack are the most infamous culprits, and inhalants such as gasoline and various solvents also destroy cells up and down the nervous system. But opiates don’t damage the brain, in and of themselves, unless you OD, in which case you can lose a little, a lot, or all of your brain.

Yet some of the byproducts of opiate addiction can lead to behaviour problems so severe that the question of brain damage becomes a matter of definition. The first byproduct is craving itself. In a recent post, I compared the addict’s craving brain to that of an animal in a state of starvation. That’s not an analogy. The parallels are concrete. Drug craving laces the brain with dopamine, replacing the role of other neuromodulators. Thanks to massive gouts of dopamine in the ventral striatum, there is only one goal to pursue, and all the animal’s attention and behaviour is focused on that goal. But that doesn’t sound like the judge’s problem. Craving takes attention away from other people. The good judge was overly attentive to his daughter.

Withdrawal is another byproduct of opiate addiction. As junkies and drug counsellors know all too well, the physical discomfort of withdrawal symptoms produces a high level of irritability. Neurochemicals that have an arousing impact on brain and body (e.g., corticotropin-releasing factor, an ingredient of the stress response) are suppressed by opiates. When the opiates begin to leave the system, these neurochemicals rebound with a vengeance, yielding a state of agitation and hyperarousal. And with many common painkillers, that can happen within 6-24 hours following the last dose. So, was the judge going through withdrawal at the time of the beating? Probably not. The video clip, posted on Youtube (not fun to watch!) shows anger and methodical aggression, but there is no sign of the twitchy irritability that characterizes withdrawal.

I think the judge suffered from a more common ailment caused, not only by addiction, but by almost any kind of personal failure; and that’s shame. Shame is a powerful emotion, and it’s one of the few emotions that literally hurts. That cringing, crumpling feeling deep inside, the wish to fall through the cracks in the floor, to disappear from the world, because one’s own self is just so despicable — that hurts! Addiction to anything is shameful. It feels like, and perhaps is, a personal failure. But abusing a helpless child, over whom one holds both power and responsibility, is at least as shameful, and maybe a whole lot more. Being an addict and an abuser…well you see where I’m going. So the judge, like many violent people, was probably responding to and at the same time inducing intense feelings of shame. In himself.

Does that excuse his behaviour? Not at all. Shame doesn’t make you harm others. Shame is painful, and it elicits all kinds of defences. Violence is one of those defences, but to roll up your sleeves and indulge in it, to watch yourself doing it and not stop, is unjustifiable — especially for a justice of the peace. It’s one thing to abuse yourself: not nice, not logical, but you’re the one who suffers. It’s quite another thing to abuse someone else as a way to make yourself feel better.

Notice, first, that I say “resulting from” choice. Nobody choses to be addicted. But as people become increasingly hooked, they may increasingly choose to take the pill or the drink, or to gamble or purge, and that’s the thing we need to examine. What is the role of choice in the onset of an addiction? What is its role in recovery?

The voices that oppose the “choice” model often argue that addictive behaviour is nothing like free choice. It is like a compulsion. There is a feeling of need and desire, and perhaps not just a feeling but an actual need, that compels them to choose to use, each and every time. From the “disease” camp, this argument is further bolstered by our understanding (as described last post) that addiction really does change the functioning of the dopamine system. Since our organ of goal-pursuit (the NAC, or ventral striatum) is thus compromised, how could we possibly make free choices. Finally, opponents of the “choice” model argue that framing addiction as choice just invites the humiliations and accusations, both from within ourselves and from others, that become so unbearable. “If it’s a choice, then you damn well need to choose differently, and that’s your responsibility!” That usually makes things worse, not better.

The problem, I think, comes with the phrase “free choice”. Who said choice is free? I’ve covered this topic in two previous posts. In the first of these, I argued that choice comes from the brain – obviously – and it specifically springs from a contest between the striatum’s goal seeking and the role of the anterior cingulate cortex (ACC) in monitoring probable outcomes. In the second, I described how neuroscientific data places the moment of choice in a stream of brain activity, occurring seconds before we’re even aware of making a choice. But I also claimed that we can insert “reflection” into that stream and nudge it one way or the other.

With addiction, the ACC is increasingly weakened by ego fatigue, and the v. striatum responds ever more strongly to gouts of dopamine triggered by addictive cues (including thoughts and memories). So choice becomes increasingly irrational, increasingly spontaneous, and increasingly uncontrollable. Then should we still call it “choice” at all?

One of the most persuasive advocates of the choice model is Gene Heyman. For Heyman, addiction is a result of choosing what is most rewarding in the moment at the expense of long-term gains: choosing ‘‘locally’’ rather than ‘‘globally.’’ He cites studies of delay discounting that investigate these effects. Remember the marshmallow test? Same idea. Rewarding events are much more attractive if they are expected “now” rather than “later”. But this poses a problem: repeatedly choosing the immediate reward makes both immediate and long-term rewards less desirable. In terms of the immediate benefits, heroin becomes expensive, boring, and smeared with self-rebuke. It’s never as good as it was at the beginning. But the value of long-term rewards goes down as well. Once your marriage is shot, you’ve lost your job, and/or you’re deeply in debt, the future doesn’t hold much attraction at all. It becomes less and less rewarding, in fact it becomes painful to contemplate. So the immediate reward, a shot of heroin, remains the best option.

On any single occasion, says Heyman, the local choice continues to be valued above the global choice. In other words, an immediate reward—‘‘one more time,’’ as addicts often tell themselves—is always more attractive than waiting for the long-term picture to get brighter. In this way, addictive choices are like normal choices. You choose what you want based on its expected value. But, unfortunately, the expected value of things gets shifted by the self-perpetuating nature of addictive behaviour.

What’s wrong with the “choice” model? It sounds pretty rational. Just a problem of behavioural economics, as they call it. We keep choosing what feels best. And that also means that we can choose differently, providing a gateway to recovery. Once the future backs right up to the present moment, then the immediate choice, the addictive choice, loses its attraction, and we can choose to stop.

What’s wrong is that the “choice” model ignores the brain. Big mistake! The brain that houses the famous dopamine pump, and its eagerly awaiting customer, the v. striatum, is the same brain as the one we use for making choices. From a brain’s-eye view, the reason people choose the immediate reward is that dopamine highlights immediate possibilities. That’s its function, and has been throughout evolutionary time. Research shows that dopamine rises proportionally as the goal gets closer and closer at hand, driving motivation with it. Now, if that’s the case for marshmallows and other normal rewards, imagine how powerful the dopamine surge is in response to addictive substances or acts! (See recent posts and comments.) That swelling wave of dopamine, announcing the availability of a supremely attractive reward, recasts the balance between present and future appeal — more quickly and more thoroughly than anything else could. To choose future gain, over immediate reward or relief, becomes incredibly difficult when every synapse in the striatum and frontal cortex is resonating to the “neural now”. Especially once ego fatigue sets in.

So, yes, the addictive act is a choice. Each and every time. That means that there is always the possibility of saying No. Yet, saying No is incredibly difficult, and that’s a problem the “choice” camp can’t solve…

…without the help of neuroscience.