Understanding Addiction

…by Kate Benet…

Marc here: Perhaps the one question I get asked most often is whether it’s possible to go back to safe use (of alcohol or other substances) after being addicted. So, after reading Kate’s story, please reserve half a minute to read my comments at the end. It seems crucial to embed the diversity of people’s experiences in a general framework that can make sense of them all.

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Now, Kate:

Approaching my 25-year anniversary of sobriety in early September 2019, I had thought for weeks, if not months, about whether I could now drink moderately. I had been sober way more years in my life than I had spent drinking (now 57 years old). More importantly, my life in the past 25 years had changed dramatically for the better. I had worked hard for years to create a stable and rewarding life.

I read a lot on the internet about whether moderate drinking was possible after a long abstinence. I read the posts on this blog with great interest. I talked through my thought process with my husband, a normal drinker, and he was supportive of my wish to be able to enjoy a nice glass of wine or good craft beer now and then. This is what I had missed over the years. Those certain occasions when it is so nice to be able to add alcohol to the experience: a fine dinner or a sunny afternoon relaxing on the porch. He was supportive — whether I had a drink or did not, whether I tried it and continued, or tried it and stopped.

Last Saturday night I took the plunge and had one glass of red wine. Waves of fear washed over me. The experience was surreal. Who was I? What was this thing that I was doing? The wine tasted fantastic. I could feel the effect but, amazingly, I did not like it. This was in stark contrast to how I used to experience alcohol, thinking the taste wasn’t too bad and the effect itself was incredibly nice.

One week after this experience I can say this. The unleashing of craving from this one drink after 25 years of absolute sobriety was beyond belief. It   was like the 25 years had never happened. The portal to a horrible, frightening feeling had been opened. I had the sense of a dual persona hovering at the edges of my life, ready to be activated in full.

In the days that followed that one drink I was gripped with craving and mental obsession about when I could reasonably have another.  When I went to work on Monday, to a challenging job that I enjoyed, in my new “maybe a drinker” mindset, the job felt too hard on many subtle but powerful levels.  My feelings towards my husband and my children shifted ever so slightly. I felt annoyance at first, and then a more ominous sense that I would not be willing or able to navigate the nuanced ups and downs that are human relationships.

No one would be the wiser if I continued along this path. Outwardly it would look the same. I could force my life to keep going. But there was something really wrong with how it felt, to me, internally, at a deep and vivid level — that this would be a disastrous path. The degree of effort and struggle that would be introduced into my life would be dreadful. That became obvious — painfully obvious.

One week later the ripples from throwing that stone in the pond are finally settling down and I know I will never do that again. If there are times in the future that trigger my thoughts about the pleasures of drinking, instead of feeling deprived, I’ll think back on this experiment and I will remember how lucky I am.

Not everyone will have this kind of experience. Some people can drink moderately after a long abstinence. Some will have matured out of the problem. I am just not one of those people. I hope this helps anyone else who is facing the big choice. If you are like me, trying to drink again unleashes a unique sort of hell.

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Marc again: When I speak to naive audiences, as I did on Wednesday to a group of college students, I often remark that roughly half of those classed as problem drinkers (those with an “alcohol use disorder” in the current DSM parlance) can return to “social drinking” or “safe” drinking at some point. (There’s plenty of research on this, but perhaps start with James Morris, who specializes in alcohol misuse research and intervention with a harm-reduction focus.) Then, during the Q&A, I often get asked, as I did last week, how to know which side of that 50%-line you (or a loved one) might fall on.

To me, Kate’s tale packs at least two take-home lessons: Lesson 1 is that many people can’t return to controlled/social drinking, so the harm-reduction approach is just wrong for them. And the harm can be insidious. It can start off unconscious and quickly become entrenched. This is of course the nose-dive, we-told-you-so, addiction-doing-push-ups message that AA flaunts unceasingly. And…it just happens to be relevant — for many people. Lesson 2 is that one drink doesn’t usually wreck your life and destroy everything you’ve been working to achieve. In other words, it is possible, and sometimes highly desirable, to examine, to question, and to explore your options — as Kate did. Certainly that is NOT the message we get from AA.

To guide your thinking further on the social issues, psychological issues, and available help associated with Harm Reduction for alcohol, I encourage you to check out HAMS (Harm Reduction, Abstinence, and Moderation Support), founded by Kenneth Anderson, now co-led by April Wilson Smith. Also check out their recent book, a collection of  intimate memoirs introduced with a brief but comprehensive overview: BETTER IS BETTER! Stories of Alcohol Harm Reduction. A guest-post by April is coming up soon.

Yesterday was the day. I was pretty nervous all week. About every second time I practiced it, I seemed to get something wrong, like taking a wrong turn on a country road and ending up at a muddy dead-end, looking at a swamp. But the auditorium was beautiful. Plush and purple and warm with people who really wanted to be there. The audience was roughly 1,200, and that’s a lot, but the house lights were up halfway, so you could see their faces, and I think that’s what made it okay. I felt their interest and their support.

As my turn approached, I kept expecting my heart to start racing. But it didn’t. I told myself quite a few times: Self-trust, remember? Then when I went out there and started talking, I felt insanely calm, if you can say such a thing. And it just went fine after that. There were a couple of minor goofs, quite a few um’s and ah’s, but nothing too serious. There were even a few chances to crack a joke. For one thing, the clicker that advanced the slides was very sticky, and I had to stab at the button in order to get it to cooperate. While this did not produce gales of laughter, it at least got some chuckles. So here it is.

Today feels like the first day of summer vacation. I even slept in. Now I will study my Dutch for the first time in ages. Lesson this afternoon. And hey, the sun seems to be out!

Hi again. Sorry I’ve been so…absent…lately, but I’ve had a number of ideas I’d like to share with you in the next few weeks. The first involves psychedelics, whose benefits have long remained mysterious. We are finally getting a glimpse of how psychedelics work to improve mental health. And it’s fascinating. So consider this a sequel to the post before last.

I hope you read Eric Nada’s guest post on the promise of psychedelic therapy for helping overcome addiction. Eric reviewed the therapeutic side of psychedelic therapy, and he stressed the importance of working with a knowledgeable and supportive therapist. He emphasized the transformative power of psychedelics, and pointed out that recovery from addiction requires transformation in how we think and feel.

Here I want to focus on how psychedelics act on the nervous system, whether they are taken in a controlled setting with a therapist or on a hilltop in the forest. How do these drugs actually work? Eric began his post remarking on how counter-intuitive it feels to recommend a drug experience for people trying to overcome addiction. But I’ve never felt quite that way. Psychedelics don’t invite us to be cheered up, entertained or numbed. As Eric also concluded, they invite us to open up and change.

When I was a young man, dropping acid and climbing trails through the Berkeley Hills, what I experienced was a massive perspective change, an opportunity to be more attuned to the beauty of the natural world and to my own consciousness. During those years I was also fighting my attraction to opiates and other potentially dangerous drugs, and it took me years to resolve those issues. But LSD and psilocybin (magic mushrooms) were different animals. These substances seemed to offer a way to outgrow the rigid perseverance of my mental habits, my stuckness, my depression and my addiction. If only I could rise to the occasion.

These days we are inundated with research showing that, indeed, psychedelics can help improve mental health. Anxiety and depression have been shown to be reduced by LSD and psilocybin, in various forms and doses, over dozens of studies.  In a study of cancer patients, a single dose of psilocybin “produced immediate, substantial, and sustained improvements in anxiety and depression and led to…improved spiritual wellbeing…” Psilocybin has also been shown to help people quit smoking, and to relieve other addictive spirals. Psychedelics prove to be as effective or more effective than conventional antidepressant drugs for relieving depression, even if taken just once or twice. And there are no side-effects, no measurable addiction potential, and very little risk of ongoing thought disturbance. See this recent review and commentary in Scientific American.

The benefits are no longer speculative. They’re real, and mainstream psychiatry is finally starting to embrace them. But what might be the cause of such improvements? Does anybody know?

Recent research suggests that “opening up” with psychedelics has a very distinct biological basis. Published last month in Neuron, this study shows something almost unbelievable to students of the brain. We’ve been convinced (brain-washed?) for at least 50 years that brain cells don’t regenerate. (By brain cells I mean the “grey matter,” composed of neurons and their thread-like extensions — dendrites and axons.) They are considered the only cell type in the body that does not reproduce, except for a structure called the hippocampus, and even that shows only limited change beyond early adulthood. The ominous conclusion is, of course, that the brain runs down. Aging seems to reveal a brain that loses its plasticity, its capacity for novelty and change, and even its basic functionality. More to the point, mental problems such as addiction and depression are really hard to fix. Both can be seen as products of neural entrenchment. Maybe you can grow new connections, probably that helps, but you’re stuck with the same complement of grey matter you had at the age of 18. How depressing!

But maybe it’s not that way at all. The Neuron article shows that a single dose of psilocybin produced a rapid and long-lasting increase in the size and density of dendritic spines (the “twigs” that grow out of dendrites) throughout the frontal cortex. The subjects of the study were mice, not humans, but that hardly matters. When it comes to the characteristics of brain cells, like cell growth and regeneration, we mammals are all in the same boat. The researchers reported that the change took place rapidly, with 24 hours, and it was still evident one month later. The extent of growth was approximately 10 percent, a huge number when applied to spontaneous brain change. And — get this — neural transmission (excitatory connection strength) increased measurably, while stress-related behaviour diminished.

So psychedelics appear to actually grow additional grey matter! Note that this is not the same as strengthening or reinforcing synapses, something which occurs during learning but is far less extensive in terms of actual physical change and far more gradual in time. What are the implications? If psychedelics have this kind of firepower, in changing the biological substrate of cognition, then they should be able to induce rapid changes in thinking. In other words, they would be natural habit-breakers! And that’s just what it feels like — that wave of novelty, new paths opening up — to be on psychedelics, whether in a psychiatrist’s office or in the fire-lit circle of an ayahuasca ceremony.

But when it comes to addiction and other mental-health problems, that’s only half the story. As Eric emphasized in his post, the transformative potential of psychedelics has the greatest traction when it’s guided or directed by someone knowledgeable, whether therapist or shaman, and when we have a chance to process, practice, and consolidate what it is we are learning. As he says, “the healing benefits of psychedelics are not just produced by the compound itself but through the whole of the experience they inspire.”

Conclusions? I should clarify that single studies showing remarkable results need replication. That’s next. As well, I’d like to see the present findings jibe with other neurobiological models. In particular, research from a few years back showed that psychedelics increase connectivity across multiple neural regions, in contrast to the usual concentration and boundedness of activation within the default mode network, a region that mediates thoughts about the self (reminiscence, daydreaming, rumination). It would make sense: rapid change in neural maps would be impossible without some kind of “growth booster,” and the rapid, spontaneous improvements reported in the clinical literature point to rapid change.

So, if we take the present results seriously, the conclusion seems pretty straightforward: We use psychotherapy to help people think and understand themselves differently, so that they don’t just respond impulsively or compulsively (as in drug taking) to their needs and fears. It’s been known by various indigenous peoples, for thousands of years, that there are natural chemicals that shake people out of habitual patterns and promote mental change. And now we are starting to learn how this works at the cellular level. Bringing these streams of knowledge together seems an obvious and optimistic route toward improving our mental health…across the board.

P.S. Didn’t your mother tell you that mushrooms are good for you?

Hi All. I just got back from a week in the French Alps. I know: poor me. But I spent the first day trying to snow-board, and fell on my ass with bone-jarring impact about once a minute. And I thought I was past the suicidal thing…

But while I was away, my US publicist sent me the link to a New York Post article, for which I was interviewed by phone in depth the week before. Most newspaper and magazine coverage of the book has been pretty good, despite various factual errors. But this article had some of my words and convictions turned completely upside down. For example:

Along with many other leaders in the field, Lewis believes that the recovery model needs an overhaul, that addiction should be treated as manageable disease, akin to HIV, rather than a curable one.

I don’t think of addiction as a disease at all. Sure, the disease metaphor resonates with aspects of addiction. But whenever I’m asked (as I was this time), I describe addiction as a form of learning. It’s a kind of learning that’s vastly accelerated and self-reinforcing. But it’s not a disease. And I would never, in my wildest dreams, compare addiction to HIV — there is NO VIRUS at work here.

But I don’t blame this columnist for trying to fit addiction into a familiar mould. The gist of her article was about inadequacies in the 12-step approach, and we were in synch on many points. In fact, her aim was to find a simple answer to a complex question. What the hell is addiction and how do we “cure” it?

My book and my other writings highlight the commonalities among addictions and among addicts. I emphasize a “common pathway” of addiction in the neurochemistry of dopamine, the role of the ventral striatum in craving, and the sculpting of synaptic pathways (in the orbitofrontal cortex) that imbue drug, drink, or whatever it is with value. Other neuroscientists also believe in a common pathway for all addictions. Along with ego fatigue, and a few other well-documented findings, these neuropsychological realities reveal something universal about addiction.  So a lot of my message is that we share the same brain — with its characteristic frailties — and when we fall, we fall down the same rabbit hole, and share the same challenges when we try to climb out.

And yet…what I have learned, not only from the addiction literature but from you, dear readers, is that people recover in vastly different ways.

First come the statistics. About 5% of alcoholics stop for good on their own every year  (see this opinionated but fascinating review). The rate of spontaneous recovery appears to be far higher for narcotics addicts (see the recent book by Gene Heyman. Though I disagree with some of Heyman’s arguments, his statistics on spontaneous recovery are informative.) Second, harm reduction really works: many people don’t stop using but they slow down or clean up enough to stop destroying themselves — another natural process of healing. Third, comments on this blog clearly demonstrate that, as difficult as it is to ignore craving, many of us manage to resist it or outsmart it until it becomes manageable, on our own, or with friends, or with family, or with our partners, or in the care of recovery programs (12-step based or not), or in therapeutic communities, or with private therapists, or, or, or…

I’m continuously blown away by how much diversity there is in how people get by and get out.

So what do I tell journalists who want to know the answer ? Yes, brain characteristics are fundamentally relevant to the addiction process. Yes, finding a “common pathway” in the neuroscience of addiction is critical, both for addicts and for those involved in helping them. But no, there is no common pathway to recovery. Some of us take comfort in following rules. Others abhor them. Some of us need to feel cared for before we can stop. Others need to feel more independent. And there are all those shades of grey, those mixtures and variants, among them. We are each individuals, with unique experiences, capacities, affinities, and aversions, and our creativity is probably the most important element in our recovery.

That doesn’t sound at all like a disease.

Hello people. I’m writing this using a voice recognition app — and then editing the result. Which is pretty strange after all these years using my fingertips. I had a torn tendon in my shoulder repaired last week, and for the next 5 weeks I will have to keep my right arm in a sling. What a drag! At least I’m learning to e-nun-ci-ate more clearly. The most frequent turn of phrase in our household is “What?!” This could help.

For today I just want to draw your attention to the new look of my website. The title, understanding addiction, is clearly what we’re trying to do here. The subtitle, linking brain, behavior, and biography is meant to highlight the importance of integrating viewpoints across these radically different modes of inquiry.

Perspectives on addiction from psychological research, neuroscientific data, and biographical accounts (including addiction memoirs and stories) are so different that it seems we are describing unique phenomena or different species. But there is just one phenomenon we need to grapple with, and our understanding of that thing will be greatly enriched and articulated by unifying these perspectives.

You probably agree with me or you wouldn’t be reading this. And I don’t need to preach to the converted. Rather, I want to highlight the importance of combining perspectives for newcomers — former and recovering addicts, their families, and writers, scientists, and treatment providers. Because it just isn’t done enough. It’s hardly done at all! How often do you think addiction memoirs are read by addiction neuroscientists? How often do people mesmerized by stories of addiction and recovery delve into the brain processes going on at the very same time as those stories are unfolding? Not interested? Too complicated? Psychologists sometimes dip gingerly into each of the other two spheres, but they often don’t use what they learn to design more meaningful studies.

Noted exceptions are Gabor Maté (no, not gay bar message, not game board Maytag, not Gameboy anything!!! This voice recognition software is hilarious…I mean, at least it’s trying) and more recently Carl Hart. It can be done. It’s not all that difficult. The trick is to realize that we are describing the same human being going through the same immensely difficult and powerful transformation and to recognize that this person’s brain, mind, subjective experience, and behaviour all reflect it, though in very different ways.

I also want to encourage my readers to send your stories for me to post on the Guest Memoirs page. It’s still there. Do your part! Let’s keep reading, thinking, and telling our stories — and listening to each other.

You’ve heard of the blind men and the elephant? Each man describes what he gleans from touching a different part of the animal, but it takes all of them together to get a sense of what an elephant is. So I’ll end with a sentence from Wikipedia I got by clicking “blind+men+elephant”

At various times the parable has provided insight into the relativism, opaqueness or inexpressible nature of truth, the behavior of experts in fields where there is a deficit or inaccessibility of information, the need for communication, and respect for different perspectives.

That pretty much says it all.