Understanding Addiction

Hi again. My work was recently criticized (politely) by a respected philosopher — Owen Flanagan — who specializes in the study of addiction. Here is a very nice article of his, on the topic of addiction and shame. His point was that the word “addiction” is an umbrella term used to refer to many distinct and diverse phenomena, and it is therefore unhelpful and should be replaced. If he’s right, then obviously I’m not the only perpetrator. Most of us in this field use the term “addiction” to describe what we see as a holistic phenomenon. But that doesn’t mean he’s wrong.

I’ve had to take a break from blogging because I’ve been so busy writing pieces for a journal called Neuroethics. I sent them a fairly dense article about a year ago, basically a summary of my book. I vowed to myself that this would be my final piece of academic writing. I much prefer writing “pop science” these days. Surprised? Anyway, I was told that my piece would be followed by several commentaries, and half a year later the total came to 15 — shock! — many from well-known researchers and journalists, including Kent Berridge, George Ainslie, Maia Szalavitz, and Sally Satel. The punchline for me was that I had to write replies to each of these commentaries, to be printed along with them in the journal. And let me tell you, these were sculpted pieces of academic writing — some of them many pages in length — so I’ve had to sweat blood to reply to them. And I’ve still got more than half left to do.

Enough whining?

So let me share with you a few paragraphs from my reply to Flanagan — edited as a brief stand-alone: my answer to the claim that “addiction” is too general a term, given all the distinctions it tries to cover.

According to Flanagan, we should recognize that different attractions to different substances or behaviors really are distinct, and that the umbrella term “addiction” does the field a disservice by lumping them all together. So, he said, it’s a good thing that the DSM has dropped “addiction” (almost) from its vocabulary. Just like the phrase “nervous breakdowns” has disappeared from the popular lexicon: it’s about time we got rid of the outmoded term “addiction.” The culprit, for him, is imprecision. Addiction is an imprecise term, and worse, it brings with it “many problematic accretions and connotations” — no doubt he means accusations of blame, self-indulgence, moral decay, and the resultant stigmatization of addicts.

So Flanagan replaces the word “phenomenon” with “phenomena.” But what are these distinct entities? To me this is like trying to describe and differentiate the various species included under the label “birds” — so that we can do away with the term “bird” altogether. Is that a good idea?

It may seem surprising but Flanagan and I agree on the value of finer distinctions in talking about the phenomena comprising what we’re in the habit of calling “addiction.” The variations in personality factors, the diversity of negative feelings that fuel addictive tendencies, and the nature of the substances or behaviours themselves…altogether provide a cornucopia of distinctions that I think we should discuss and analyze in far greater detail. Here’s just one example:

I have long believed that the kinds of feelings and personality patterns that attract some people to psychostimulants are fundamentally different from those that attract others to opiates. I think that people who get addicted to meth have tended to feel an absence of power, or commitment, or relevance in their lives. They are most bothered by the flatness of their existence. Whereas people attracted to opiates (like me) are fundamentally afraid of losing warmth, acceptance, and connection with other people. We grow up feeling unsafe because we are hyper-aware of our aloneness, and the soothing quality of opiates eases the hurt.

So, lots of differences — important differences! But in my mind, that doesn’t erase the commonalities — the features that different addictions have in common. Such as the growing magnitude of our attraction to one reward at the expense of all others, the impulsive and then compulsive nature of that attraction, and the way that “now appeal” — a cognitive distortion that overvalues immediate rewards — funnels that attraction into a self-reinforcing cycle of thought and behaviour. In other words, all the stuff I wrote about in my recent book.

I believe that neuroscience can move us forward in specifying and understanding what different addictions have in common. But it can also help us understand the distinctions. Depression looks different from anger on a brain scan, impulse looks different from compulsion, and so forth. Our next step should be to discover the brain pathways that tie these mental states to specific addictive patterns.

As for the term “addiction,” I don’t think replacing it with “substance use disorder” is going to get rid of the “many problematic accretions and connotations” Flanagan worries about. That kind of modernization of terminology doesn’t seem to help alienated or marginalized groups. For example, replacing “retarded” with “delayed” never erased the stigmatization of people who can’t think as quickly as others. So in this case, let’s not throw out the baby or the bathwater. Let’s continue to explore how all addictions embody fundamental changes in how we think, feel and act. But let’s also try to clarify how those changes take different forms, leading to different outcomes, for different people.

What a great conference!!! PINC (People, Ideas, Nature, Creativity) is like a Dutchified version of TED, and the main theme seems to be creativity — that’s what the “C” stands for — and what creativity looks like across disciplines including: science and its societal relevance, art and design, food, philosophy, and a few others. It was beautifully executed, as would be expected given the price tag of  €900/seat for non-speakers — the timing and lights, stage design, headphones with spontaneous translation of the Dutch talks (about half), sound quality, music…yes music!…and dance! The day opened with a pair of tap-dancers who were just excellent, and it ended with a 13-year old boy playing Brahms and something else on piano, at a level that easily matched adult solo concert performers. He was shockingly good. And in between, all these 20-minute talks…

The talks were so good that I felt quite insecure about mine. So I snuck out during coffee breaks and lunch to revise and upgrade my slides. Then, at the end of each break, they played a recording of an oom-pah-pah band..which actually got louder by the minute, in order to herd people back in. Pretty progressive, don’t you think? Rather than flashing the lights and hollering. Boisterous happy music at swelling volume to get people to stop chatting and sit down. That’s the sort of creativity that characterized the whole thing.

How do I give a sense of the diversity of the talks? Well, one was by an American living in Antartica to study penguins and another was by a Swiss biologist who had camped out with bears for 3 months in Alaska. Then there was the harder science stuff — but mixed with liveliness and humor and surprises. For example, a pair of guys who came on like comedians — Mikael from Finland and Roman from Switzerland — Laurel and Hardy? They stood on either side of a tippy blackboard, took turns with the chalk, and showed how the curve describing the success and failure of political figures (high rise, low dip, then slow rise and plateau, or not) was mathematically identical to that describing the rise and fall (and hopefully rise again) of marriages. (By the way, that corresponds perfectly to a neurochemical model, by which the first year of a romantic relationship is all about the rise and then fall of dopamine, as the “reward” gets more “predictable” — to be followed by an attachment relationship based on endogenous opioids. Must publish that some day, though it’s probably been done.) Then, my favourite, a condensed history of the Corduroy Appreciation Club in NYC.  The speaker was dry and pedantic (a spoof, as it turned out)  and revealed many interesting factoids, including the significance of meeting dates. The annual meeting is always held on November 11, as the date so nicely symbolizes the very essence of corduroy (11.11). Of course the big one was held in 2011. The secret handshake, that involves interlacing but parallel fingers. There was even video footage of one member being dragged out by (hooded) security guards for a major infringement of the society’s policies: he was only wearing two pieces of corduroy — not three, as required for the annual meeting. The silly bugger: I mean, adding a corduroy tie would have been sufficient. Other talks included one session on baking bread in Africa and one on how to fold paper so as to create amazingly detailed works of art, such as the Escher-like staircase you see here. The angle of the light turns out to be all important.

Then there was me, talking about addiction, self-destruction, ego fatigue, and the absence of self-trust. I felt like a bit of a downer, but I tried (and got away with) a few jokes. Examples?  One about my ambivalence about the publicity I’ve gotten here in Holland — like bringing the boys to school and having the other parents smile and nod at me: Oh, you’re the drug addict! Saw you on TV last night. Chuckle. People seemed to appreciate the talk. Lots of nice compliments afterward. The Dutch really like honesty — one reason why I really like the Dutch. I’ll see if I can figure out how to post the talk. But maybe TED will be more polished. I can only hope.

For years, Maia Szalavitz has been making insightful, practical, and evidence-based contributions to the struggle against “the War on Drugs” and the harmful policies that emerge from it. With her permission, and the permission of editor Will Godfrey, I’m posting passages from an article she published in Filter, a magazine covering drug use, drug policy and human rights, on October 8, 2018. This is the most important article on opioid addiction treatment I’ve ever read.

The following text is Maia’s writing, though I’ve spliced and diced it and extracted only the key components (in my view).

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As panel after summit after commission after white paper is put forward claiming to solve the overdose crisis, you’d think that somewhere there’d be a short, sensible guide for how to improve our health care system to better manage addiction and pain.

But most of these reports and discussions dance around the edges and bureaucratic obstacles to change. Few address the fact that deep systemic change is needed.

1) Genuinely expand access to medication treatment—yesterday.

We have two drugs that are proven to cut the death rate from opioid addiction by half or more when used long term: methadone and buprenorphine. Anyone who is addicted to opioids and  wants to get even a single dose once should be able to access these medications on demand—in hospitals, doctor’s offices, emergency rooms and syringe exchange programs…. No urines or counseling or abstinence from opioids or other substances should be required to get these drugs, just as those barriers are not imposed on people with other disorders who need medication.

The DEA and state prosecutors also need to stop targeting buprenorphine prescribers, regardless of whether they are providing optimum care. Simple access to the medication saves lives: Get out of the way!

2) Stop forced tapering of pain patients and provide real access to proven alternatives.

In response to the overdose crisis, in 2016 the Centers for Disease Control released a set of guidelines intended to reduce overuse of opioids in the treatment of chronic pain in primary care…  [T]hese were rapidly “weaponized,” as Dr. Stefan Kertesz of the University of Alabama put it in an excellent paper.

Basically, the guidelines are now seen as the national standard of care—and stepping outside the maximum recommended dosages is viewed as flirting with medical board or even prosecutorial scrutiny, even for specialists. Their recommendations are being applied indiscriminately, with even some cancer and end-of-life patients being denied adequate pain relief.

Simultaneously…many doctors have simply decided to stop prescribing opioids, period. States are also creating rigid policies while insurers and pharmacies are increasingly restricting what they will allow… The result is tens of thousands of patients—many of whom were formerly medically stable—being left in pain, increased disability and withdrawal. Dozens of suicides by pain patients have been reported. People with addictions whose prescriptions are cut are not being helped either. This simply makes their addiction more dangerous by pushing them to street drugs. It is not treatment…

No evidence shows benefit from forced taper; some suggests severe harm.

3) Create a tiered system for addiction medication access.

For harm reduction, what’s needed is a welcoming place where people can simply get a dose of medication and see some friendly faces. This…provides rapid access and guidance into care for those who decide they do want additional help…If you are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic.

For stabilization, people who want to put their lives back together need easy access to services that meet their particular needs, such as counseling, medication-friendly peer support, psychiatric care, housing and job training…. [T]he goal is no use of non-prescribed opioids, but it is flexible and nonjudgmental. For example, in an effective system, non-medical marijuana use would be ignored…

After people have been stabilized, however, they will need the third track, which [avoids] interaction with people who are still actively addicted. If you have a job and family and are successfully managing any ongoing mental health issues, you don’t need to keep showing up at a clinic or get further counseling.  This track—sometimes called “medical maintenance”—basically requires a once-a-month check-in to get medication via a primary care doctor and ensure all is well.

5) Create and fund a full range of harm reduction services.  

In order to save lives, we need safer consumption spaces (or better yet,  call them “overdose prevention sites”) in areas where drug use and sales are concentrated…

We also need shelters and housing, separate from those aimed at stabilization and abstinence, for people who are actively addicted, many of whom are also mentally ill and have symptoms related to severe trauma. When people have safe places to live and to use drugs, they are both much more likely to survive and much more likely to find ways to sustained recovery.

6) Decouple “beds” from treatment.

People with addiction have a wide range of individual needs, and institutional “programs” will never be able to meet all of them. Moreover, once a treatment “bed” is labeled as such, it generally becomes more expensive than an ordinary, safe place to stay. “Sober homes” also tend to be based on a 12-step ideology, which is fine for those who find that pathway amenable, but not for those who don’t—and not when that ideology is interpreted to stigmatize and discourage medication use.

For most illnesses, medical and psychiatric, people recover better when they can stay in their own home with their friends and family nearby…….

The mental health field has recognized that institutionalization is generally harmful and that, when needed, should only be used for the shortest possible time. Addiction treatment needs to catch up.

We need a system that provides a menu of individualized options—not residences staffed mainly by non-medical people that charge inpatient hospital care rates.

9) Decriminalize drug possession.

Since possession arrests do not deter drug use, raise drug prices or treat addiction, every cent spent [arresting and jailing people for drug possession] is wasted. But it’s actually more harmful than that. People arrested and jailed for opioid addiction lose their tolerance and are three-to-five times more likely to overdose after release than if they had not been incarcerated.

Worse, the primary purpose of criminalization is to stigmatize drug use and people who take drugs—if criminalization is to deter people, it must stigmatize. And that stigma, of course, is a huge barrier to getting people into treatment whether for addiction or for overdose; to making treatment more effective; to expanding harm reduction; and basically to everything we need to do to end the crisis.

10) Make universal health care happen.

While having a national health care system in the US once seemed to be a pipe dream, the increasing embrace of “Medicare for all” by Democrats and the fact that majorities now support it in polls means that—providing we survive the current administration—it may soon be possible.

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Reprinted from an article by Maia Szalavitz, October 8, 2018. Please see the full article, published by Filter. Here is the direct link. You can follow Filter on Facebook or Twitter. Maia’s recent book is available at Amazon and other outlets.

The relationship between addiction and emotional anguish — primarily anxiety and depression — is well known. When we look for root causes of addiction, we inevitably ask why so many people are suffering. Here I reflect a bit, and link to a mind-blowing video, on suffering and evolution.

Why is it so hard? Why is there so much suffering, in the world, in ourselves? That question comes up all the time, especially among us addicts (recovered or not). We’re not the only ones. We just tried to find a way out through the back door. The proportion of people in the Western World (e.g., the US) who suffer from anxiety and/or depression (and related conditions) is astronomical. And for today’s young people it seems to be getting worse, though that conclusion is conflated with changes in the way people communicate with each other and with mental health professionals.

One simple answer is that we evolved from physical matter to become the unfathomably sensitive and intelligent creatures we are. And evolution doesn’t concern itself with suffering. In fact suffering (struggle, loss, and death) is a big part of what drives it.

This question, always cycling though my dialogues with people in this community and others in my life, came back to me a few days ago when I received a long, detailed email from someone I don’t know, someone who has struggled on and off with addiction throughout his life. He told me of his childhood traumas and hardships, and of the brutal treatment received by his parents in an internment camp during World War II who, as a result, were never able to give him what he needed as a child. He sees himself as someone who has to struggle and persevere just to get through each day, fending off anxiety, depression, hopelessness, and meaninglessness — you know, the usual quartet of background singers.

What could I say to him? Advice? Meditation…sure, but he’s tried that and it hasn’t worked for him. Therapy? Tried that too. In a nutshell, there was nothing at all I could say to help him. I recalled my own explosive introduction to utter, fundamental helplessness, an experience on ayahuasca that I tried to convey to you in this post. Accepting one’s helplessness might be a way toward struggling less, or even giving up the struggle, and just living in the present, accepting the ebb and flow of forces that sometimes bring happiness but undoubtedly bring suffering and lead, inevitably, to loss and death. And certainly these forces are intermingled with the disconnection, competition, and often cruelty that we face from other humans who are, when you stop and think about it, just as caught up in their own struggles to survive from day to day and hold onto a bit of happiness.

You just want to scream: it’s so unfair!

But there are other ways to think about it. Fairness is a construction we learn at around age five, and it has absolutely nothing to do with the natural universe. It’s just a social norm, a code for resolving petty rivalries. It’s no more relevant to nature than tea ceremonies or Facebook.

In fact, we are lucky as hell to be here at all. And suffering is just part of the process that brought us here and that continues to give us the chance to evolve and, hopefully, to grow more intelligent, compassionate, and beautiful.

I’m in San Francisco now, mainly to spend time with my father, who just turned ninety. He’s had a rapid but luckily temporary decline in cognitive function. He’s doing better. I’m going home soon. On my way here, I bought a book called Dancing with Elephants. It’s about how to be present, engaged, and even happy in the face of terminal illness, oncoming dementia, and — you guessed it — the inevitability of death. Yeah, cheery stuff. But it’s written by a guy with Huntington’s Disease, a guy who is presently in the process of losing everything, his body and his mind. And he’s talking about connecting and accepting and loving. He’s nowhere close to despair. I’m only partway through and I can’t yet recommend it confidently, but take a look if you like. There are certainly gems of wisdom in the book, and even the fact that this guy can think this way and write this way is astonishing and uplifting.

Anyway, I have nothing more to say on the subject of suffering. But I want you to watch this video, especially if you’ve not seen it before. I recently rediscovered it, and I think it is wonderful. There is so much in it, complexity and symmetry, perspective, and a vastly comprehensive view of who and what we are. But there’s also a simple message: evolution isn’t easy, suffering and death are always with us, but there is tremendous beauty in how we got here and where we might continue to go.

Last post I reviewed a study showing powerful correlations between traumatic experiences in childhood and adolescence and addictive behaviours in adulthood. Although several readers found significant holes in the research, the study maintains a fair bit of respectability, and besides, if we look at our own lives, I think we often see clear connections between personal hardships and addiction. This sort of “anecdotal” evidence, subjective and biased though it may be, is often the strongest reason, deep down, for accepting (or rejecting) the self-medication model.

The self-medication model portrays addictive behaviours as attempts to diminish the feelings of anxiety, loss, shame, and loneliness left in trauma’s wake. For me, the connection is too obvious for words. I was lonely, depressed, and constantly on the lookout for personal attacks while at boarding school as a teenager. Within a year of leaving, I had shot enough heroin to end up unconscious in a bathtub, appearing to my friends to be dead. I don’t for a moment doubt the connection between these episodes of my life. And I say that, not as a scientist, but as a regular person, trying to make sense of my life.

I recently spoke with a reader who has serious problems with alcohol, but only when things go wrong in her personal life. Eleven months of the year she has no craving, no attraction to alcohol. She doesn’t even have to be on guard because there’s no urge to get drunk. However, when her (now, thankfully, ex) husband became verbally and physically abusive, when her custody of her child was being challenged, when she had to go and live with her parents because the matrimonial home was a torture chamber….those were the times she drank to excess. Emphasis on excess. How can you be an “addict” only when things get tough, and then become a non-addict when life goes back to normal? The disease model simply can’t explain that sort of pattern, whereas the self-medication model predicts it. Threat and anxiety lead her to take alcohol, which makes it easier for her to bear.

But there are problems with the self-medication model that need to be addressed.

First, although trauma may lead to addiction, it isn’t necessary — addiction does not have to be preceded by trauma. Some people fall into addiction without any evident history of trauma. Instead, other factors, such as peer pressure or simple exposure, might be sufficient. Check out the video recommended by Steve Matthews as a prime example.

Second, we know that self-medication doesn’t work very well. The things we take or do to diminish bad feelings actually increase them in the long run, or even in the not-so-long run. Maybe we’re not very good doctors. We prescribe for ourselves treatments that do more harm than good. Or they work for a little while — a month, a week, an evening — and then we get hit by the after-effects. Our dopamine-powered beam of attention cares only about the immediate, not the long run. Pretty short-sighted for a doctor.

These iatrogenic (more harm than good) effects don’t actually conflict with the theme of self-medication. If you’ve ever tried prescription antidepressants (SSRIs) or painkillers for legitimate reasons, you know that many medications produce iatrogenic effects. These drugs often lead to dependency and an uncomfortable period of withdrawal. But the fact that self-medication often makes matters worse leads us to another question: Is the trauma we are “medicating” produced by the medication itself? That’s about as vicious a circle as I can imagine, and it challenges the very idea that trauma causes addiction — rather than the other way around, as pointed out recently by Conor (in a comment following my last post).

So let’s imagine a causal story that goes completely opposite to that proposed by the self-medication model.

As I noted above, some people start down the road to addiction without having lived through serious trauma. But even given a certain amount of trauma in childhood/adolescence, one’s PTSD or depression might be under control. When I first tried heroin, I wasn’t terrifically happy but I wasn’t in great psychic pain, relatively speaking. Then I stumbled on a substance that made me feel terrifically happy. Enter the choice model: I want to do that again, because it’s more valuable to me than any alternative. After a while, the substance or activity is a presence in one’s life. And that presence takes on increasing value: it’s sorely missed when it’s gone. Now the source of my anxiety wasn’t so much my historical injuries (e.g., my mother’s depression, my stint at boarding school).  Rather it was my present fear of going without dope, and wanting it badly, and not being able to stop thinking about it. Now we’ve got at least two of the most common outcomes of trauma – loss and anxiety – both caused by present drug-taking rather than historical events.

Then along comes outcome number 3: shame. The loss of self-control – whether due to dirty underwear at age 4 or slavering desperation to get high at age 24 – is contemptible. That’s how others see it, so that’s how we see it. The result is shame, and guess what? Shame is one of the most common residues of trauma.

From an article in The Fix, on 25 Sept 2011, comes the following:

Of all the ACEs (adverse childhood experiences) that muck up one’s life, “’the one with the slight edge, by 15% over the others, was chronic recurrent humiliation, what we termed as emotional abuse,’ says Dr. Vincent Felitti, one of the directors of the study.” Shame is one of the few emotions that is directly, viscerally painful. Now, combine the loss you feel after running out or stopping, with the anxiety you get from craving what you can’t seem to get, with the shame that comes from your lack of self-control, and you’ve got a feast of negative emotions. The need for self-medication is now at its peak — indicating that the addiction itself is the trauma.

The vicious circle — connecting addiction to psychic pain leading to further addiction – may well be the causal engine we’ve been searching for. But self-medication is only one part of this cycle: it doesn’t work all that well as an explanation that connects traumatic life events to a special, intrinsic need for self-soothing. What it really shows, as suggested by Nik, is that, for some period of time, we believe that there’s one thing in the world that can make us feel better.

Of the three models of addiction, self-medication works best for me. As long as we acknowledge that trauma is an ongoing progression with its roots in our childhood but its branches still growing, still advancing, sometimes wildly, out of control, with each addictive act.