Understanding Addiction

Let’s return to John’s driving metaphor and fit it with what we know of the brain. As per my last post, let’s look at choice as a blip, a flash of intention, that rides on the momentum of underlying habits. Skillful drivers have built up a repertoire of good habits, like alertness, sensitivity, self-monitoring, and flexibility. So, even though they can’t promise to never have an accident, they can minimize the risk.

“Driving responsibly” like “drinking responsibly” sounds like Big Brother claptrap. In fact driving well is very Zen. Today I took the car out on the winding roads at the foot of the French Pyrenees. I thought about John’s metaphor and became more aware of what I actually do when I’m driving. I took the curves gracefully, skillfully, even though the skill wasn’t something I could put my finger on. It wasn’t something I possessed. Rather, it felt like a moment-to-moment balance between assertion and surrender, focus and flexibility. It had to be that way, because I was moving fast through complex terrain, and I was thinking with my head but also with my body, my instincts, and that vast unconscious part that puts it all together, moment by moment.

This view of choice fits well with brain mechanics. Sensory input pours in from the retina to the occipital area at the very back of the brain. That’s the primary visual cortex. Then it gets passed forward toward the centre of the brain, and it becomes more holistic, more comprehensive, along the way. Stage by stage (but very quickly) it joins with other sensory information (e.g., the feeling of the wheel in my hands) as well as memories and feelings. By the time it arrives at the orbitofrontal cortex, it is a gestalt with a familiar meaning.

At the same time, motor output cascades from the centre of the cortex outward toward the periphery, going through stages in the opposite order. It starts in the dACC, or a region just north of the dACC called the supplementary motor area. That’s where plans seem to emerge. From there the output stream gets increasingly articulated, as it passes through the premotor cortex, where plans are translated into global action patterns, and finally to the motor cortex, where the actual muscle movements are orchestrated.

These streams, input and output, flow at the same time – the output stream doesn’t wait for the input stream to finish before it starts up.(If it did, we’d respond to our environment at the pace of a slug.) So a special trick is needed to coordinate these streams. The brain connects the input stream to the output stream at each level, from detail to gist, with multiple connecting links, like rungs on a  narrowing ladder. At the bottom rung, concrete sensory details connect with concrete action commands, so the visual details of a sudden curve in the road are coordinated with the movements of my hands on the wheel. The rungs continue to connect the two pathways, as they get closer to the centre of the cortex, where a meaningful visual scene connects with a meaningful motor plan: I’m driving this narrow winding road, which feels good, but a car could come around the corner at any moment so I’ll downshift to second gear and slow down. Which I do.

Intention – where “I” make a voluntary choice – is a difficult thing to locate in the brain. But our best guess is that it happens near the centre of the cortex, where orbitofrontal meaning connects with emerging plans in and around the dACC.

So choice takes up a rather small part of the whole sensory-motor process. Think of it as the top rung of the ladder, with all the other rungs stretched out below it, doing their business of integrating perception and action. Was it a choice to change gears just then? Certainly. But that choice was the cream at the top of a dark, frothing mixture of perception and action at multiple levels. And what about those links below the level of choice? They are automatic, unconscious, and they are shaped and refined through repetition, through learning. Those links are where habits get built, by way of synaptic shaping, and those habits determine a very large part of our behaviour.

Driving is a great metaphor for how we negotiate the attractions and hazards of life, which is also complex and difficult, and which also comes at us around each corner with great speed. Driving relies on something like flow, but flow depends on smoothly running habits. Being a good driver requires good habits, to give choice a chance (paraphrasing John Lennon). Being a good ex-junkie or ex-drunk also requires good habits, if you’re going to stay on track. First we try to build up those habits, then we simply do our best to make good choices, whenever the road takes an unexpected turn.

Some people say that addiction is not a choice, it’s a disease. As you know, I’m not one of them. But even those of us who believe in choice ask how much volition (intention or will) is involved in the choice to use or not. I think that choice is a lot more complicated than most people think. For now, I’ll skip the philosophical objections to the idea of “free choice.” Sticking to brass tacks, I think that volition interacts with many other factors when we make choices — especially choices about addiction.

Choices are based on appraisals (interpretations) of situations. People with addictions choose whether to get high or abstain based on appraisals of the quality of the high, the consequences of indulging, the proximity of other people who might approve or disapprove, and so forth. Since our appraisals are determined by factors outside our volition or awareness, especially in a complex situation changing moment by moment, the choice we make in that situation is less determined by our volition and more determined by luck and circumstance.

Appraisals are also strongly affected by internal variables: mood states, present emotions, beliefs, (biased) recollections of previous events. But this list doesn’t yet scratch the surface. There is my sense of emptiness and dislocation at this moment, compared with how I think I’ll feel after getting high, compared with how much drug I possess or can afford, in the context of building excitement and/or building anxiety and shame. These “internal state variables,” as psychologists call them, are highly complex and they change from moment to moment. Since that mix of factors will certainly affect one’s choice (e.g., to use or abstain), I can’t see how the choice can be entirely voluntary, entirely an expression of “free will.”

Over the time scale of development, habits evolve and consolidate, creating a spiral of increasingly strong predispositions to seek addictive rewards while alternative rewards become less meaningful. Is there any voluntary choice left after those habits congeal? Yes, I believe there is. Which is how people can slow down or quit. Recovery involves choice, and choice cannot suddenly be imported into a system that has none. Changes in appraisal, emotion, and social factors strongly influence volition, which influences actions, all of which alters one’s belief in oneself — one’s self-efficacy. That’s why self-talk and help from other people (friends, partners, books, stories, podcasts) can be so important. Once addicts tune into the possibility of volitional choices, the mechanism underlying volition itself grows in strength and availability.

In my book and elsewhere, I emphasize how synaptic networks can compete with each other, but when any of these networks is activated repeatedly, it becomes stronger, more likely to win the competition. This is the case when addiction arises in development, but also when it declines, replaced by the desire for and belief in alternative outcomes. I also think that addicts temporarily lose the capacity — or at least belief in the capacity — to make reflective judgments, and that loss is underpinned by a loss of connectivity between the prefrontal cortex (“the bridge of the ship”) and the striatum (“the engine of desire”). Then this connectivity can return, gradually, as people recover. Now newly forged connections between these neural systems allow desire and decision-making to work together in the service of future-oriented goals. To put it simply, I see this as the resurgence of volition in a system overwhelmed by habit.

There are many other goads, nudges, constraints, and impacts on volition — the voluntary component of choice. Most important are the psychological mechanisms of “now appeal” and ego fatigue. The passage of time also has enormous impact on volitional choice. Also critical are the roles of impulsive and compulsive action tendencies. How much volition is available during the impulsive phase of addiction, as one’s imagined future slides down a sort of chute into the “now”? Some, I think, but not much. Once the compulsive stage of addiction is reached, how much volition is present? Now action is put in motion before one is even aware of making a choice. Still, compulsion is not abnormal or pathological. When we examine more mundane decisions, like whether to check that the stove is turned off, it’s clear that volition and compulsion mix together, competing and cooperating, as we make choices. It’s not mandatory to recheck the stove.

According to a developmental-learning model (like mine, or that of Maia Szalavitz), interpersonal, social, emotional, and personality factors all contribute to a developmental trajectory that continues to adjust itself, to consolidate itself. So we don’t have to waste another moment conceiving of addiction as a disease. Using personal reports, psychological research, and neurobiological findings as our sources, we can achieve a far more detailed understanding of choice in the context of development, with its phases of relative stuckness and relative flexibility. We can also study the links between brain changes and environmental forces, to increase our knowledge of how addiction develops and how it can be overcome.

I’m still half asleep, and I should do some yoga and I should meditate and I should put something more than coffee down my throat. But I wanted to share my  excitement and anxiety about the steps leading to my October visit with the Dalai Lama. It all starts in a week. I fly to Boston one week from today, then spend five days in New York State at the Mind and Life summer research institute.

Click on that link if you haven’t already. “Research institute” is a bit misleading, because those five days are spent doing meditation and stuff (some of which is guided by pros) as well as listening to scientists present their findings. They even have concerts. I went once, about five years ago, and the last evening was spent listening to a singer who was able to sing harmony with himself. I mean literally. He could produce two or three different pitches at the same time, and they worked together. He even had a backup band of six or seven weird-looking dudes, singing and chanting, one of whom played the didgeridoo. Bizarre and beautiful. Much melting and bonding among the 200 or so people in the audience.

Mind and Life  is amazing. They’re  the group that organizes the DL’s interactions with scholars, and especially with scientists, and especially especially neuroscientists. They’ve been doing it for more than 20 years. The DL is particularly interested in linking Buddhism, neuroscience, and social problems — which seems like a pretty ambitious project. They get a lot of donations and they do a lot of very good work. Their projects include these special annual meetings with the DL, like the one I’ll attend in October on “Craving, Desire, and Addiction.”

So I applied to this 5-day New York event so I could get my myself a bit more “cosmic” (as my brother and I used to call it in the 70s) in preparation for a meeting in Boston — the “premeeting” for the meeting with the DL in October. I want to be at my best. And that’s the part I’m nervous about. I guess there’ll be a couple of contemplative/Buddhist types there, but the group includes at least three top neuroscientists, two of whom are stars in the addiction field: Nora Volkow and Kent Berridge. I’ve linked to Berridge quite a few times on this blog. I think his theory rocks, and he seems like a good guy anyway. But Volkow scares me a bit. She’s a very famous person, head of the National Institute on Drug Abuse (NIDA) for quite a few years, and a crusader for the “disease model” of addiction, which I’ve made it my business to refute. This premeeting goes on for 3-4 days, and we’ll each get up and say whatever it is we think we have to say to the DL. So I’ll no doubt talk about why I think addiction isn’t a disease. And then — will she squish me? Like a bug?

But it’s not only Nora Volkow. The whole thing makes me nervous as well as excited. These guys are the DL’s Palace Guard, at least in the intellectual world. Everyone’s a pro. So I feel like I should do about two more years of prep — especially reading in neuroscience, and maybe learn something about Buddhism — before I’m ready to hold forth. Not only that, but I’m the one presenter (out of 8) who’s, um, supposed to represent the “experience” or “phenomenology” of addiction as well as some thoughts about what’s behind it. Translate: I’m the druggie in the bunch. Not sure how to roll with that one.

Anyway, I’ll be back home July 4th. I’m planning a road trip with my daughter between the two meetings. But I’ll try to keep you posted while these events are unfolding. They are the steps to my meeting with you-know-who, and it’s all still like a dream.

Hello! I recently heard a talk about something called intertemporal choice, which is a fancy label for delay discounting, which is a fancy label for people’s tendency to value immediate rewards over long-term gains, even though the latter are objectively more valuable. Here’s a simple description from the first few lines of a scientific article:

Humans and animals prefer immediate over delayed rewards (delay discounting). This preference for smaller-but-sooner [SS] over larger-but-later [LL] rewards shows substantial interindividual variability in healthy subjects. Moreover, a strong bias towards immediate reinforcement characterizes many psychiatric conditions such as addiction and attention-deficit hyperactivity disorder.

—Peters and Buchel, Trends in Cognitive Sciences, May 2011, Vol. 15, No. 5

So addicts go after smaller-but-sooner (SS) rewards more than larger-but-later (LL) rewards…more than “normal” people do. You probably knew that, especially if you are or were one. And I’ve posted about it and talked about it ad nauseum.

One interesting question: were we already like that and that’s why we became addicts? This SS/DD overdrive is related to other personality traits, like, oh, impulsivity. Or does being an addict gradually wear away our cognitive controls, reflective skills, etc? Until there’s nothing holding us back from I want it now! I think both are true, in different proportions for different people. I’ve seen some pretty well controlled people fall into addiction, and they weren’t so well controlled after a year or two.

In this talk, a colleague named Bernd Figner (I know, it sounds like Burnt Finger — how else do you think I remember it?) talked about an experiment using transcranial magnetic stimulation (TMS).  Basically, you put an electromagnet right on the person’s scalp, over the part of the brain you’re interested in, and turn it on. And the effect is that that part of the brain becomes discombobulated. The magnetic field causes it to become disorganized. Temporarily.  So he put his TMS device over the top-side (dorsolateral) part of the prefrontal cortex. And when he did that, people’s tendency to go for the SS reward increased significantly. Especially when he did it on the left side of the head: the left hemisphere does a lot of our thinking for us. Cool. Cognitive control helps us keep those SS rewards at bay while we work toward the LL rewards, like having a life, a wife, a bank account, etc. And the finding might pull for explanation #2: that addiction itself (which depletes cognitive-control on the spot) increases delay discounting. A vicious circle if ever there was one.

Another interesting thing: look at the graph: the effect disappears 30 minutes after the TMS application. In other words, your brain can go back to normal within 30 minutes of whatever it was that interrupted self-control. Which might include drug cues, thinking about drugs or booze, craving, driving toward the liquor store or your dealer’s house… Turn around and drive home, and you should have your brain back within half an hour.

Then Dr. Figner reported on experiments in which they adjust two parameters: The first is the value of the SS and LL rewards. They often use money with adult subjects, so all they have to do is increase the amount you receive after waiting, or reduce the amount you receive in the short term. The second is the time interval. If you can increase the waiting time for either the SS or LL rewards, people’s choices will change also. So some researchers look for the break-point for their subjects. Let’s say you offer me 10 euros today vs. 20 next week. I’ll take the 10 today, thank you. But you increase it to 45 euros next week, and I’m willing to wait. Or if the immediate reward gets less immediate, and I have to wait for the SS payoff for a few hours, then I’m more likely to wait for the bigger payoff next week. But a month? Maybe not.

So by adjusting the value and the timing, you can find the point at which any person will switch from choosing the sooner payoff to choosing the later payoff. Now if you’re an addict, or you’re working with addicts, think about whether this might help. Make the long-term benefits more valuable. Not only will your wife give you back a key to the house, but she will make you your favourite dinner on Tuesday evening, if you don’t get loaded tonight. Or make it sooner. She’ll do that for you tomorrow. Or delay the “immediate” reward. You can do this with self-programming (see recent posts). Get rid of all the booze in the house, so you have to walk four blocks to get some.

See my point? An important strategy for overcoming addiction might be to fiddle with these parameters: how much, how high, when’s it coming? Versus how good will it be, how long do I have to wait? Fiddle with them until the value of the future matches and exceeds the value of getting high today. It’s like saying: Everyone has their price. But instead you’re saying: Everyone has a point at which sanity returns.

Hi all. A number of you have asked if I could post that talk I gave at CAMH (“the scene of the crime”) on the evening of March 27th. Here’s my talk, converted into a PDF file and annotated for “easy reading”. Still X-rated of course. Enjoy…