Understanding Addiction

As promised, here’s Part 2. But note that this section (on implications for treatment) is based on eight and a half chapters you haven’t read yet. To distill some of the main points is tricky, but here goes:

Addiction is maintained by an entrenched set  of connections between the striatum — the part of the brain that generates goal-directed desire and thrust — and regions of the prefrontal cortex (e.g., the orbitofrontal cortex) that hold the goal in mind, embellish it, imbue it with value, and “remember” it as the salvation you hoped it to be. My argument about recovery is that you can’t turn off the striatum — the motivational engine. You can’t turn it off because it’s at the very center of who you are, it is the pulse and drive that moves you from one moment to the next. So, if you can’t turn off the “biology of desire”…then you have to connect it with different goals, goals that can also be consolidated by synaptic networks in the prefrontal cortex. But to do that, you need to engage yet another part of the prefrontal cortex that is critical for perspective change — the part of the brain that can make choices (the dorsolateral prefrontal cortex) — what I call “the bridge of the ship.”

Sounds simple—re-engage the bridge of the ship, and get it to take on a new set of goals, goals that will synch up with the motivational engine.

Only two problems:

Problem #1. These goals for future wellbeing can only be achieved through long-term plans, not the short-term plans for immediate relief that have been central in addiction. And these long-term plans are supported by a different set of synapses than those that supported your addictive goals. Different but overlapping! As with the webbed fingers example, goals for future wellbeing and immediate relief have become fused together in addiction — but now these two synaptic patterns need to be allowed to separate. This requires thinking and feeling differently — a shift in perspective — at least for awhile. What fires together wires together, and what fires apart wires apart. The long-term plans and goals have to establish their own distinct connection with the motivational engine, with desire.

Problem #2. The goals for achieving short-term relief are highly compelling, very much in your face, hard to disengage from, because the dopamine pump continues to activate them — rapidly! I call that “now appeal” (technically, delay discounting)– and it’s a well-known obstacle to quitting. And by the way, it completely bypasses “the bridge of the ship,” the part of the prefrontal cortex necessary for perspective change.

So how do you shift the beam of desire from highly practiced short-term goals to much less practiced long-term goals — what might be called the assembly of a future self — and then reinforce the new roadwork? First, you need to avoid killing the motivational thrust that comes from you and only you. Yet becoming a “patient” (in a disease-model-based treatment environment) is very likely to squelch that motivational thrust…. I mean, doing what you’re told is not the same thing as doing what you really want. Second, you need to act fast, strike while the iron is hot. Because the brain gets so quickly caught in the dopamine-powered pursuit of short-term relief — in now appeal — you have “catch” it when it’s looking toward something different. In other words, you have to catch it just when the “bridge of the ship” gets activated — so that desire and future wellbeing make contact. That’s when a different synaptic channel between the striatum and the prefrontal cortex can open up. Like an arc of static electricity leaping to a new target. And that channel is there, and it does light up.  At least sometimes. Like when you wake up feeling zonked, shitty, shaky, with withdrawal symptoms revving up, looking at the deterioration of your face in the mirror, and running to the toilet — and for the next half hour you want like anything to quit. You want to choose a future. Right then, you want to quit.

So there’s a condensed lead-up. Now I wish I could provide a brilliant new design for optimizing treatment for addiction — one that sits like a crown on this neuro/experiential modeling. But I can’t. I don’t know enough, and I think that job really belongs to people within the treatment world, not “science writers” like me. But here are a couple of paragraphs, from the last section of my book, showing where this kind of logic might lead us. And again, my thanks to Matt Robert and Cathy O’Connor, who helped me see things from this perspective.

What alternatives might stem from a developmental approach to treatment, applying the power of momentary desire to a personal time-line for quitting? Most important, there is no single strategy, organization, method, or philosophy that commands center stage. Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because there is no fortress wall that needs to be scaled, no line-up at the door, and no financial minefield that needs to be crossed. Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future.

Community-based groups, including SMART Recovery and progressive AA groups, can provide a kind of narrative scaffolding, a concatenation of stories about addiction and recovery, that can help addicts work on their own future “stories” — their personal narratives — addicts who are ready to move on. Group meetings are frequently inserted into institutional treatment as well, but whether they’re available when addicts really need them and can use them is entirely hit-and-miss. And while group processes can be helpful, they are certainly not always helpful, nor are they the only way forward. Treatment only requires the attention of one other human being who can hold, possibly distill, and hopefully extend the vision of a future self energized by an individual’s desire to change.

What will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change. This can be the presence of a friend who accompanies you to your first 12-step meeting, as was the case for Brian at the very point when he’d had enough. Or the attention of a therapist who really gets where you’ve been and where you want to go, as was the case for Donna at the fulcrum of her despair. It can even be the horrific embrace of a jail cell where you see your options with brutal clarity, as was true for Natalie. (To read these hair-raising accounts in full, I’m afraid you’ll have to wait for the book.) It can be a month on your uncle’s farm, a book that captures your heart when you think you’ve lost it, or the stuck window opened by meditation, romance, or antidepressant therapy when you’ve been buried in your cave for too long a time.

Quitting requires a merger, perhaps a collision, between desire and perspective­ — again, what fires together wires together­ — yet it doesn’t demand any particular brand of intervention.

Nevertheless, next week I’ll describe a radical treatment initiative that I think exemplifies a right-minded approach to recovery. And I hope that, through your comments, you might also provide some ideas for how to awaken the treatment world.

……

After all this public speaking, I’m going to get really personal in this post. Sort of like spring cleaning. It’s also a good chance to practice my narrative writing, in case I ever manage to start my next book.

I just woke up from two rotten dreams. They used up half my night. In the first, I was in love with, or at least dating, an unknown woman. It seemed we had a future together. Then, in the middle of some sunny, social activity, she turned to me and said: “The trouble with you is that you talk too much.” I was stunned. How could she? It reminds me now of the time Lissy, the girl across the road, suddenly turned to me and said: “The trouble with you, Marc Lewis, is you’re fat!” I was eight at the time, not actually fat, but the memory still burns. Back in the dream, this woman’s invective spelled the end of our relationship. I flung back a stinging rebuke: I told her she raised her voice unpleasantly at the end of her sentences. So there! But now I was stumbling down a dirt road, utterly alone and lost, wondering where I could find drugs or booze.

Next, I was in a Chinese restaurant with family, friends, and someone resembling my ex-wife. I’d been dumb enough to order the buffet menu, when only a few scraps remained in the big pans on the counter. I saw the contempt in her eyes. I felt humiliated and isolated. The restaurant was going to close soon, and there I was, with a big bill and a small meal. But Ms Ex was not only contemptuous, she also turned cold and distant. Disconnected. That’s always been my worst fear. Next scene, I was at home (some home) with family, wondering if our visitors had brought a bottle of painkillers I could steal from.

When I woke up, ouch! What a way to start the day. But I lay in bed for awhile,  thinking about my second marriage and how it ended. I’d been a good husband, actually a very good husband. Loving, supportive, faithful, as passionate as possible with three kids around, working my butt off to take care of those kids while earning tenure at the University of Toronto. Rushing home to help with dinner, then working late to get everything done. (Was that the problem?) And teaching an extra course to pay for our trip to England — my first sabbatical! Eleven days after we landed in Cambridge, nine years after we first got together, I discovered that she’d been having an affair with some Italian guy the last several months in Toronto. There was a half-finished email to a friend, open on the computer in the living room, describing how much she missed him.

A million times ouch! I drove around England for three days, nearly suicidal. Drinking and driving. Taking crazy risks. Then back to Cambridge, where there were kids to consider.

Things went downhill pretty fast after that. She left for Toronto within four months, then we separated legally five months later. She had not been eager to patch things up. Meanwhile, I’d spent most of my sabbatical in beautiful Cambridge slumped in depression, pretending to work and caring for my 8-year-old daughter. I’d loved that woman. And now she’d become cold, distant, and uncaring. Just like the woman in my dream, her ghostly descendant. I’d been off opiates for roughly 15 years at the time. Was I tempted to go back to them? Of course I was! But instead I drank. Every evening for a few months, scotch and/or beer. A lot. But not too much to put my kid to bed and get her up in the morning.

For me, substance use and substance addiction have always been a remedy for loneliness, abandonment, disconnection. The formula in my child’s mind is a simple one: disconnection from someone you thought was there for you = isolation = danger!!! Opiates made me feel safe. Booze at least numbed the anxiety. Ever since those years in boarding school, and probably long before that, loss of connection was my primal fear. It’s why I became an addict. And it’s still my primal fear, hence the dreams last night. I don’t think those things ever go away.

Yesterday I had a long lunch with a 24-year-old guy who’d had a serious — really serious! — video game addiction. “Pieter” wanted to meet me after reading my book. While nibbling and basking in a rare stretch of Dutch sunshine, I asked him about the games he’d played. He’d been a captain, a general, a Roman conqueror, leading his army over the mountains to subjugate foreign armies and occupy new lands. He was a great leader of men — for 10-15 hours a day. And then he’d come back to the real world and realize that another month or another year had passed, without having accomplished anything at all. Finally, at the age of 19, he was so tortured by his addiction that he managed to give it up. He couldn’t stand the idea that he was a hero in his games but an abject failure in his life. He spent the next two years emerging from a deep, lingering depression.

The longer I talked with Pieter, the more I noticed something odd. He had a strange, half-hidden arrogance mixed with his humility. He ended our lunch telling me, in great detail, how he’d connected deeply (during a workshop) with a really unattractive woman and taught her that even she could be accepted by a man as, um, accomplished, cool, and desirable as himself. It hit me like a ton of bricks: he still construes himself in terms of status and prestige. He always has. Which means he’s always been afraid that others would not recognize his value — something he soon confirmed.

What he’d gotten out of his gaming was a sense of mastery — exactly what he couldn’t find in his life.

He’s still missing epic-hero status, but he stuggles to stay in the running. At least he’s past his addiction and has a chance to recognize what he’s missing. And maybe to learn to live with the next best thing: a modicum of success. And I’m still missing a deep sense of security. But at least I’m past my addiction, and I’m (still) learning to live with the next best thing: a degree of self-trust, and a family who loves me and needs me for now.

…But if you try some time, you might find…you get what you need!

–The Rolling Stones

What I’ve called self-trust in recent posts can be paraphrased as compassion. Compassion for oneself. In the last couple of weeks I’ve been exposed to the Buddhist perspective, which clearly sees compassion for others and compassion for oneself as two sides of the same coin. Compassion, or love, or trust, is considered a kind of natural state once all the cognitive cobwebs get cleared away. But how do you achieve it?

Meditation, of course.

So while I’m cruising the canals of the Netherlands, the next four days, with a great horde of relatives (my wife’s family), quite likely to tip over and sink, either physically or emotionally, or both, I’ll leave you with a description of a great little study by David DeSteno, a professor at Northeastern University. Here’s the link, but I’m pasting most of the article below to save you the trouble of clicking on it. (Now, that’s compassion.)

This article was brought to my attention by someone whom I’d love to acknowledge, except that I can’t remember who it was. Very embarrassing. If you’d like to step forward and receive due credit, then please do.

One more thought before you read the article. I’ve recently been perusing a lot of the literature on the neuroscience of meditation. The state of the art amounts to what’s usually known as a dog’s breakfast, not to be confused with a god’s breakfast. It’s a mess of overlapping and sometimes discrepant findings. But there’s one bit of the brain that reliably lights up as a result of meditation training: a wee bit of cortex called the insula — a structure that is thought to mediate enteroception, the feelings one gets from one’s own body. When you are consciously feeling your feelings, whether sadness, anxiety, fatigue, or pain, it’s the insula that’s giving you the message. So, meditators seem to be able to switch on that conscious state of feeling more easily than controls.

Maybe that’s no big surprise. But here’s the cool part: insula activation is a reliable correlate of empathy, induced through various experimental protocols, like looking at pictures of people who are suffering. In other words, you have to be able to feel your own feelings in order to feel empathy. Meditation seems to improve that ability. And given the results of the following study, that can translate into being good to others as well as good to yourself.

MEDITATION is fast becoming a fashionable tool for improving your mind. With mounting scientific evidence that the practice can enhance creativity, memory and scores on standardized intelligence tests, interest in its practical benefits is growing. A number of “mindfulness” training programs, like that developed by the engineer Chade-Meng Tan at Google, and conferences like Wisdom 2.0 for business and tech leaders, promise attendees insight into how meditation can be used to augment individual performance, leadership and productivity.

This is all well and good, but if you stop to think about it, there’s a bit of a disconnect between the (perfectly commendable) pursuit of these benefits and the purpose for which meditation was originally intended. Gaining competitive advantage on exams and increasing creativity in business weren’t of the utmost concern to the Buddha and other early meditation teachers. As the Buddha himself said, “I teach one thing and one only: that is, suffering and the end of suffering.” For him, as for many modern spiritual leaders, the goal of meditation was as simple as that. The heightened focus on and insight into one’s own  mind, offered by meditation, plus the enhanced cognitive skills of clarity and self-regulation, were supposed to help practitioners see the world in a new way — in which  we are no longer the center of the universe. And that’s what allows for compassion — a genuine regard of other people and an intrinsic wish to end their suffering as well as our own. And a relaxation of the habitual categorizations (us/them, self/other) that commonly divide people from one another.

But does meditation work as promised? Is its originally intended effect — the reduction of suffering — empirically demonstrable?

To put the question to the test, my lab, led in this work by the psychologist Paul Condon, joined with the neuroscientist Gaëlle Desbordes and the Buddhist lama Willa Miller to conduct an experiment whose publication is forthcoming in the journal Psychological Science. We recruited 39 people from the Boston area who were willing to take part in an eight-week course on meditation (and who had never taken any such course before). We then randomly assigned 20 of them to take part in weekly meditation classes, which also required them to practice at home using guided recordings. The remaining 19 were told that they had been placed on a waiting list for a future course.

After the eight-week period of instruction, we invited the participants to the lab for an experiment that purported to examine their memory, attention and related cognitive abilities. But as you might anticipate, what actually interested us was whether those who had been meditating would exhibit greater compassion in the face of suffering. To find out, we staged a situation designed to test the participants’ behavior before they were aware that the experiment had begun.

WHEN a participant entered the waiting area for our lab, he (or she) found three chairs, two of which were already occupied. Naturally, he sat in the remaining chair. As he waited, a fourth person, using crutches and wearing a boot for a broken foot, entered the room and audibly sighed in pain as she leaned uncomfortably against a wall. The other two people in the room — who, like the woman on crutches, secretly worked for us — ignored the woman, thus confronting the participant with a moral quandary. Would he act compassionately, giving up his chair for her, or selfishly ignore her plight?

The results were striking. Although only 16 percent of the nonmeditators gave up their seats — an admittedly disheartening fact — the proportion rose to 50 percent among those who had meditated. This increase is impressive not solely because it occurred after only eight weeks of meditation, but also because it did so within the context of a situation known to inhibit considerate behavior: witnessing others ignoring a person in distress — what psychologists call the bystander effect — reduces the odds that any single individual will help. Nonetheless, the meditation increased the compassionate response threefold.

…recent findings by the neuroscientists Helen Weng, Richard Davidson and colleagues confirm that even relatively brief training in meditative techniques can alter neural functioning in brain areas associated with empathic understanding of others’ distress — areas whose responsiveness is also modulated by a person’s degree of felt associations with others. [see my comments on the insula!]

So take heart. The next time you meditate, know that you’re not just benefiting yourself, you’re also benefiting your neighbors, community members and as-yet-unknown strangers by increasing the odds that you’ll feel their pain when the time comes, and act to lessen it as well.

 

 

 

…by Hanna Anderson…

In marijuana news, the government of Canada is looking to create and finalize a bill that will legalize marijuana in the spring of 2017. Some changes are already in motion.

Just recently, Minister of Justice, Jody Wilson-Raybould, announced the Task Force for Marijuana Legalization responsible for creating Canada’s drug policy on marijuana — and it will be a great undertaking. Thus far, the illicit drug isn’t legal for recreational use, and there are many reinforced misconceptions about the soft drug that make people see it as a hard drug. What regulations can be made that will allow Canadians to see the drug in a different light?

The Current State Of Marijuana

As a soft drug, marijuana is already used for medical purposes. The psychoactive substance in marijuana, THC, is widely used to treat the side effects of certain medical conditions, like nausea experienced by cancer patients.

Currently, only medical marijuana is legal in Canada under its Marijuana for Medical Purposes Regulations (MMPR). This Health Canada program provides users with access to medical marijuana only through licensed producers with a medical document signed by an authorized healthcare practitioner.

Despite this, there are still many legal gray areas and confusion. Moreover, with only 33 licensed producers in the entire country and a policy mandating the substance be distributed only via registered mail, marijuana activists are upset by the inefficiency of the system. Marijuana entrepreneurs, on the other hand, are taking advantage of the marijuana mess.

The Gateway Overlap

In general, soft drugs like marijuana (which are usually illicit) don’t produce physical dependence and are less addictive than hard drugs (such as cocaine and heroin).

Yet it is interesting to note that some smokers may experience withdrawal symptoms that can cause a psychological dependence and use disorder. This is part of the reason why many think of marijuana as a gateway drug to harder drugs and so advocate its prohibition.

But does that indirect connection mean that strict law enforcement is needed? Does it mean strict laws and swift action will solve the problem?

In Canada, illegal dispensaries have been popping up to both establish a stake in the future market and to address the supply shortage. However, marijuana is still officially illegal. Consequently, vendors are being arrested and shut down on the basis of violating municipal zoning bylaws.

When access to medicinal marijuana is limited, drug policies and restrictions are themselves the gateway to hard drugs. Why? Because legal prohibition encourages users in need of medical marijuana to turn to the black market, opening them up to unmonitored marijuana supplies, harder drugs, and criminal charges.

Penalties On Hard Drugs And Marijuana

Currently, the penalties on hard drugs in Canada range from 7 years for possession of cocaine and heroin to life imprisonment for trafficking or possession for the purpose of trafficking the substances.

On the other hand, it takes over 3 kgs of marijuana or hashish to be considered trafficking or to be considered possession for the purpose of trafficking. The maximum penalty for both is life imprisonment. Possession of marijuana penalties range from a 6 month and $1000 fine (for up to 30 g) to 5 years less a day in prison.

The war on drugs in Canada is seen as ineffective. For example, drug-policy spending under the Conservative government (in power for the last eight years) went to apprehending, charging and defending users in possession of small amounts of marijuana! With the new Liberal government, the focus is on approaching marijuana policy with an emphasis on regulation, not prohibition.

What New Policies Should Canada Implement?

But what key areas in marijuana law and policy should Canada look at to ensure that the regulations are appropriate for a soft drug? To which countries can Canada refer?

The USA, Portugal and the Netherlands — countries that have legalized marijuana (or chosen to ignore it) — offer examples of what to expect regarding the implementation of a national framework. OMQ Law (the author’s law firm) has put together an infographic that takes a close, visual look at how these countries have legitimized marijuana use.

From the Netherlands, which allows users to smoke in openly accepted, though illegal, marijuana cafes, to Portugal, where all drugs were decriminalized and addiction treatment programs aggressively implemented, the infographic explores the nuances in soft drug policies. In the USA, though five states have legalized marijuana medically and recreationally, it still has yet to be fully legalized across the country.

Laws are constantly evolving to ensure that effective drug policies are in place. Part of the task will be to keep in mind how a legalized soft drug will impact other international drug policies, social acceptance, and the perception of hard drugs in general.

In Canada it seems likely that supply and production will be controlled at the federal level and the provinces will control distribution — in the same way that the provinces control distribution of alcohol. Some provinces are advocating or suggesting that their liquor distribution networks are an obvious choice for distribution.

Our position is that a distribution framework should be set up separately, and have room for both public and private avenues for sales. We expect there to be a phase-in period of several years, as current levels of supply will be completely inadequate to handle initial demand.

omqlaw.ca

I’m nervous. I’m leaving for Toronto tomorrow for a publicity tour. The book is getting a lot of press, including a full-page article by Ian Brown in yesterday’s Globe. People seem to be grabbed by it. Some admire it. Some are shocked, even horrified, that this professor guy could ever have done such awful things. Some might feel both admiration and disdain. I don’t know for sure, but I’m about to find out. My publicist at Random House has set up a dozen radio interviews and three or four TV spots, including Canada AM and The Hour with George Strombo (gulp). And that’s great for the book… but I’m not sure I want to be there.

The book became more honest the longer I worked on it. I was going to reveal some of the past. Yeah, talk about the acid trips, the bust, well okay the busts, plural, then first experiences with heroin, maybe leave out the OD thing, get into the opium dens in Calcutta—that seemed suitably exotic. But those years of breaking into places, to get drugs, the intense compulsions, the suicidal risks, the lying and cheating and stealing and more stealing…I wasn’t planning to tell it all. But it just kept pouring out.

And then suddenly the book was finished. It was in the hands of the publisher, and I couldn’t have censored it or recanted it if I tried. Okay, I quit thirty years ago. And I’ve redeemed myself, haven’t I? Got back into grad school, worked really hard, got hired as a professor. I’m a neuroscientist now: all brain, no body, no pustules, no scars. Hah! You don’t live through a decade of addiction without a lot of scars, or without some crazy compensations to keep the wounds from opening up again.

So what I’m nervous about is that my squeaky-clean persona is going to be in front of that camera or that microphone and it’s going to turn transparent, so that everyone—relatives, colleagues, friends, ex-wives, children, ex-children—everyone can see the dirt below the surface. What am I going to talk about? How bad it was? How sick it was? How much fun it was? That crazy roller-coaster ride? Not knowing how to get off? And how my brain made me do it… How’s that going to go over?

Wish me luck, because it’s all going to happen in a few days. Feels like another roller-coaster ride, this one legal and acceptable, but with some of the same icicles dripping down the back of my throat.