Understanding Addiction

Hi people. It’s been awhile. I left off with some brief descriptions of the Dialogue and summaries/links for two great talks. Now I want to tell you something about Nora Volkow’s presentation and, more interestingly, the chat we had afterward.

I have been running to keep up with myself for at least a month, and now I’m finally able to slow down, relax, and post something. I’m in Toronto for a week. I came to give a couple of talks, see family and friends, and just hang out. Isabel and I have literally been playing tag team to accommodate travel and children. I’m away, she’s at home with the kids, she’s away, I’m at home with the kids. We’ve spent only 4 days in the same place for over a month! She was returning from the US last Thursday, the day I left for Toronto. We were in the Arnhem train station at the same time but texting, trying to meet up, when we must have walked right past each other. By the time we connected, I was in the train and she was getting in a taxi. Funny and a bit sad.

Ok, Nora Volkow, head of NIDA (National Institute on Drug Abuse).  She’s often been a voice in my head when I’ve argued against the disease model of addiction in my writing and blogging. Why? Because she is one of the most eloquent and knowledgeable proponents of the disease approach, she is a powerful force in the worlds of research funding and policy-making, and because she’s a highly respected researcher. Who better to argue with, at least in my head?

She gave her presentation on day 3 of the dialogue. Here’s the link to the talk itself and here’s Shaun’s summary. She focused mostly on the blunting of dopamine reactivity in the brains of addicts, resulting both in the reduced “rewardingness” of drugs and a reduced capacity for cognitive control. A lot of people liked her talk. She’s a great speaker: passionate but clear, with well-defined logical connections between data and interpretation. His Holiness looked like he enjoyed her presence, and Richie Davidson seemed enraptured. I liked her talk too. However…

I was listening for a rethink or even a mild qualification of her well-know contention that addiction is a chronic brain disease. But it wasn’t there. She continues to see addiction as resulting from the “damage” caused by repeated drug use. And she uses that word “damage” insistently, even though the measures available for assessing brain changes generally show them to be reversible (e.g., grey matter density changes). Two things have bothered me about this position for quite some time: (1) it makes drug addiction a completely separate animal from all other addictions (e.g., gambling, sex, food), despite evidence of overlapping or identical brain changes; (2) it places the cause of addiction squarely in the molecular action of the substance itself, something Nora emphasized repeatedly, ignoring the crucial lessons of Rat Park and subsequent research on environmental determinants.

Ok, so she’s Nora Volkow, she’s a pillar of the medical establishment (NIH), and she finds it valid and convenient to classify dysfunction as disease. So what’s my problem? Maybe it was in reaction to a comment she made later that day that my blood boiled over (gently of course). During a discussion period she proposed to debate whether addiction is “a disease of the brain or a disease of the mind.” She was so sure of herself. I looked around the circle of fellow presenters and organizers. Doesn’t anyone else question whether it’s even a disease?

So during the final hour of the final session (Day 5, morning, following Sarah Bowen’s talk) I picked up the microphone and waved it around for a good 20 minutes before I got my chance. The clock was ticking toward the end of the session. Only a few minutes left. I waved the microphone a bit more frantically, and Richie Davidson, the moderator of that session, gave me the last few minutes before lunch. I was nervous. I’d been aware of my heart pounding most unprofessionally. I didn’t want to defy the great Nora or piss off my newfound colleagues. The proceedings so far had been quite lovey dovey, almost devoid of serious academic debate. I didn’t want to breach that policy. Yet it seemed cowardly to sit back. I thought of you guys and some of the heated comments you’ve made about the disease model — how the logic never quite spoke to you, or how it left you feeling boxed and helpless.

So I said my bit. (Most of you have heard it before.) Maybe addiction isn’t a disease at all…given that recovery seems to derive from self-reflection, concentration, and effortful revision of one’s perceptions and goals, given that brain change is essential to all learning processes, and given that radical synaptic restructuring is the rule at developmental transitions (e.g., adolescence). And if addiction isn’t a disease, then perhaps it is best treated, not by the medical profession, but by programs of the type that Sarah Bowen had just described so beautifully — based on mindfulness and other methods of revamping our responses to our own cravings.

Nora did not look particularly pleased with my comment. But Sarah did. Richie I couldn’t read. Then, as people got up and milled around, preparing for lunch, I sampled the vibes as much as I could. And concluded that some were glad to have an opposing perspective on the table, a few were not, and most didn’t much care.

Since Nora was among the last to leave the room, I walked over to her and asked her what she thought of my comment. Surely she’s been confronted with opposition to the disease model. And sure enough she had a string of arguments already loaded and ready to fire. Here they are:

• Not all diseases show up as major bodily disruptions. Some are far more subtle.
• Calling something a disease doesn’t mean that it can’t be helped by psychosocial interventions. Even cancer recovery can be aided by mindfulness (to improve the mood and the self-care practices of patients).
• Drugs damage brain tissue. For example, cocaine has been shown to directly damage the brains of rats, and by extension, probably humans, as does alcohol.
• But beyond the damage issue, when something doesn’t work the way it should, we call it a disease. That’s how the word is used — that’s how language works.
• Calling addiction a disease mitigates massive volumes of stigma and guilt, and it deflects blame from those who’ve fallen prey to addiction.
• Arguing definitions is futile. Call it anything you want. The point is to get help for people who need it. And if we don’t treat addiction as a disease, it won’t be treated at all.

I could argue with most of these points, I thought. For one thing, I just don’t believe that most drugs cause brain damage, except in cases of extreme quantities and other critical factors, such as the impact of vitamin deficiency in Korsakoff’s syndrome, impure or toxic concoctions, overdose, etc, etc. And if you don’t believe me, look at the articulate prose of someone like David Carr (the New York Times journalist who smoked a ton of crack and drank a ton of booze over many years, then wrote The Night of the Gun). And sex addiction, gambling, and the other behavioral addictions aren’t likely to cause brain damage either. And in a country where the government is not in the business of helping people in dire need of help (including the poor, the sick, the old, the young, single parents, victims of accidents, abused women and children…the list goes on), perhaps the disease definition is the best avenue for getting help for low-functioning addicts. But that’s politics, not science, and it’s politics that fits one country, not the world at large.

As (my now friend) Kent Berridge tried to convince me later, we shouldn’t have to accept one definition or the other — both might be accurate for different individuals, stages, or circumstances. Yet the working (sub)title of my current book is “…why addiction is not a disease.” So I’ve got quite a stake in the argument. I don’t want to get bogged down in a useless war of words, and I certainly don’t want to spend my efforts trying to dismiss a “straw man” — a contrived version of my intellectual opponent that’s easy to refute because it’s exaggerated or fraudulent. And Nora wasn’t interested in further debate just now. That was clear — and lunch was calling.

But I’ll end by saying that, if my scientific beefs about the disease model turn out to be valid, something fundamental has to change in the way we label, understand, and treat addiction. Because it’s not just a war of words. After reading thousands of comments and emails from ex- or recovering addicts, I’m convinced that calling addiction a disease is not only inaccurate; it’s harmful. It’s harmful because it replaces one stigma with another. People don’t often boast about their incurable diseases — they are nothing to be proud of. And a sense of responsibility probably doesn’t do much to combat most diseases, but it’s a crucial part of the arsenal for combating addiction. To put it differently, those who have fought addiction and won — really won — hardly see themselves as lacking responsibility. Nor are they keen to walk on egg-shells for the rest of their lives, lest the latent virus erupt once more. For them, for us, there are more satisfying ways to define ourselves than “My name is Joe and I’m an alcoholic.” Most of the recovered addicts I’ve talked to would rather see themselves, not as in remission, but as free. Maybe better than ever.

I said I’d use the next few posts to share what I learned at a recent conference on behavioral addictions. I should emphasize that the conference, held in Budapest, was billed as the the First International Conference on Behavioral Addictions. The idea that gambling, hypersexualized behavior, eating disorders (including obesity), and internet addictions are in fact addictions is quite new, and even today there are many professionals, policy-makers, and researchers who bristle at the thought.

Think for a moment about the implications. If the medical world accepts, say, internet addiction and eating problems as addictions, requiring treatment, then insurance companies in the U.S. will go bust within weeks. Not that they don’t deserve it. If internet use is an addiction, then how do parents and teachers moderate kids’ internet use? Almost nobody would claim that internet use should be forbidden, yet, if it’s addictive, then shouldn’t it be tightly controlled? These are just a few of the problems society will face when behavioral addictions are acknowledged as addictions.

I say this as if the matter is resolved. Well, it is for me. I saw enough evidence in those two days at the conference to convince me, beyond a doubt, that behavioral addictions not only resemble substance addictions in “real life” but also arise from the same brain processes.

The most convincing parallels between substance and behavior addictions start by recognizing their common denominator: compulsion. When gambling is considered an addiction, it’s called compulsive gambling. Eating disorders including binging and bulemia are often discussed as compulsive. The same goes for sex addiction and a few other things. Then we cross the line into substances. Smokers smoke compulsively, alcoholics drink compulsively, and as for drug addiction,the National Institute on Drug Abuse defines it as characterized by “compulsive drug seeking and use.” In my last few posts, I’ve described a set of stages in the onset of addiction (and addictive acts), and the final stage is compulsion. So, if we are seeing evidence of a common denominator underlying both substance and behavioral addictions, both in people’s behavior and in their brain mechanisms, then the defense rests.

Interestingly, the most fundamental behavioral addictions are the individual actions people perform repeatedly when they suffer from OCD (obsessive-compulsive disorder). When you wash your hands or check the stove 50 – 100 times a day, that’s a behavioral addiction! So a number of speakers at the conference directly compared the behavioral and neural portrait of OCD with both/either drug and/or behavioral addictions.

Naomi Fineberg, a well-recognized researcher in this area, sees OCD as the archetypical compulsive disorder: People with OCD can’t inhibit impulses, they show low cognitive flexibility, and narrow, limited goals. She uses a button-pressing task in which the “reward” is turning off a mild electric shock. After training on the task, the reward is withdrawn. From that time on, pressing the button accomplishes exactly nothing. Yet compulsives keep on pressing the button. Ordinary people do not. Compulsives report that they keep on pressing simply because they feel the “urge” to do so. Sound familiar? Sound like addiction? She concludes that OCD is not about repeating a behavior to get a reward — nothing good is anticipated. Rather, actions are performed to avoid “punishment” — the negative consequences of not doing something. And the negative consequence may simply be the build-up of anxiety. I’d say it’s very much the same with addiction.

Dr. Fineberg also talked about her neuroscience research. OCD “patients” (I hate that term, but that’s what they call them) and stimulant (e.g., coke and meth) addicts show a host of similarities in the scanner. The ventral regions of the prefrontal cortex (such as the orbitofrontal cortex) are where emotional meaning grows and solidifies over time, and these regions show reduced connections with more dorsal areas involved in self-control. So the brain becomes less capable of exerting self-control.

Giacomo Grassi, from the University of Florence, talked about OCD and addiction as caused by “reward dysfunction” — a condition that starts out with anxiety but ends up as a behavior problem, becoming “addicted to compulsion” as he calls it. Dr. Grassi’s brain scan images showed that OCD patients have higher activation of the amygdala (the centre for emotional conditioning) and lower activation of the nucleus accumbens (or ventral striatum — the brain centre for motivated reward-seeking) — a pattern repeatedly shown in addicts as well. He also demonstrated a shift in activation from the nucleus accumbens to the dorsal striatum as compulsions set in, just as I discussed two posts ago as the final stage of addiction.

So we could say that OCD is the pure form — the grand-daddy syndrome — in which people fall into loops that are no longer rewarding, just difficult to turn off. Substance addictions and behavioral addictions are two derivatives or variants of that form. Two lines of descendants — its offspring. Substance addictions and behavioral addictions look the same, sound the same, smell the same — common sense suggests that they are, at least, very close cousins.

When I said I wanted to move further into the psychology of addiction, I didn’t mean I was about to forget the brain. The subtleties of your thoughts and the cellular activities of your brain might seem like different planets, impossible to gaze at simultaneously. Yet both are going on at exactly the same time in exactly the same place.

Addiction is usually characterized by two psychological states: craving and loss of control. But when we look very closely at the flow of time leading to each occasion of using (or drinking, or whatever it is), there seems to be a blurring of the two. Giving in (loss of control) starts to look like a well-worn path, initiated by craving. Can we reconceptualize the relationship between craving and giving in? So that it makes sense? — at least more sense than the notion of falling through a trap door that was bolted shut? What if craving and surrendering are not two processes but one? Just a single time-line, a building momentum, leading from a state of determined abstinence to a headlong plunge?

Imagine that you can be two different people. That’s not such an absurd idea. It’s been around in psychoanalysis for a century, and even the cognitive science of the last three decades finds it reasonable. Not multiple personalities, but something subtler. The you that screams for vengeance when your favourite player gets tripped from behind and the you that turns off the TV and tucks your kid into bed can easily be seen as two distinct yous. So let’s imagine that the you who anticipates how wonderful it will feel to get high is simply a different you than the one that knows that’s insanely stupid.

Of course this isn’t an original idea in addiction studies. Twelve-step fellowships continue to broadcast warnings that your addiction is waiting to get you, doing push-ups in the parking lot, and even the more contemporary cognitive-motivational tactics of SMART Recovery might counsel you to ignore the addict voice — as though it weren’t your own voice at all.

So let’s think about the two yous differently, by aligning the psychology of wanting versus abstaining with two distinct brain states. That’s not difficult. When we anticipate getting high with excitement and attraction, the striatum, which is the part of the brain that initiates goal pursuit and powers it with desire, is strongly connected to the orbitofrontal cortex (OFC), a region of the prefrontal cortex on the border of the “limbic system” that encodes the value of things — good things like a friend’s smile and bad things like sour milk. The striatum and OFC are quickly linked (an “orbitostriatal” bond is formed) in anticipation of a valued outcome, and that’s when you become the child, yearning, anticipating, and falling forward into the treasure trove at your feet.

But what happened to self-control? A much smarter part of the brain — called the dorsolateral prefrontal cortex — often oversees the impulses generated by your striatum. The dorsolateral PFC is where judgments are formed by comparing possible outcomes and making conscious decisions. We can call the dorsolateral PFC the “bridge of the ship.” Its job is to steer.

But addiction and other impulsive acts are accompanied by a “loss in functional connectivity” between the orbitostriatal alliance and the bridge of the neural ship. A loss of connectivity simply means that activity (measured by an fMRI brain scan) in one region becomes less correlated with activity in the other region. This disconnect is exactly what is observed in addiction. When pictures of drug paraphernalia are flashed on a screen, addicts show a surge of activity in the orbitostriatal region and reduced activity in the dorsolateral PFC. Some studies show this disconnect to become more severe with the length of the addiction. Other studies show the same disconnect when “normal” people surrender to tempting (but dumb) impulses. The disconnect is real. And when it happens, you become the unfettered, unconstrained child.

Craving is simply desiring what feels attractive, and surrender is the natural order of things when desire is unconstrained.

So you get high, you start drinking, you click on a tried-and-true porn site or you call that forbidden phone number. An hour later you are bored and you know you didn’t get what you wanted. Two hours later the regrets pile up like unanswered mail. Three hours later (if it takes that long) the child’s excitement is replaced by self-reproach, recrimination, and perhaps a determined commitment to never do it again. You are no longer thinking or feeling the way you were a short time ago; your values have locked in again. And your brain is no longer functioning the way it was functioning a short time ago. The orbitofrontal cortex (occupied now with something like sour milk) is reconnected with the dorsolateral PFC, its overseer. Because desire is now just a memory, an empty husk. With desire slaked, no matter how unsatisfactorily, your brain changes back again. It’s just the way it works.

Let’s say you’d been abstinent for weeks, maybe months. How could you have done something so stupid? Again?!

The answer is simple: it was a different you.

The news has been so depressing lately, it seems like a good time to post something positive. So here’s a look at some new research suggesting amazing benefits from psychedelics like psilocybin — especially for people who need help overcoming anxiety. The main question is: how do these drugs work and what new directions do they suggest for replacing loneliness with connectedness as our biology, culture, and technology continue to evolve in sync?

But first, a few laughs about how bad things have been, thanks to John Oliver.

The new research was conducted at Johns Hopkins University and New York University (NYU) and published December 1 in The Journal of Psychopharmacology. Here’s a nice overview. In this post I want to consider the brain changes produced by psilocybin (very similar to those caused by other psychedelics, including LSD and ayahuasca).

The participants in the study were cancer patients (understandably) experiencing lots of anxiety and depression about their illness. To quote from the Scientific American article, “more than three-quarters [of these patients] reported significant relief from depression and anxiety—improvements that remained during a follow-up survey” six months later, after taking a single dose of psilocybin (magic mushrooms) in a controlled setting. These long-term effects are exciting: lasting changes in people’s feelings and behaviour, which of course suggest enduring brain changes. I think these changes put a positive spin on how humans think about drugs, which is a refreshing change from all the negativity.

As my readers probably know, I have long divided drugs into good, bad, and somewhere in the middle. Heroin, crack, and meth…bad! In the middle we’ve got cannabis, maybe ecstasy, alcohol (for some but NOT others), and mild mood-helpers such as kratom. The good drugs — the psychedelics — aren’t good for everybody. There is always that minority who have bad trips, scary psychotic detours that may last hours or even weeks. But for most people, at least those willing to let go of their day-to-day constructions of reality (for a while), I think psychedelics can be a real boon. They can take us on a journey that reveals a universe we may not have known existed. Kinda like the explorers of the 1400s and 1500s who sailed past the horizon and discovered that the world was round, not flat. (If interested, see my piece on LSD and the brain in The Guardian, and a review in Scientific American.)

To quote from Scientific American, lead author Roland Griffiths says that psychedelics show “remarkable potential for treating conditions ranging from drug and alcohol dependence to depression and post-traumatic stress disorder….They may also help relieve one of humanity’s cruelest agonies: the angst that stems from facing the inevitability of death.” Griffiths’ interest in psychedelic research arose partly from his interest in mindfulness meditation, and he’s actually studied meditators who have taken psychedelics to enhance their “spiritual” practice. So when we look at the brain changes triggered by psilocybin and LSD, the most interesting finding is that psychedelics and meditation both reduce activation in something called the default mode network (DMN).

The brain is divided into several functional networks, each responsible for a different kind of engagement with the world. A network connecting prefrontal (and other regions) is in charge of problem solving, something we do a lot. A network anchored in the parietal cortex (that big middle part) is responsible for shifting attention to incoming stimuli, events that are potentially important in the here-and-now. But the default mode network is a set of cross-linked regions that extend from the middle of the frontal lobes (social cognition) to the hippocampus, which keeps track of the details of memory, to parts of the cingulate cortex involved in compacting memories into a gist-like overview, to areas in the posterior cortex that underlie our perception of other people’s motives and feelings.

As the name suggests, the default mode network is “on” a lot of the time. In fact it’s where we go, so to speak, when we’re not doing much else — when we’re daydreaming, reminiscing, imagining, rehearsing tidbits of future actions and possible conversations. But what does this network actually do?

To experience what it does directly, just try to meditate or still your mind for a few minutes. All those wandering thoughts, snatches of conversation, all the what-if images…maybe if I said this, she’d say that…I should really get on with updating my CV…I wonder what’s for dinner tonight…am I supposed to cook, or is it Isabel’s turn? The DMN network is what manufactures all those wandering thoughts and fantasies. (And note that more advanced meditators show less activation of the DMN.) So the purpose of the network seems to be to propagate the sense of a coherent self, an ego, a me. And the problem with that is that ALL of our worries, negative thoughts, concerns about how meaningless it all is, concerns about whether I’m going to get sick, die, be lonely, or get high, relapse, and how long that might go on…all that fussing is simply a cascade of revisions of how best to care for oneself, protecting, optimizing, enhancing…ME!

That self-involvement isn’t wrong, and obviously it has adaptive value. But it’s also precisely the condition for anxiety — the state of being uncertain about what will happen to ME. So muting the default mode network might be a very good thing, at least on occasion, leaving us less self-involved, less concerned about what might happen, and less motivated to make things “better” by, oh, you know, taking stuff.

Psychedelics release us from a preoccupation with ourselves by reducing DMN activation. They allow us to be more open, more connected with other people, with our planet, with our universe. Psychedelics can usher us through a Copernican shift from viewing ourselves as the centre of the universe to viewing ourselves as interested participants in something much larger and possibly much more interesting.

I have little doubt that, within a couple of hundred years, genetic engineering will advance to allow us to modify our biological makeup, that is if we survive that long. Maybe psychedelic exploration and mindfulness meditation will help point the way toward changes that serve as improvements. Maybe the DMN could be turned down, or even turned off, through a bit of neural restructuring, to reduce our concerns for self-optimization and make more room for the rest of the world. Less anxiety, less greed, less power-mongering…more love.

Sound cheesy? What can I say? I’m a child of the sixties.

Finally got a wi-fi connection. Better get this posted quickly before I lose it!

Written yesterday evening: I’m pretty tired so I’ll try to make this brief. Today was day 1 of the conference. This morning there were various introductory remarks. Then, just after a vegetarian lunch, I was to be the first speaker. I was to be in the “hot seat,” next to him, for two hours — 1.00 to 3.00 PM — powerpoint presentation on the screen, words stuck in my throat, talking to him. Not to the audience but to him. Gaaaaggghhhhhhh!!!!!

Yes, I was a bit nervous. I had sat in that room for three hours already, with 2-300 other people in seats arranged around our inner sanctum of easy chairs, with his chair (and the hot seat, the one next to it) at the front. About 60 Westerners (some very famous) from the Mind & Life Institute plus donors — the folks who made it all happen. Plus a hundred or so Buddhist monks, plus various people from all over the world who’d managed to get invited for various reasons.

The security was tight. Every person who crossed from “the temple” to “the residence” had to show a passport, a visa, fill out a detailed form, have everything in our pockets checked, and then undergo a full body search. Once you got to the other side, you knew you were some place unique, reserved, protected.

(And by the way, these folks have good reason to be vigilant. The Chinese have not been very friendly toward the Dalai Lama. They seem to hate him, and that plus any whacko who’d like to get famous shooting a good guy…well, that’s why they’re careful.)

But once you enter the conference room, you are in another world. The main thing is the energy. Before His Holiness (HH) arrived, the air was thick with anticipation, hope, affection, excitement, admiration. The Dalai Lama, whatever you might think of him, has a lot of people who love him. He IS special. And when he came out and greeted everyone — and I mean everyone — with waves and nods and hand holding — you got a sense of what was so special about him. He was cheerful, penetrating, personal, warm, sincere, exuding both gravity and humour — if you can imagine all that in one man.

My talk was pretty much what you’ve already heard on this blog. Insert: my talk posted here. Thank you, Shaun! In a nutshell, I did good. I got a lot of hugs and handshakes and big thank-yous from the team and audience members afterword. And a few riveting looks, wry smiles, and some friendly pats from him during the process.

Written this evening: There is a live webcast of the remaining days of the conference, and then the whole thing will be archived on the Mind & Life website, viewable, soon. Sorry, but the wi-fi connection here has been extremely intermittent. Anyway, there are three more days of talks about “desire, craving, and addiction” and I especially urge you to tune into Kent Berridge’s talk. Kent spoke this morning — Day 2 — and I just had dinner with him in some funky Tibetan cafe — lovely guy. I know, he looks about 14 years old. But he’s got an amazing head on his shoulders. INSERT: Here is the link to Kent’s talk. All other sessions can be accessed by going to YouTube and searching for “mind life craving desire addiction”. The full program can be accessed at  http://www.mindandlife.org/dialogues/upcoming-conferences/ml27/ The PDF is towards the bottom of the page, and also creates summaries of the various presentations. (Thanks, Shaun, for this information.)

Feeling happy here today, a bit star-struck but holding my own. Nora Volkow just arrived this afternoon. So she’s missed Kent’s talk and mine, which is unfortunate. But it was cool sitting next to her and passing the mike back and forth during the discussion periods. She seemed just like the firebrand I’d expected. A small, lithe woman with a LOT of self-confidence. A great scientist, no doubt, but also someone with strong opinions and no hesitation in expressing them and backing them up with the latest data.  She still sees addiction as “hijacking the brain.” So her basic stance has not changed over the years. I’ll hear her talk tomorrow morning, and you can easily catch it live-streamed at the above links.

And then there’s Richie Davidson, smiling and schmoozing, moderating and guiding things, being knowledgeable but at the same time rather sweet. And a few other people I’d never heard of before the meeting in June — people I’m really growing fond of.

I’ll tell you more about the viewpoints expressed and debated among Buddhists and Westerners next post. And by the way, I talked about you, my “blog community” quite a bit yesterday. You’re my data base now, my compass — not to mention where I send my letters from overnight camp.