Hello! It’s been awhile. This is vacation time in the Netherlands. The kids are out of school for two weeks and we’re trying to do family-type things. I know, it’s a strange time to vacate, but the weather here is so spotty, this might be one of the few periods likely to get some sun and warmth.

So I thought! Last Saturday we rented a boat. A very large boat (11.5 meters/ about 38 feet) with cabins below deck and all that, and the four of us set off from a town called Sneek (pronounced Snake). Well named, because the waterways leading out of the harbour were so incredibly narrow and sinewy that we got lost before we ever got to the main canal. Ended up in some cul-de-sac where an irate man with a house on the water kept waving us away. That’s because we kept almost ramming his house, which was very close to the shore. We were trying to make a U-turn in a narrow spot — just about impossible, especially because I had not yet discovered the “bow-thrusters” among the many Dutch-named switches on the instrument panel. When he finally realized that we didn’t understand a word he was saying, he started again in English: “Practice!” he yelled. “Go on the lake and practice!”  Yes, yes, an obvious suggestion. If only we could find the lake.

Anyway, we had a lot of fun. Isabel and I mostly sitting up on the top deck sharing a big steering wheel, watching the cows and sheep going by, and the boys down below, playing cards, with occasional sojourns to the upper deck to help steer. As I am constantly reminded, seven-year-olds don’t want to watch; they want to do. But it was cold out! Polar winds blowing through us except when we were huddled under this massive flapping plastic tarp. Oh well, it was still great, and we didn’t hit a thing in four days. Well maybe just a few tiny bumps. Tiny!

Isabel and I are going to drive over to France in a couple of days. It’s only a few hours, and it’s worth it just for the food. But meanwhile I have two talks to prepare, and one of them is a TED talk. Yes, TED! I was invited to join this TEDx event held at my university, and I’m getting pretty jazzed about it. The theme of the conference is “trust,” so naturally my talk will be about trust and addiction.

At first, I wasn’t sure how to approach this topic. You can’t trust an addict, right? How do you know an addict is lying? Because his lips are moving… Hah hah. No, wait a minute, how about…addicts can’t trust the treatment community? We know that people are almost always let down by their experiences in rehab, whether in- or out-patient, and so much of the treatment world is dominated by 12-step philosophy, which is certainly not for everyone (right, Persephone?), and a 30-day stint of treatment is about as useful as a bath during a dust storm, and the revolving door of addicts coming in and out is closely matched by that of the treatment staff, who come and go at an alarming rate themselves, and most of whom really don’t have the knowledge or the credentials to help people in serious trouble. The general public can’t trust addicts, addicts can’t trust public institutions..etc, etc… Could that work?

But is seemed a bit superficial, a bit too obvious, no real bite to it. And then, about two weeks ago, it hit me: The main issue with trust and addiction is that addicts can’t trust themselves. Of course! You can’t trust yourself to take care of yourself. Because, when you tell yourself you’re going to stop, or at least slow down, or at least stop injecting, or whatever it is, and swear up and down that this time is the LAST time, and it will NOT happen again….you end up betraying yourself. Time and time again. Why would you trust yourself after you’ve let yourself down 50 or 500 times?! But it’s worse than that: you hardly even have a self to trust. You (or I) lose the sense of a grown-up conscientious self that can soothe you, hold you, get you through the rough times, tell you that it’s just craving and it will not last forever… That self is so damned hard to find after a while that you stop believing it exists. No, you can’t trust yourself. (And surely, as a consequence, no one else can trust you either.) So who/what do you end up trusting? Your addiction, of course! You trust that a hit of smack or a bottle of vodka or a few grams of coke or yet another roller-coaster ride of sex or gambling or that bowl of chocolate ice-cream or even the glazed eye of your computer screen will make you feel better. At least for a while. And it might. For a while. We put our trust in the thing we’re addicted to…because there is no one and nothing else to trust. And of course, of course, each time we do that, we lose even more ground with our self. The ability to trust ourself takes yet another soul-crushing hit. Vicious circle. And how.

This TED talk thing makes me nervous. I have to stand on a stage in front of 1,200 people, knowing that every move I make, every sound I utter, will appear on computer screens all over the world and become inscribed in the holy scrolls of YouTube for time immemorial. With no notes! No powerpoint slides at my fingertips to remind me of what I’m trying to say. Not even a podium to hide behind. Scary!

But I think I have a good talk. I’m going to present two psychological phenomena that make it particularly hard for addicts to trust themselves: ego fatigue (see previous posts) and delay discounting (the tendency to place way too much value on immediate rewards, at the expense of long-terms gains….like, oh, keeping your marriage or your job intact — a result of that dopamine/craving wave). I’ve got it down in my head, why these phenomena stack the deck against us. And why that makes it just so hard to quit. I’ve practiced it in the car. And once in front of Isabel. It’s going to be good.

And I’m going to practice it with you. Next post. Stay tuned.

It’s been a while since my last post. I did some relaxing, hung out with my kids, but mostly I spent my time writing a long, dense article summarizing my book — an invited article for a journal. I found myself back in the ring, fighting the Disease Model of Addiction… Round 17.

Is this some imaginary nemesis? Am I some demented Batman doing battle with hidden enemies? My dear cousin, Karen, who’s given me advice on all matters of personal deportment, diplomacy, table manners, and proper toilet practices since the age of three (she even instructed me to wipe after peeing, which turned out not to be necessary for boys) …Karen tells me to put down my slingshot. Goliath is more imaginary than real, and I should try to be nice and get along with others.

And then my knowledgeable email buddy, Sally Satel, sends me an issue of the New England Journal of Medicine, published only last month, in which the disease model is centre stage once again. The title of the article is…

Neurobiologic Advances from the Brain Disease Model of Addiction

The second sentence says it all:  “In the past two decades, research has increasingly supported the view that addiction is a disease of the brain.” Nothing new there. In a nutshell…

Addiction is a chronic, relapsing brain disease, evidenced by changes in the brain, especially alterations in the striatum (the brain part that underlies goal-seeking) and in the prefrontal cortex (responsible for cognitive control). These regions become partially disconnected with ongoing drug use. (my summary)

The argument hasn’t changed in years. (For a detailed account, read my book.) But the next sentence takes a new tack: “Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…”

Indeed it does, more and more, and the appendix to the article spells out some of the criticisms leveled by writers such as Maia Szalavitz, Carl Hart, Sally Satel, Bruce Alexander, our cantankerous and relentless Stanton Peele, and yours truly. (Gabor Maté and Johann Hari will agree if you ask them.)

As you might expect, the appendix also includes a brief counter-argument posed against each of these criticism. Here I’m going to review just two of these arguments/counterarguments and tell you why I think we should keep the slingshot loaded.

“1. Most people with addiction recover without treatment, which is hard to reconcile
with the concept of addiction as a chronic disease. This reflects the fact that the
severity of addiction varies, which is clinically significant for it will determine the type
and intensity of the intervention. Individuals with a mild to moderate substance use
disorder, which corresponds to the majority of cases, might benefit from a brief
intervention or recover without treatment whereas most individuals with a severe
disorder will require specialized treatment.”

So are they saying that most people with addictions don’t have a disease, and only those with severe addictions do? But you wouldn’t say that people with mild cases of cancer, pneumonia, tuberculosis, malaria, or even diabetes don’t have the disease. You’d say they do have the disease but it’s not too bad…yet. So maybe they’re saying that most people with a mild to moderate level of the brain disease of addiction don’t need intensive treatment? That might make sense, except that it doesn’t. This majority of addicts start using more than they should for a few months or even a few years, and then most of them just stop, without treatment. (The statistics on that are indisputable, so it’s good that the disease folks are finally acknowledging it.) But that doesn’t sound like a disease at all. It sounds like a bad habit that most people recognize is unhealthy and learn how to control. Then is there a threshold at which addiction goes from an overlearned habit to a disease? If there were, it would be measurable. But no one has ever succeeded in measuring it. Few would even try.

“3. Gene alleles associated with addiction only weakly predict risk for addiction, which
is hard to reconcile with the importance of genetic vulnerabilities in the Brain Disease
Model of Addiction. This phenomenon is typical of complex medical diseases with high
heritability rates for which risk alleles predict only a very small percentage of variance in
contrast to a much greater influence of environmental factors (i.e., cirrhosis, diabetes,
asthma, cardiovascular disease). This reflects, among other things, that the risk alleles
mediate the response to the environment; in the case of addiction, the exposures to drugs and stressful environments.”

My last post covered the genetics issue in some detail (and I’ll get back to it in a later post). But here’s the crux of the issue. Yes, weak genetic predictors may be typical of many diseases with high heritability. But they’re also typical of a bunch of other stuff…like personality! Personality outcomes fall into distinct categories: extrovert, anxious-neurotic, sociable, suspicious, dependent, etc, etc. (Should we add “addict” to the list?) And all of these “types” have weak genetic predictors (though high concordance between, say, identical twins). The reason is because people become the way they become based on what happens to them in life — the environment shapes them while they shape their environment. So the whole “genetics issue” — which has been a holy cow for disease model advocates — ends up saying nothing at all about whether addiction is a disease.

I’ll end by saying that holy cows get my goat (that actually means something in American). Next post, I’m going to tell you why I think it’s so hard (though it would be nice, Karen) to actually reconcile the disease and learning models of addiction.

Yesterday I watched “Ben is Back” — a recently released feature film about a heroin-addicted young man (Lucas Hedges) and his heroic and tenacious mother (Julia Roberts) who tries her best to keep him “clean.” Ben is around 20 years old (at which age I too was also shooting heroin). He scams a trip home from his residential rehab so that he can spend Christmas with his family.

Ben seems to be trying with great determination to keep away from drugs. Yet the demon of addiction is doing pushups in the parking lot, just as they warn at the 12-step meeting he attends with his mom. He finds a bag of dope in the attic, but manages to avoid taking it and gives it to his mother instead. He looks the other way when dealers and drug buddies from his former life show up magically on elevators and at car windows. He bravely endures the cultural ambiguity of an American Christmas and tries his best to connect with his sibs and step-sibs. He’s a good guy, and he fights the good fight, but…well I don’t want to spoil it in case you decide to watch it.

I thought it was a pretty good movie (I love Julia Roberts) with a half-assed ending, but there were a few impressions I want to share with you — impressions that epitomize a lot of what’s wrong with the mainstream perception of drug addiction.

Although the subtext of the movie is clearly the overdose epidemic, there is hardly a wave at the real causes of overdose deaths: fentanyl in street drugs, drug/alcohol/drug interactions among pharmaceutical users, and impediments to getting methadone or suboxone when needed. (However, to its credit, the film provides a snapshot of the lunacy of pharmacies unwilling to dispense naloxone.) See Maia Szalavitz’s excellent synopsis of what we’re thinking and doing wrong.

Instead, the usual “Reader’s Digest” simplifications are offered. For example, Mom meets the doctor who first prescribed pain pills, which got Ben “hooked” years ago, and says she hopes he dies a horrible death. We know that the OxyContin surge in the 80’s and 90’s did increase exposure to opiates and fueled increased rates of addiction. But to continue to blame doctors is insane. As Maia Szalavitz (and I) have made clear with arguments and statistics, doctors aren’t the problem, and the result of blaming them is the cutback of pain meds for people who really need them, while driving addicts to the street — to heroin that’s laced or replaced with fentanyl.

The 12-step presence is portrayed somewhat accurately. Both the good (fellowship, honesty, and mutual respect) and the not-so-good (brain washing, propaganda, and the all-or-none trappings of the disease model) correspond well enough with reality.

There is some recognition that addicts have choices. Ben fights his impulses bravely, and he makes sensible choices to avoid contact with the people and places that serve as triggers. And yet there is this creepy sense of fatalism sneaking up on Ben and other addicts. As though whatever choices they think they’re making, they’re bound to succumb. By the way, addiction isn’t referred to as “a disease” in this movie. Yet the miasma of an alien presence or infection lurks behind much of the dialogue and plot.

Junkies are portrayed as zombies. They are the opposite of clean. They’re dirty. They hover in alleyways, under bridges, around trashcans brimming with burning litter. It’s a classic and grossly overdone stereotype. When I was shooting heroin or morphine in my twenties , garbage-strewn alleys and river banks were not my preferred home away from home.

Despite the biases, stereotypes, and omissions, the movie does portray the struggle to avoid temptation rather well. And despite the Hollywood heroism and unlikely confrontations between good and evil, the plot and characters are engaging. The movie may well be worth seeing.

But here’s my biggest beef. People who take drugs are shown to be occupied by some demonic force (or disease, or what have you) that makes them another species. They are not anything like normal people. They live in a different world, they’re not to be trusted, and they ought to be sent away to residential rehabs (where they won’t infect the rest of us) until the demon is exorcised — itself a rare event. This dichotomous “us vs them” perspective is the real message of the movie.

An alternative message, which I hope you’ve encountered in my posts and the comments and guest posts of others on this blog, is that people who use drugs are so crushed by emotional confusion and pain, much of which is served up by American culture itself, that they seek and sometimes find substances and activities that help them turn down the volume of their anxiety and depression and bring a semblance of balance to their lives — what I referred to as “substance” last post. The cause of addiction can be found in mall culture itself (portrayed in the movie as a sort of heaven on earth), the rampant commercialism that sucks meaning out of day-to-day life, the often immutable stamp of privilege vs. poverty and the stultifying dead-end lives of those who don’t make the cut. Not to mention the sheer hypocrisy of a society that proclaims Christian values but rewards self-serving, self-protective priorities. I wonder if Ben was infected by these horrors rather than a magical drug high, and whether that’s what made it so hard for him to quit.

By  Elizabeth from the blog….

I am very pleased to present a guest post, created by Elizabeth, who has been a member of this blog community for at least a year. Thanks, Elizabeth, for your contributions until now, and especially for this fascinating post–

The present “obesity epidemic” has given rise to public concern about the level of refined sugars, especially high-fructose corn syrup, in the North American diet.  While we can all agree that an excess amount of sugar is probably not good for anyone, more controversial questions about the “addictive nature” of such sugar intake have also emerged.  Public policy measures to curb access to this “addictive substance” (see NYC soda ban) are designed with intentions to prevent individuals from developing a “sugar dependency” and hopefully curb the rising rates of obesity.  But, is overconsumption of these sweet and calorie-dense foods really reflective of a widespread “addiction” to sugar?  Perhaps there is some truth to the matter, and perhaps we can understand this phenomenon better by looking at studies of drug intake.

Several years back, researcher Roy Wise argued that drug intake could be viewed as an “ingestive behavior.” He noted that animals who were limited to short periods of drug access at regular times throughout the day show signs of “regulated drug intake” to maintain a steady blood serum drug level similar to “regulated food intake” to maintain energy balance.  When the self-administration studies were halted, these animals displayed little, if any, signs of withdrawal.  Thus, they were probably not really addicted or dependent on the drug at all.

So what could make this regulated intake spiral out of control?

Marc has provided a wealth of information regarding the predictors of drug addiction, including the effects of stress, low feelings of self-worth, and the need to compensate by “self-medicating.”   I won’t belabor these points.  What is interesting to me is that these factors seem to aid the development of “addiction-like” drug intake in animals — when the self-administering rodents escalate their use over time, pursue the drug in the face of punishment, and show physiological withdrawal symptoms. In other words, when they seem to become addicted.

So, additional factors — beyond drug availability — may be necessary to make the “ingestion” of drugs more “addiction-like.”  Does this mean that the ingestion of foods can also be normal, versus addictive, depending on external factors?

Indeed, stress and negative self-worth also play major roles in the development of eating disordered behavior (e.g., excessive caloric restriction, binge food intake, purging, etc..).  Food and drug rewards act on the same neurotransmitter systems, so disruptions in reward circuitry can confer drug addiction and, likewise perhaps, change the meaning of food. Get this: If you want to get an animal to REALLY want to take a drug, you can deprive it of food.  This suggests that dysregulated food intake cross-sensitizes with dysregulated drug intake (kind of like how abuse of one substance can lead to abuse of another). Basically, since the brain interprets the value of both food and drug rewards through similar circuits, alterations in these circuits can cause EXCESSIVE pursuit of both.  The brain is saying “hey, I’m deprived of some necessary sustenance…give me more!  The next time I get that reward, it’s going to be REALLY reinforcing, so I will seek it harder and make SURE I get all I can!”  So, the next time drugs are encountered, we binge on them.  The next time we get access to a sweet treat, we are likely to binge on that as well.  In fact, there is a striking comorbidity between binge food intake and drug abuse.

What this means is that there can be addiction-like components to both binge eating and drug taking.  The super-sensitivity to both rewards appears to be greatly influenced by the individual’s history:  Have there been significant life stressors?  Has the individual been deprived? (Think of those with eating disorders who have excessively restricted their caloric intake in order to look or feel thin.) These factors come together to promote a sort of “super-craving” — for food, drugs, or both.

I’m not sure that these factors are widespread enough to completely explain the obesity epidemic, but they sure help put it in context.

I had read about a third of Johann Hari’s powerful book, Chasing the Scream: The First and Last Days of the War on Drugs, in quick snatches during my weeks of travel. I’d seen his TED talk and read reviews in the press. He’s the guy who traveled the world uncovering the damage done by the War on Drugs. He’s the poster child of decriminalization – and perhaps legalization. I liked his book a lot, and I kept looking forward to spending more time with it.

Hari is a journalist by profession, and he writes in stirring detail about the victims of the draconian punishments handed down by court systems all over the world, intended to stamp out the scourge of addiction. He writes about the mayhem and murder that keep sprouting up in the footprints of drug prohibition – resulting not from drugs but from the clashes of criminal gangs. And he writes about the feelings and beliefs of those who’ve supported, enforced, and legitimized anti-drug policies for compelling personal reasons.

Now I was about to meet him: He was designated as the chair of my final talk in Australia, to be held in the magnificent Sydney Opera House. Who was this guy? What was he like?

I had a foretaste a couple of days before my talk. We were interviewed together on a popular Sydney radio station. He was rather manic, or so it seemed in the flat silence of the studio. His answers went on too long. Isn’t it my turn now? I thought, maybe success has gone to his head. We’d agreed to go out for a drink after my lecture, but maybe that wouldn’t be such fun after all.

Then I met him again onstage. He was a delight. He introduced me with real generosity and warmth. His clever, sometimes pyrotechnic wit and sparkly knowledge of the addiction field created the perfect backdrop for my talk, and we got into an easy banter in response to comments from the audience. I started to like him a lot.

We left the Opera House and found an outdoor café – one of dozens lining the harbor in a royal road of good cheer. And I noticed a couple of times without really noticing it that he had his voice recorder on the whole time and he kept asking me questions. The guy was interviewing me! I guess I was flattered – I really didn’t mind – but by the time we parted I realized I had done all the talking. I regret that now…

Before meeting Johann, I’d gotten into an email discussion with a guy name Percy Menzies, a thoughtful and passionate man who worked for a major pharmaceutical company, a division of DuPont, for many years, training doctors in the use of medications derived from opium. This company had produced a number of well-known medicines, most important among them being Naloxone and Naltrexone, opioid antagonists which suppress the effects of heroin, making it almost impossible to OD. Now he runs several clinics combining drug therapy with counseling to help addicts withdraw, stay clean, and reconnect with their community.

Well Menzies has what can only be called a simmering contempt for Hari. Like other “pro-choice” advocates, Hari reminds us that heroin-addicted American GIs mostly quit the habit once they got back from Vietnam. Just as in Rat Park, environment mattered hugely, so addiction could be seen as a response to trauma and disconnection rather than a characteristic of drugs themselves.

But Menzies makes the following counterargument:

Yes, they came home to a “park” mostly free from fatal threats and populated by loved ones. Environment mattered.

But what mattered most was supply. In their day-to-day lives, most returning soldiers were in no position to continue scoring dope, especially not at the potency they had enjoyed in Southeast Asia. The 1980s Soviet experience in Afghanistan is particularly revealing: many soldiers found themselves addicted to the region’s pure heroin. But unlike their American counterparts, demobilized Soviet troops continued using heroin back home as it was readily available. Today Russia has one of the worst heroin problems in the world.

Menzies goes on to another potent example of why access matters so much:

Hari ignores all historical evidence that identifies access and price as the two most significant factors contributing to the spread of addiction. We as a society have known this for the longest time, yet people like Hari ignore these facts.

In his intellectual arrogance, Hari fails to consider the larger consequences of drug legalization. Returning again to Afghanistan, before the early 1980s that country had virtually no heroin addicts. Local drugs of choice were hashish and smoking opium. This was because most of the opium grown in Afghanistan was smuggled into other countries for processing into heroin. But a combination of international trafficking disruption and supplier economic savvy relocated processing to the countries where opium originates. Cheap, potent heroin was now available to Afghans for the first time ever. As a result, today Afghanistan has more than 1.5 million heroin addicts.

Now what are we to make of this? I am very taken with Hari’s investigation of the War on Drugs. I’ve plunged back into his book, and I’m now savoring every chapter. I am taken with his intelligence, compassion, his courage, and his mesmerizing ability to write about suffering without muting the pain or descending into sentimentality. And his argument about the damage done by drug prohibition is indisputable.

In fact, Menzies agrees that criminalizing drug use and locking up addicts is inhumane, ineffective, and wrong-headed. He says:

If we…tackle the drug addiction [problem], we have to begin with decriminalization and start dismantling the ‘treatment industrial complex’. These entrenched silos of residential treatment programs, jails prisons, methadone clinics, buprenorphine clinics have to be inter-linked. Indeed, the present treatment sets the patient up for failure and sometimes overdose deaths.

This is someone whose views resonate with my own.

Where Menzies and Hari differ is on the issue of legalization. If we decriminalize drug use, then do we make drugs legal? That is essentially what happened in Portugal, and Hari sees that small revolution as a huge step forward. But will cocaine and heroin be sold in stores in my town? Do I want my kids to be able to meander down to the local smartshop (we have these here in the Netherlands — very progressive) and buy a gram of methamphetamine?

Let me know what you think. And I’ll think about it some more myself.