Understanding Addiction

I want to start unraveling the talks I heard, beginning with Kent Berridge’s talk. If you haven’t been following this blog or read my book, here’s some background: Berridge has made two major contributions to the study of addiction. The first is the idea that “wanting” and “liking” are independent neural systems. Wanting (or craving, as we understand it in addiction) is mostly fueled by dopamine, which is sent from the midbrain to the nucleus accumbens (NACC; or ventral striatum), a major center for goal-directed pursuit, lying in the middle of the brain, deep within the cortex and surrounded by the limbic structures. Here’s that slide once again. The NACC is represented by that yellow explosion, to convey the growth of craving over a matter of seconds or minutes. On the other hand, liking (or pleasure) is provided by — guess what? — opioids, whether they come from your local dealer or from the natural processes of your own brain (the hypothalamus produces opioids, which are critical for calming us down and relieving pain). The idea that wanting and liking are truly dissociable is pretty radical, both in psychology and in neuroscience. In the present post, I want to tell you about Kent’s recent research, as reported in Boston two weeks ago, where he demonstrates this independence — in that pristine way scientists have of breaking things down to their fundamental components.

Berridge’s other main contribution is the idea of incentive sensitization. This is the notion that particular cues or stimuli (whether out there in the world or generated from our own fantasies, memories, daydreams, etc) become strongly associated with our drug or drink of choice. And those cues — all by themselves — activate the wanting circuit. They directly release dopamine to the NACC, so that we find ourselves suddenly beset by craving, simply by exposure to a cue. The strength of that incentive sensitization obviously increases the more often we use, because the experience itself serves to reinforce the association with the cue. But I won’t discuss this further for now.

Okay, so Kent gets up in front of this group of 15 or so people, including only two other neuro people (Davidson and me). And he’s explaining his recent research with rats, in which he’s set out to show that wanting and liking truly are separate systems. He wants to get his message across to the group, of course, but the main goal is to develop a talk that will be of interest to you-know-who. He wants, we want, the Dalai Lama to say: Hey that’s really cool! Now I get how you can want something without even liking it! For Kent, and for me, this issue gets to the heart of the problem of desire — a problem which is as central to Buddhist psychology as it is to addiction psychology.

So here’s the experiment: The rat is “trained” to press a lever that delivers a sweet solution. This is a very typical “Skinnerian” learning paradigm. Rats love sweetness — don’t we all? — and it’s been shown that sugar speaks directly to those opioid-fueled cells in the NACC. So here’s a rat that has experienced liking which has led to wanting, in the very natural way that we are “trained” to go after rewarding experiences in life. So they are willing to press the lever many times over, as motivated by their wanting for the sweet taste — and as shown, through other studies, to depend on the flow of dopamine following that initial opioid rush.

But there’s another lever in the cage. When the rat presses it, just in the process of exploring its environment, it delivers a very salty taste. Kent is sitting in front of his computer, at the end of the table near the screen, and he looks up at us, wanting to get across how very nasty this liquid tastes to the poor rat. Imagine the taste of sea water, he says. Now imagine something that’s at least 10 times saltier — beyond the level of the Dead Sea. And I feel like I’m glimpsing the soul of this scientist. He is right there in the minds of his rats, trying to imagine — and communicate — what they are experiencing. Because that’s the necessary link here. The connection between experience and behavior. And if you’re studying it in rats rather than humans, you’d better be able to imagine what it’s like to be a rat. Anyway, the rats don’t need another trial to learn to stay away from lever #2. They hate what it gives them. There is no pleasure to be had there.

Now here comes the essence of being a good scientist: being clever enough to find the fracture point where you can split a phenomenon into its parts. We’ve got liking and wanting for lever #1. And zero liking or wanting for lever #2. Then the experimenter gives the rat a drug that reduces their blood level of sodium way below normal. They become salt-deprived. And now the punchline: The rats immediately go to lever #2 and start pressing like hell. Kent and his assistants have completely bypassed liking to get to wanting. There is clearly a high degree of wanting present, but there was never — not even once — an experience of liking that led to it.

Half the people in the room didn’t get it at all. So…the rats were salt-deprived. So they went after the salt lever? So what? Kent read their blank expressions and tried his best to convey what was so cool here. I sensed his disappointment. Who wants to go to all that trouble and have the punchline fall flat? The rats didn’t know they were salt-deprived, he explained. But the wanting circuit was immediately activated by something, some change in their biological state. It doesn’t really matter what activated it. The point is, wanting does not have to arise from liking. It’s an independent process, in mind and brain. It can arise from anything!

For me, the parallels with addiction were immediately striking. That sudden wanting, craving, compulsion that we experience for our drug of choice doesn’t have to depend on how much we liked it in the past — either the distant past or the recent past. You can crave something that you’ve never liked — just because, at some level, you need it. Granted, with drugs and booze, there is usually pleasure the first many times, then the pleasure fades, and after awhile there is no pleasure. Not even the anticipation of pleasure. The wanting comes from needing it, not from liking it. (Mind you, with tobacco, it seems you never have to experience any pleasure to graduate to craving.) So addiction is sort of like the rat experiment with a hunk of time subtracted out. After we become addicted, wanting has nothing to do with how much we do or did like it.

Following some questions and discussion, I think most of the group got it. You had to go right into Kent’s world — the world of a scientist as clever as he is determined. The point wasn’t what caused the sudden wanting. The point was simply that wanting and liking can be shown to be totally independent processes. Will the Dalai Lama get it? Will it help him, and the rest of us, understand something crucial about addiction?

Let’s hope so.

Hi people. I haven’t posted anything in the last couple of months. My last post went up in mid-July, then there was a guest post, and then…the silence of the tomb.

But I’m still here.

It has been a challenging and chaotic summer. Our planned (temporary) move to Toronto got rescheduled and rescheduled due to a death in the family and our wish to support the person left behind. Which meant a few trips back and forth to Europe for Isabel (my wife) and one extra trip for the kids and me. It wasn’t all bleak. We spent two weeks in the south of France, and there aren’t many places more beautiful than that. But it was surely disorienting.

Now back in Toronto, finally to roost, for at least four more months. But we had to shift from one rental to another. We’re still trying to get settled. And four days before the start of school, we found that our boys (12-year-old twins) weren’t allowed to attend the public school we’d planned for them. Frantic search for a new school — which now seems to have panned out well. Discovered a great ping-pong spot. Life goes on.

Now, with a little peace, I’m tempted to start blogging again. But I ask myself: do I have much more to offer in the domain of addiction and “recovery” or have I covered what I’ve got to say? I’m not sure. I’ve become a little less interested in the neurobiology of addiction for a very simple reason. Short of neurosurgery (and a very few available pharmaceuticals, which were already in use decades ago), there’s not much to do about the neural basis of addiction except to understand it better and then get to work on changing behaviour. So why not go straight to the behaviour? Which of course means the thoughts, feelings, internal voices and psychological background (emotional difficulties at younger ages) leading to the behaviour. I’m more interested in that right now.

This interest is fed by my growing psychotherapy practice with people in addiction (or struggling at the border of it). I am learning a lot. And I hope I’m helping my clients. At the same time, I’m pretty tuned into the gradual evolution of the treatment field, the growing strength of the harm reduction ethos, increasing frustration with the dominion of AA and its offshoots, and gradual changes in the policy/legal/medical/political issues that swirl around the enormous problem of opioid addiction in the US. Not to mention the social and societal factors that make it so hard for many people to quit or cut down. I get what residential rehabs sometimes do right and what they so often do wrong. I get the power of mindfulness/meditation and the various psychotherapeutic approaches (e.g., ACT, mindfulness-based relapse prevention, dialectical behaviour therapy) that incorporate it, along with the best (hopefully) from clinical psychology. So maybe there is more to talk about.

By the way, I still give talks on addiction all over the place and write occasional articles for scientific journals as well as the popular press. And I’m still working on that novel.

I also wonder if I should get more personal. I haven’t done anything illegal in a long time (except when it comes to parking and such). But am I a completely different person than when I was using opiates and coke (and acid and a few other things) and breaking the law almost daily? Of course not. I sometimes still feel incomplete and empty in ways I’ve felt since age 18. I still attach a particular meaning to substances, though my substances these days are pretty benign — and occasional. But I don’t talk about myself much, and maybe I should. You guys share a lot. Maybe I should share more.

That’s it for now. Just wanted to indulge in some speculation, thinking aloud. And I have an excellent guest post coming up in a few more days.

I hope you, my readers, are doing as well as you can. Warm wishes to all.

The word “substance” may have a double-meaning when it comes to addiction. The basic meaning is obvious: the substance is a chemical that we want badly and pursue relentlessly. But the second meaning of “substance” is suggested by a well-documented phenomenon: the parallel between substance addictions and behavioural addictions.

The feelings, actions, and brain changes seen with compulsive gambling, sex addiction, porn addiction, and many eating disorders (e.g., binge-eating disorder) look very similar to those seen in substance addictions. The feelings and behaviours include craving, gorging, risk-taking, reduced inhibition and compulsive repetition. The brain changes include sensitization of the dopamine system and reduced interaction between the prefrontal cortex and certain subcortical regions (in specific contexts). Because attractive drugs and attractive activities are craved and pursued in similar ways, it might not be too far-fetched to give “substance” a second meaning. The substance common to drug addictions and behavioral addictions may be the feeling of wholeness, once lost, now regained.

A substance is what fills up a space. The lack of substance equals, well, nothingness. When people talk about their addiction they often talk about a sense of profound emptiness, a psychological void, that gets filled by a something they can only get from what they’re addicted to. To replace a sense of nothingness with a sense of somethingness (what else to call it!) is more powerful than words like “pleasure,” “relief,” or “satisfaction” can possibly convey.

At first glance it seems that chemicals provide pleasure directly while certain behaviours provide pleasure through taking action, and that’s the whole story. But in real life, you need to take action to get those nice chemicals, to put them into your body, and that’s what the dopamine system is triggered by: not just reward but reward-seeking. Hundreds of studies have shown that dopamine release in the “craving centre” (the ventral striatum or nucleus accumbens) corresponds with effortful action, not with pleasure per se.

So whether we think we’re addicted to chemicals or to actions (behaviours) doesn’t much matter to the brain. Actions (like gambling) release dopamine because they are pathways to a monetary reward. Actions like shooting heroin release dopamine because they are pathways to a chemical reward. In both cases, the hook is a feeling state that springs from an action more than an outcome. To put it another way, it’s not really the heroin that you get addicted to. Heroin will bequeath satisfaction or pleasure. But what you get addicted to is the feeling of acquiring this special something: anticipating it, going after it, and getting it.

One of my favourite models of addiction (and one highly regarded in the field) is Robinson & Berridge’s theory of “incentive sensitization.” This phrase means that dopamine release in the brain (e.g., in the striatum) gets triggered, more and more predictably, by cues connected with the thing you’re addicted to. These authors specify that dopamine uptake signals wanting, not liking, a drug or other reward, and this has been a major contribution to our understanding of addiction. But to bring this understanding home, we have to clarify what incentive we’re talking about. Does “incentive” just mean urge, attraction, or motive? Just “wanting”? No, the incentive that powers addiction — what the brain gets sensitized to — is the availability of something you not only want but feel you need.

Berridge has compared this urge to the desperation of a starving animal seeking food. So it may be useful to view substance and behavioural addictions as fulfilling biological needs, or at least their psychological expression. Whether we take pills, snort powder, smoke, or inject, we are putting something into our bodies. This “inputting” is a behavioural prototype. It’s primal. It’s how we eat. In the case of binge eating, the target of the behaviour makes obvious biological sense. But perhaps all behavioural addictions relate to biological needs: e.g., winning against competitors (gambling), sexual needs (obviously sex and porn addiction), even social inclusion (internet addiction) and resource acquisition (compulsive shopping). In my book, The Biology of Desire, I make the case that addiction serves symbolic goals. For example, the warm feeling you get from opiates symbolizes the warmth that comes from being hugged or cuddled (no small matter for us mammals).

This may all sound a bit abstract. But the feeling of emptiness we (addicts) feel when we don’t have, or can’t do, or can’t get the thing we’re addicted to is very concrete, and very palpable. It’s the feeling of an empty day that can’t be filled. It’s the total eclipse of purpose, when there’s no point in doing anything. This is what I mean by the absence of substance.

Many see addiction as an attempt to repair a rupture in attachment (as in child-to-parent attachment) or care (by a parent, lover or even oneself). Certainly these are biologically-grounded needs. Gabor Maté’s study of addicts in downtown Vancouver, mostly aboriginal, mostly from foster homes, mostly abused or neglected in childhood, highlights the enormous holes in the lives of people with devastated attachment histories — holes filled by drug use. Bruce Alexander extends this idea of loss to groups cut off from their cultural roots and resources. What’s lost for these people isn’t just pleasure or relief; it isn’t just something they like or want. Rather, it’s something they feel they need. In the words of Johann Hari, it’s connection itself. People who have lost this “something” walk around with a sense of their own emptiness, and it hurts like nothing else. By filling that emptiness, a drug (or habitual behaviour) becomes the main source, maybe the only source, of the substance they have gone without.

Marc,

I’ve been working on a drug education video series for a client who works mostly with classrooms of 5th-8th graders, and stumbled on your blog while doing research. It’s been extremely valuable to me in getting my head around addiction and the action of drugs in the brain. The challenge has been how to translate that into information that might help insulate a kid from going down that path when drugs are encountered.

Do we focus on kids never trying drugs, or on preparing them to stay away from “abuse” rather than “use”?

My question about addiction is perhaps most what I see as a non-drug-addict (as you rightly elucidate, there are plenty of my behaviors that mirror those of addicts, but I don’t have any addictions to drugs) who is working in the space between kids and drugs. One thing I haven’t read here in your blog or the resulting comments is a sort of social prism. Thinking of myself as a youngster, the feeling of getting out of my body or being in some ecstatic space was extremely important. I dabbled in various hallucingens mostly, but I think because I had enough other experiences of joy that I saw them as interesting but not essential. If anything, I feared drugs because the resultant come-down deprived me temporarily of access to the more natural experiences of authenticity I treasured.

I think of Ben in the video you link to up there. Sure, he had no overt trauma, but he grew up in what seemed one of those imprisoning and somewhat dulling strata of UK society…loving family, but perhaps not much room for connection to anything other than a row house and a job? Isn’t there a trauma in culture? In growing up in a civilization or particular society that requires a certain kind of adaptation — an adaptation that many of us are unable to make, whether biologically or, if you bend that way, spiritually? I think of the kid in Into the Wild…it wasn’t drugs for him, but he needed something out of his life that his sweet upbringing couldn’t provide.

Drugs for many might provide the only experience of ecstasy they’re likely to have…and who are we to ask them to prefer a long life of frustration and being an upstanding citizen to a few fleeting moments of feeling truly alive? What are we alive for, exactly? To execute our biological and social functions? I think these discussions of being and the brain are extremely fascinating, and I think a lot of work is being done lately to understand how brain networks affect behavior and health, but I feel like there’s a big gap here as we individualize and anatomize too much around addiction and think less of the more philosophical question of our purpose here.

For non-traumatized kids, what do we offer them as a culture that makes resisting drugs an appealing choice? Fear of ending up like Ben obviously isn’t enough. What’s the positive path we give them to choose? If we value euphoria, or even just wellbeing, as a culture, does our current system work?  How available is the state of wellbeing in ordinary life? Or are drugs the best way to get there; and that’s how they get so deeply into our brains?

I started reading your book and couldn’t help feeling that there was more to your drug use than the obvious trauma. Not only were people mean to you and you felt loss leaving home, but it seemed that drugs gave you a path to the sublime that was missing in your surroundings. Your lyrical writing in those passages certainly attests to a sense of doors being opened…maybe the lack of major psychic pain you allude to was also the lack of venues in your social situation to access joy or hope?

I often think about this when working with kids at risk. Are we really telling youth to work at McDonald’s (if they can even get a job there) and be upright citizens for the minimal sense of satisfaction and safety that comes with that choice — rather than choosing either the visceral thrill and sense of joyful community of being in a gang, or the (temporary) euphoria and wellbeing that come with drug use?

…by Shaun Shelly…

I just pulled into a lodge in Banff, Canada at 2 AM (roughly noon for me) after a flight delay and missed shuttle. I’m way too tired to introduce this intelligently. All I can say is that I have huge respect for Shaun’s understanding of what goes on in opiate addiction, both above and below the surface we call treatment. See for yourself:

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Firstly, I think that the most important thing to remember is that OST (either agonists such as methadone or partial-agonists such as Buprenorphine, with or without naloxone) saves lives. There is up to 75% reduction in mortality for those in these programmes as opposed to those who do not have access. That alone should sweep away almost any argument against the utility/ethics/need for OST programmes. OST is well researched and has been shown to work and save lives over many years. (*1 for examples -there are many)

Secondly, low threshold programmes, such as the one you describe [see last post], that do not insist on abstinence or accessing other services, are a vital part of the continuum of care. The data tells us that psychosocial interventions such as CBT add nothing to the outcomes of these programmes in terms of drug use, retention, other health issues etc. Personally I have some issues with the design of some of these studies, and as with most “addiction” research they are too limited to draw absolute conclusions from, but certainly the lack of availability or the lack of willingness to engage in psychosocial services should NEVER prevent the supply of OST.

Thirdly; there is plenty of evidence that these programmes improve access to health services; improve compliance on ARVs and TB meds; reduce criminal activity; improve quality of life in some people; can help people become employed; lead to people choosing to engage in other “addiction” treatment programmes, including abstinence based programmes (but this increases risk of mortality in the short-term!) etc etc

So, it is clear, in my opinion, that we should be offering low-threshold OST programmes. I think it is also very important to note that this type of programme, along with needle and syringe programmes, offers a unique opportunity for drug users who are highly stigmatised to engage with health and other services, and, perhaps vitally, to engage with people who are part of a wider community without stigma or judgement. This interaction can, and sometime does, provide the “scaffolding to construct a vision of future self” (to paraphrase one of my favourite quotes from Marc).

For some people the simple move from a street opioid to a pharmaceutical opioid with a longer half-life is all that is needed to find some stability and start “living” again. If they have the correct support structures, mental faculties, education, family or alternative family structure, the right lucky break or a guardian angel individually or in any combination, they will be able to build a productive life. I know many such people. They are still dependent on an opioid, but are not addicted – so what! Just the structure of attending the clinic and not having heroin be their all-consuming vocation, can give them the space and the belief  to start making changes, and these are often self-accelerating. Some of these people will eventually down-titrate to zero or close to zero dose, some may not. Their choice. Some may have, as Dr Mark Willenbring has suggested to me, a hypoactive endogenous opioid system that requires a life-long agonist to function optimally.  Either way, they, and many of the rest of the world, except the abstinence Nazis, are happy.

However, there are many exceptions. While many of the people you saw “weren’t anywhere close to safe and stable in the big picture” I would argue that this has little to do with their drug use. I certainly do not want to paint all street dwelling dependent heroin users as victims – they are often the most resourceful and resilient people I have ever met – but many of them (but not all as Gabor Mate would have us believe) are sufferers of serial trauma and most have been highly stigmatised, ciminalised and ostracised. In this case, they may not have the resources, intrinsic and extrinsic, to build on the new-found structure of methadone or buprenorphine and create a “new life” or find “recovery”. Indeed, for many that may not even be desirable.

For many of these people heroin is a form of vocation and indeed the thing that binds them to their street family (see the video I have linked at the end of this post). I have worked extensively with these populations, and I find that for many drug use is a supremely logical choice in the face of little chance of finding meaning in what others would call “normal” pursuits. As I stated earlier, this is not a problem of pharmacology, this is a problem that lies beyond the individual and in the structural and systemic issues of modern society – the work of Alexander (his FULL BODY of work!) is very relevant. To expect methadone programs to address these issues is unrealistic!

This leads me to the one area where I do have a problem with methadone programmes and the reductionist approach that reduces harm reduction to a set of bio-medical interventions. Just because people are being kept alive does not mean we have solved the problem. The other issues that need attention are criminalisation, stigma, inability to address the needs of those with mental health and other issues. These are not (only) drug issues, but societal issues.

One of the steps towards addressing these wrongs lies in the fact that agonist therapies work – they are the only consistent therapies to work with “addiction” when it comes to health issues. The logical conclusion is that we should make pharmaceutical agonists easily available to all drug users – allow these street users the same benefits that many of us “functional due to privilege” users enjoy – access pharmaceutical quality drugs with the minimum of barriers. That is decriminalise, legalise and regulate all drugs. This will not solve all the problems, but will go a long way to prioritising who does and doesn’t need “treatment”!

Video on “street families”:
http://www.featureshoot.com/2015/11/photographer-chris-arnade-on-street-addiction-and-the-devastation-it-leaves-in-its-wake/

*1 EG :Caplehorn, J. R., Dalton, M. S., Haldar, F., Petrenas, A. M., & Nisbet, J. G. (1996). Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use & Misuse, 31(2), 177–196. http://doi.org/10.3109/10826089609045806
Connock, M., Juarez-Garcia, a., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., … Taylor, R. S. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment (Winchester, England), 11(9). http://doi.org/10.2165/11632820-000000000-00000