Understanding Addiction

Hi again. I’ve been back home in the Netherlands for exactly two weeks, and there has been so little time for anything…so I have not posted anything. Lots of course work to catch up on. One new class started last week, and I had to prepare my lectures…with eye-catching Powerpoint animation, jokes that might seem funny to 21-year old Dutch students, and oh yeah, all that neuroanatomy that had gotten slightly rusty… I was a bit nervous. There were 300 of them sitting there chatting while I was standing at the podium clearing my throat. English is their second language, one they had to learn in high school. And Neuropsychology 101 isn’t intrinsically entertaining to everyone. The text book was dry, so was my throat, and how was I going to say anything comprehensible and interesting enough to get their attention off their cell phones?!

It didn’t go badly after all. I really got into talking about the brain. I pranced around the stage, pointing to different spots on my head and extolling the marvels of this self-organizing system of rapidly emerging subnetworks, that are the physical basis of all experience, a system that is designed to be underdesigned (because we need to learn almost everything we know — and that requires massive reorganization), and I’m talking about 20 billion or so cortical neurons, ladies and gentlemen, dames en herren, with 1,000 or more connections. EACH!  That’s at least 20 trillion nodes, each node affected by complex concoctions of neurotransmitters, which tune them, just so, influencing how much information gets through, what kind of information gets through, and how we FEEL about that information…

Someone (I think Joseph Ledoux) boldly said: You ARE your synapses. That shifting configuration of tiny electrochemical connections: that’s YOU!

They were happy and smiling at the end. A good sign, I thought, except maybe they just liked watching me stride about tapping myself on the head. I had to wonder what was getting through to them.

I wondered the same thing, a week and a half ago, while participating in an hour-long talk show, via Skype. It’s called The Agenda with Steve Paiken, and a lot of Canadians watch it. So I was a bit nervous that night too. Behind me the camera picked up vague shapes in a dark, messy living room — watching it afterward, I thought I looked like a resident in some unlit chamber of hell, compared to the bright faces in the studio in Toronto.  But the real problem was that one of the three other guests was an MD, a psychiatrist, named Peter Selby — a guy who does both research and clinical work — at this psychiatric/addiction institute in Toronto. CAMH, it’s called, I mentioned it in my last post. And he, like many of his colleagues, really sees addiction as a disease. But I don’t. So we argued about it. It was all quite civilized, but we weren’t seeing eye to eye. And yet he had some good points.

Politics and pontification aside, am I really so sure that addiction is NOT a disease? This is a topic that I’ve gotten into before, but not in much depth. I know how to talk the talk. I’m used to arguing cleverly that the “disease concept” of addiction is really just a metaphor, and a sloppy one at that. It can be useful. It helps us refrain from beating ourselves up if we think we’ve got a disease. But maybe it robs us of the sense that we can overcome it through our courage and our creativity — something you can hardly do with a real disease. I have some good sound bites… like: if addiction is a disease, then you must CONTRACT it at some point, and then you HAVE it, and then you GET treatment, and if the treatment works, then you’re CURED. And if it doesn’t, you have the disease until you die. I can talk like that, and I can smugly conclude that those are NOT the characteristic features of addiction. But now I’m not so sure, and I wonder if I’m the one being too superficial, too mentally lazy, to give this matter the attention it deserves.

Because Selby was right about one thing: “disease” is not such a simple black-and-white concept. Take Type 2 diabetes. You don’t catch it or otherwise contract it. Rather, it grows — it’s really a developmental disorder that comes about when people make bad choices about what they eat. Or live in unhealthy environments. And it’s not something you try to cure, it’s something you try to treat. The same could be said for quite a few “medical” diseases. Like high blood pressure? Like colitis or irritable bowel syndrome? Like carpal tunnel syndrome? When I’m on an anti-disease rant, I often fall back on the argument that brains change with development, they change with experience, they’re supposed to change: learning changes the brain, addiction is a kind of learning, it’s highly accelerated, it’s very focused, but it’s still a process of learning. So I’m thinking, diabetes, colitis….do they change the structure of your body too? Well, of course they do. And yet your body isn’t supposed to change in those ways. Aha! I’ve clinched the argument. Except that I have this intrusive thought: brain changes that come about with addiction are NOT so natural after all. Sure, the brain — especially the cortex and limbic system — is designed for its mutability. It’s supposed to be able to change with learning. But it’s not supposed to change so much that you can’t secrete dopamine in the ventral striatum without focusing on your drug or drink or sexual obsession or food obsession of choice. That’s a pretty fucked up brain, even if it got that way through a “natural” “developmental” process. So…is the outcome of addiction really distinguishable from what we call a disease?

I’m not going to go further with this tonight. But what do you guys think? Please share your ideas before I share more of mine. Yet we all have to try to leave our politics at the door before we get into this. Because the 12-step versus do-it-yourself versus the self-medication approach versus the “choice” position — all those territorial disputes take our attention away from the fundamental issue, the thing we really need to focus on. Which is: what is addiction? What is it really?

Nobody’s right if everybody’s wrong.  Do you remember that song from the late sixties? By Buffalo Springfield? Anyone else that old? Here, have a listen.

I’ve been in Australia for about three days. I say “about” because I truly can’t keep track anymore, though I could look it up. I dreamed that I was in Arabia for a while on the way here, but there must be a logical explanation, like I was having an astral projection or something. And yet…look what I found on my camera:

I actually woke up the other day, looked around at the standard hotel-room features and had no idea where I was. The feeling lasted about 20 seconds and I just let it be, enjoying the novelty of it. Australia evokes that readily because it seems like such an arbitrary continent. Aussies, please forgive me, and I’m sure many people feel this way about Canada, but the sense is: What’s this place doing here? Who put it here?

The Aussies are good to me. After my talk at the Melbourne Writers Festival, I was told that my book was the best seller of the whole Festival — except for a children’s book that apparently didn’t count. That’s a beautiful thing. And there was a supportive Q&A just published in the Australian version of  The Guardian, and other positive reviews online and in the press. All in the Mind, a radio show on ABC (A is for Australian) just aired this nice podcast connecting my views with those of Gabor Mate, whom I respect, not to mention Tom Waits.

And I’m still getting some great publicity from other lands. Jane McGonigal (@avantgame) has 130,000 Twitter followers and here’s a recent tweet from her. She’s a trend setter when it comes to the impact of IT on people’s thinking and behaviour, including the influence of video games on…just about everything. And look what she says…

But all this praise is only half the story. The forces of darkness have been gathering. I’ve gotten some of the nastiest reviews I’ve ever seen, ever even imagined. I’ve been called quite a few names, the mildest of which was “zealot” in the Washington Post. That review was moving along nicely until the writer, Marianne Szegedy-Maszak, got in touch with her reserves of….I guess contempt:

But despite the legitimizing heft of brain science, romanticizing the addict and turning recovery into a heroic narrative seems one of the central and unsettling aspects of Lewis’s perspective. When he writes that addiction is a “vivid instance of the role of suffering in individual growth,” he seems to imply that addiction is not just not a disease but noble. Addicts become heroes and addiction their heroic vehicle. It is difficult not to see this as a way of inserting himself, as an addict, into the story, while playing down the staggering social costs of addiction.

At least that’s marginally rational. Do I really think addiction exemplifies nobility or heroism? Well, no, actually. But I do see people’s determination to quit, and their sometimes long drawn-out battles to do so successfully, as worthy of real admiration. I see those efforts as courageous and maybe even heroic. But that’s an entirely different point.

And this business about “inserting myself, as an addict” into my writing… Sure I do, but how is that wrong? A few have argued that Lewis just claims addiction is not a disease because he got over his. So, let’s see, that was sure easy. What’ll I do for excitement next weekend? Maybe that’s what Ms Szegedy-Maszak is implying.

But some of the nastiest criticisms come from the pages of Customer Reviews on Amazon.com. One had this to say:

I will not buy another piece of garbage from this author after having wasted time and money on his last self-aggrandizing, narcissistic, egotistical piece of trash… This guy is a snake-oil salesman, a charlatan, a quack, sham and fraud masquerading as a neuroscientist interested in advancing the field of Addiction Recovery. He may have conquered his addictions, though he admits he still drinks alcohol, but he hasn’t given up the behaviors that he learned as an addict…

At least he or she isn’t pulling any punches. Other negative reviews are just as silly or rude, or too dumb to be upsetting. But there are a couple that get to me. Like the guy (I assume it’s a guy) who said…

He reminds me of a nurse I worked with on a hospital inpatient detox unit. He felt that when he was addicted to drugs, he stopped on his own without treatment, so he spent his time abusing the patients on the unit for not helping themselves. He was ultimately fired for his involvement in a patient suicide on the unit. Lewis needs to read a good work on Phenomenology to learn to bracket his experience when studying another’s addiction.

The problem is that it almost sounds rational, and it’s just so damn ugly. Although I’ve been told repeatedly — especially by Isabel — never to respond to negative reviews, I just had to reply to this one. I was almost civil. Now that’s heroic.

So here’s the net result — so far. Quite a few people really like the book. And a pretty large proportion — at least of those moved to write customer reviews on Amazon — hate it with a passion. Yet it seems to me they hate it for different reasons. Some oppose it because they think it’s so obviously wrong and others because they think it’s so obviously right that anyone could have written it. Go figure.

I’m not deeply upset by the criticism — either the stupid attacks or the cleverly devised barbs. It’s part of the game, I know, and controversy — even animosity — helps publicize ideas and sell books. I just thought I’d let you know how it’s going out here.

And by the way, if any of you folks feel like writing a flattering customer review on Amazon, nobody’s stopping you. But if you say anything even slightly negative, I know where to find you.

“Mostly say hooray for our side”

Hi guys…I’ve missed you. I’ve missed putting up regular posts for the last couple of months and I’ve kept mostly out of the discussions and debates in the comment sections….but scanned them enough to see that you are still in top form. I encourage all readers to take a look at the comments on the last few posts. There are some really valuable views, arguments, and insights being posted.

Anyway, for now, I wanted to wish you all a good year and maybe touch on some current controversies that will affect us in the coming months.

What have I been up to? Mostly editing and proof-reading a couple of articles, updating a talk that I plan to give next Saturday in London on sex addiction, planning a new talk circuit, and zillions of little things that I can’t name or categorize or even remember half the time. Paying backlogged bills, replying to emails buried in my inbox, trying once more to learn Dutch, changing light-bulbs, driving or biking (with) my kids around to various lessons, shopping, etc., and doing a fair bit of psychotherapy. Remember I mentioned that I’m starting a Skype-based counselling/psychotherapy practice for people “in addiction”? Well, it’s happening. I have about six clients so far, and I really like it. Sometimes I feel like I’m good at it, and sometimes I even seem to be helping people, which of course feels great. And relaxing…a bit more than usual…especially over the holidays. That was gooooood.

So what are some topics that should be addressed in this year’s postings? Here are some thoughts:

The “opioid epidemic” in the US. This is obviously a big issue, it’s on the front page half the time. I even get asked by people why I haven’t contributed to the debate yet. Well partly because it’s so complicated, partly because I’m not sure I understand it, and partly because it makes me sad.  One avenue of debate involves prescription vs. street drugs. And that divides into two sub-themes, addiction and overdose.

First comes the evidence that most people who end up on heroin started off on prescription painkillers. What does this mean? Does it mean that getting opiates for pain is the cause of long-term addiction and all that goes with it? Not according to Johann Hari, as revisited in his recent op-ed piece. He reminds us (despite a spat of criticism) that by far the majority of people who take prescription meds for pain don’t get addicted. Carl Hart pounds out the same message. So is this just a rehash of the gateway drug idea — remember how they used to blame smoking weed for graduation to hard drugs? Most people ride bikes before they learn to drive cars. Does this mean that bike-riding is a dangerous precursor to auto deaths? Or is it smart for addicts to avoid heroin if they possibly can? How do we extricate the logic from the rhetoric here?

Obviously prescription opioids have to be handled with great care. Yet prescription opioids are often mixed with each other and/or with heroin, by people who want to get high, not pain-free. So how do we balance their risks against the needs of  the millions who really need these drugs for pain control?

Which brings us to the overdose epidemic. Which is obviously highly interwined with the above. Although overdose deaths are reported to result from the use of prescription drugs more than from heroin, these deaths have everything to do with mixing drugs, as I’ve reported elsewhere. And this issue has taken on deadly significance now that fentanyl has entered the scene. Stanton Peele has a few things to say about that. With fentanyl so widely available (it’s entirely synthetic, you know), and with doctors getting increasingly tight-fisted (partly due to pressures from regulating bodies), what choice will addicts have other than street drugs (or abstinence)? So is legalization the only other answer? With all the problems that entails? But even without fentanyl…why exactly do people take so much dope? What does it tell us when they’re mixing heroin and methadone? I’ve touched on that one as well.

So those are a few of the headline topics that we can deal with this year. And there are others. With Trump in the US, Duterte in the Phillipines, and Putin in between,  getting arrested for using drugs is starting to look more lethal than overdosing. What is going on in terms of the international pendulum swing between draconian repressive approaches and the ever-more-enlightened drug policies of countries (like the UK, Canada, and Australia) where people are stepping away from the “brain disease” model and the nasty habit of throwing addicts in jail? Cannabis will soon be legal throughout both Canada and the US!  And it seems they’re finally about to close Tent City — that horrible concentration camp for addicts in sunny Arizona — if they haven’t already. Are things getting better or worse?!

And there’s so much more to talk about. More acceptance of the validity of “controlled drinking,” as we heard about from James Morris a few posts ago. Ongoing turmoil but also some radical new perspectives regarding 12-step approaches and AA. See next post. And sure enough we keep learning more about the addicted brain. In a radio interview with KABC Los Angeles last week, I fell back into this interminable squabble between the brain disease model and my (alternative) no-it’s-not-a-disease-but-yes-it-still-involves-the-brain model of addiction, and all I really wanted to say, by the end of it, was: it’s time for a truce! We’re not listening to each other! Well maybe this year, on this blog, we can find a way to do that.

Please suggest other topics you’d like us to explore. That would be very welcome.

So Happy New Year, welcome back, and let’s hope it’s a good, better, maybe even best year for those of us who care so much about addicts and addiction.

This guest post addresses a complex and emotionally-loaded issue: the link between pharmaceutical opiates (and the questionable way they’ve been advertised and marketed) and the current “opioid crisis” or overdose epidemic. Nick does a splendid job of recounting key milestones and contextualizing them within the history of Big Pharma.

Before getting to this post, I just want to alert you to a fact-filled, beautifully referenced and highly detailed website: everything you ever wanted to know about drugs, alcohol, the disease model, addiction, and treatment. I’ve included this link in the list of relevant sites on my homepage.

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…by Nick Johns…

 With the number of regulatory departments and protective measures in place today, we as consumers are inclined to believe that a product or service has been proven safe before it’s approved for public use. We’d like to think that if something turns out to be dangerous or harmful, the responsible party will be held accountable and similar situations will be prevented in the future.

Unfortunately, in the complex and tangled world of pharmaceutical drugs, that is frequently not the case. Take for example Pradaxa, an anticoagulant and blood thinner most often prescribed to treat and prevent blood clots and reduce the risk of stroke following hip or knee replacement surgery. The medication managed to obtain FDA approval five years before its reversal agent, Praxbind (an antidote to Pradaxa designed to reverse its effects and prevent uncontrollable bleeding) became available, leading to incidents of severe bleeding and hundreds of deaths.

Companies with ties to multiple other entities and those that have major influence on the healthcare economy are able to skirt the rules and make deals with federal agencies or court systems to avoid serious legal repercussions. Pfizer, one of the world’s largest pharmaceutical companies, marketed a drug called Bextra in 2001, a Cox-2 inhibitor. While the FDA rejected the drug at high doses for acute surgical pain, Pfizer and its marketing partner Pharmacia pitched it to anesthesiologists and surgeons anyway — at doses up to twice what the FDA had approved as safe.

What effect have these historically loose controls had on the present overdose epidemic? Sidestepping regulations to bring potentially unsafe drugs to market is only part of a larger problem, and it isn’t the only method that pharmaceutical companies have employed in pursuit of profit. When it was released in 1995, Purdue Pharma’s now-infamous opiate painkiller OxyContin was hailed as a breakthrough in pain management. The active ingredient of OxyContin is oxycodone, a long-lasting narcotic with up to twice the strength of morphine (milligram by milligram). Prior to OxyContin, doctors had historically been reluctant to write prescriptions for powerful opioids outside of end-of-life care or acute cancer pain due to fear of the addictive properties of the drugs.

In order to shift this perception, Purdue Pharma launched a massive marketing campaign to diminish concerns about addiction and to promote OxyContin as a safe treatment for an increasing range of ailments. At the forefront of the campaign, and differentiating OxyContin from other narcotics on the market such as Vicodin and Percocet, was the patented time-release formula — a characteristic which Purdue claimed was responsible for the drug’s purported addiction rate of “less than 1 percent”. This, employees of Purdue claimed, made the drug a safe choice for CNCP (chronic non-cancer pain) patients.

In an effort to maximize the efficacy of their marketing efforts, Purdue compiled profiles of doctors and their prescribing habits into databases used to identify where their campaigns would have the most success. This aggressive marketing tactic coupled with an incredibly lucrative bonus structure for sales representatives (a range of $15,000 to nearly $240,000 on top of a representative’s average annual salary of $55,000 in 2001) led to a tremendous increase in the number of visits to physicians with higher than average rates of opioid prescription. While pitching OxyContin, sales representatives for Purdue even reportedly claimed to some healthcare providers that the drug, now frequently compared to heroin in terms of potency and risk of addiction, didn’t even cause a buzz.

For millions of patients, a prescription for OxyContin provided crucial relief from debilitating pain. For many, however, addiction became so severe that the period of withdrawal between doses became unbearable — especially if the recommended dosage was exceeded. Purdue’s marketing campaign for OxyContin reached its peak in the early 2000s, and sales of prescription opioids (with Oxycontin in the lead) quadrupled between 1999 and 2016. During that same period, over 200,000 people died in the U.S. from overdoses related to prescription opioids — with many cases involving a mix of other drugs and/or alcohol.

While federal regulations have since cracked down on OxyContin and tightened around pharmaceutical practices, the opioid epidemic is far from over. Patients addicted to prescription painkillers can eventually find them too expensive or too difficult to obtain, and may turn to other drugs instead — heroin in particular. Drug-related deaths are climbing at an alarming rate, and many can be linked to the addition of fentanyl to street drugs. But there’s little doubt that Oxycontin prescriptions greatly contributed to a wave of addictions that has yet to subside.

With prescription opioids potentially serving as dangerous gateways to fentanyl-laced illicit drugs, it’s clear that attention needs to shift to pharmaceutical companies, hospitals and physicians. Doctors and healthcare professionals can help by screening and regularly monitoring for substance overuse or addiction, and by prescribing painkillers only when other treatment options have proven ineffective. Patients can help by never sharing or selling prescription pain medications, and by taking steps to ensure that they are the only ones with access to their painkillers. Friends and loved ones can help by monitoring patients for correct usage of prescription pain medications, staying alert for any signs of prescription drug overuse, and questioning and challenging potentially dangerous habits before they become entrenched. The battle can be won, but we all must fight together.

I feel heartbroken and sick this morning, as I’m sure many of you do as well. How could this happen? I had a post ready to put up today or tomorrow…I was going to wait a day or two until the election fever died down. As it is, this fever isn’t going away any time soon. It’s mutated into a chronic infection. I can’t imagine getting past this sense of tragedy, failure, disgust…for quite some time.

All I can offer for now is an analysis/prognosis provided by Michael Moore a few months ago. Moore is one smart cookie. And here’s a recent blog post by Tim Urban. This one is really excellent for post-election malaise. I promise it will cheer you up.

When things feel overwhelmingly bad, one of the things we try to do is to explain and understand what happened. These two commentators help put it all in perspective.

Too many people with damaged lives in that country of yours — which feels in many ways like my country too. Never mind that most of the damage was extended and entrenched by Republican policies over the last many years: opposition to raising the minimum wage, opposition to universal health care, guns for all, reduced taxation on the wealthy, training people to blame others for their misfortunes rather than look at the elephant (pun intended) in the room.

None of that seems to matter now. People with damaged lives will try anything to change the way they feel. They will take extreme measures to change reality, to wrench it, twist it, with whatever comes to hand, something strong, powered by defiance. Consequences be damned. It’s sort of the ultimate “fuck you” directed at…well directed at the adults upstairs….Obama, Hillary….the adults who seem somehow to be responsible for whatever pain we’re feeling.

We know about that — better than most.

I don’t have much else to offer that might help with your despair (if that’s what you’re feeling). I hardly slept. I watched the election returns until about 5 am local time….then I started to give up hoping and fatigue got the better of me.

Maybe just two things to mention:

Sometimes a sick system needs a chance to swing all the way wrong before the pendulum reverses its direction. Maybe with a Republican president and Congress, legislation, policy, the courts will have had a full run, their unfettered chance to make things as wrong as possible — and then things will swing back leftward. Because there won’t be anyone to blame and because the politics of selfishness and fear are unstable — they can’t last indefinitely.

The other thing is: I’ve been ranting to my kids about the election, what’s at stake, almost daily for a couple of months. My boys are just ten, so they’re not political pundits, but Julian would often ask me at breakfast if there was any more news about Trump in the newspaper. They knew who the good guys and bad guys were…at least from our perspective. So this morning I stumble into their room while they’re getting dressed and I tell them: Guys, the news is really bad. Trump won. At first they thought I was joking: I’ve been citing the polls to them daily — how could that be? But after a minute or two, they just went on with their day. They finished getting dressed, practised a bit of piano for their lesson this afternoon, had their cereal, and forgot about it. Life goes on for them, and I guess it does for all of us.

Shit happens. That we know. But we persevere and make the best of it. We try to look ahead and hopefully we notice the slant of the sun in the autumn leaves and the invigorating air that enters our bodies with each breath. And we try to be aware that everything is impermanent. Stuff just keeps changing. That doesn’t mean it’s the end.

We can learn a lot from kids. A little knowledge might be a dangerous thing, and just being here now is still the only place we’re ever going to be.