Understanding Addiction

Please note, if you saw an earlier version of this post, that my normal email account is now working again. Which means I can also receive mail from the “contact” field by the right margin.

Here’s where I’m thinking of going next with the blog, Feedback welcome! I’ve spent the last 8 posts on Internal Family Systems and related content, using IFS as a model of mind and as a guide for psychotherapy (especially for people with addictions). This followed a half-assed attempt to survey well-known therapeutic approaches that can be effective for people in addiction. I covered ACT, psychodynamic approaches, and I don’t think much else. I was thinking it would also be useful to look at psychedelic psychotherapy (including ayahuasca) as an increasingly popular approach, finally starting to be recognized by mainstream psychiatry. I could also dig around for other approaches that seem promising. Maybe good old family therapy (the standard brand), maybe dialectical behaviour therapy. I’m also gearing up to present a few “case histories” — clients I’ve worked with whose stories I find inspiring. Any thoughts about any of this before I go on?

I could also review mindfulness approaches to therapy for addiction. Or maybe that’s old hat. If you follow this blog, you know that mindfulness/meditation is never far from my mind. But there are modes of therapy that are specifically adapted for working with “addicts”  (as always, I use that term without judgement. It’s just handy). I’m thinking of Mindfulness-based Relapse Prevention, which has been formulated especially for addiction treatment.  Comments? Thoughts?

Lastly, the thoughts that have been gathering in the murky backwaters of my brain involve trying to model the IFS idea of a “firefighter” — the part that just wants to get high, without giving a crap about leaving a mess, the stoner voice, as in Fuck it, let’s just get high (or drunk), completely ignoring the frustrated and exhausted inner critic…to model that in terms of brain activity. Neuroscientists see the fuck-it voice as pure impulse, mediated by one brain system, or as compulsion, mediated by another (closely related) brain system. From a neural perspective, it’s the excess of dopamine reaching these systems that elicits this kind of behaviour. Is that just the brain-level explanation of the sudden appearance of the “firefighter” — the capacity to act automatically, without caring? If so, how does it actually work? IFS points to an emergent part-self that rules for a few hours. Neuroscience points to sensitization (via dopamine release) to particular cues. How on earth could we reconcile these explanations? Or are these fundamentally different mechanisms? Maybe one is right and the other is completely wrong. I’d love to try to figure it out.

That’s all for today. Please give me some guidance as to what you’d like to see in upcoming posts. And I hope you are all staying Covid-safe. The vaccine should be available within another couple of months. Maybe things will get a lot better soon.

Hi all. Here are a few updates to fill the idle hours of summertime.

First, the homepage of this site has been revised, thanks to Victor (my web guy). It now includes links to a number of blogs, magazines, and other online entities that deal with addiction (mostly drugs and booze…but other stuff too) and recovery. I hope this will make it easier for all of us to get informed, find help, and/or explore the ongoing waves of late-breaking news.

Here’s a quick guide:

The ScienceDaily Addiction News page reports on research concerning substance use and addiction.

The Berridge Lab site describes the research findings of a particular team — one I greatly respect.

Heroin and Cornflakes and The Fix present research, social issues, news, interviews, and stories related to substance use and addiction.

Addiction and Recovery News, Addiction Blog, and Dryblog give you news, stories, opinions, and links re drugs, booze, and recovery.

Drug Addiction Support, Harm Reduction for Alcohol (HAMS), and Recovery Nation specialize in what’s old, new, available and useful in treatment and recovery (along with their individual biases, of course). These are the places to go for immediate help.

Gabor Mate’s site is about…Gabor Mate. Mostly his books and talks, about addiction and other psychological messes.

PLEASE let me know if there are other links you think should be added to the list.

Second, I’ll have a live interview with the HAMS blog today at 6 PM EST. I should have announced this days ago. Oops. Anyway, these guys are pretty serious. They have a number of interesting and relevant interviews posted here. Including one with Stanton Peele, whom I always enjoy. An old geezer (older than me!) who knows a lot and likes to be controversial.

Third, through multiple communications — which I’ve been pleasantly drowning in — I’ve started to piece together a perspective on treatment politics at the international level. It seems that in North America and especially the U.S., the treatment network is dominated by the disease model and an overarching focus on full recovery (most often 12-step based). In contrast, in the U.K. and Europe, the treatment network highlights harm reduction — living with addiction.

Each of course has its benefits and drawbacks. A primary drawback of the harm reduction ethos is that people become stagnant in their addictions, living life on methadone or just continuing to use, and dropping out of dynamic contributions to their society, in terms of employment and lots else. The drawbacks of the disease model…well, I’ve already expounded on those enough in this blog, but it looks like that’s where my next book is taking me.

Which brings me to #4: Countless emails have revealed a thicket of upsetting, sometimes toxic, interactions between people who really want to improve their lives and a treatment industry that is narrow in scope, demanding in its policies, and one-sided in its interpretations of addiction. That’s where I now think my next book is going, along with my trademark (?!) emphasis on neuroscience and biography. I didn’t think I’d be heading in that direction, but more and more I see that the social-political side of addiction is important to understand as part of a well-rounded picture. (And it connects with my recurrent dreams of trying to deceive suspicious doctors in white coats. Yup, still get em.)

Enjoy your local brand of climate change, wherever you are. We’re heading to the south of France, which is just around the corner, for two weeks. But I’ll have another post up soon anyway.

I am finally caught up! My inbox is clear for the first time since October. I have no classes to teach until after January. I just completed a draft outline for my next book (at 4:30 AM, somewhat hungover). And I’m now starting to communicate with the many people who sent me amazing stories.

There is actually nothing I’d rather be doing than this “research” into others’ addiction stories. I’m pretty much certain that addicts are the most interesting people on the planet.

Oh yeah, and I finished that disease/choice/self-medication set of posts I promised. Phew.

So, now, on to other things.

…………………………….

People often ask me how I quit drugs (roughly 30 years ago, with only minor blips since). So here’s a recent email exchange (lightly edited) in which I try to spell it out. Like others, this reader thought that the passage describing how I quit was too fast and loose. Maybe it was.

> From: “Donna” [not her real name]
> To: marc@memoirsofanaddictedbrain.com
> Sent: Tuesday, 24 July, 2012 2:53:06 PM

> Message: Hi Marc,
…….

> I just finished your book last night–I could hardly put it down. I
> was fascinated with the subjective descriptions of your experiences
> with drugs and how they manifested biologically in the brain. As I
> read I became rather depressed, however–learning about the brain’s
> loss of plasticity, and the feedback loops created by addiction made me
> feel rather hopeless. I was eager to get to the part where you talked
> about how you finally stopped doing drugs, despite having “hit
> bottom” many times.
>
> I have to say that your “NO” mandala was a big letdown. I’m sure I’m
> not the first nor the last to say that. It made me think of Nancy
> Reagan and the whole 1980s Just Say No campaign and here’s your brain
> on drugs–a fried egg. I really don’t understand. How did this work
> for you? How was it “different” from the other times you were filled
> with self-loathing, got your shit together, and ended up clean for a
> period of years? I wasn’t really looking at your memoir as a
> self-help book–I wanted to learn about the neuroscience of addiction,
> and I did learn a lot. But I also couldn’t help thinking about how
> you escaped, and what I could learn from that and how I could apply it
> to my own life. Sadly, I just don’t get it. Given the changes to your
> brain, what happened to enable you to overcome what was essentially a
> biological process?
>

> Best,
>

Hi Donna,

I’m happy to reply to this kind of mail…especially when your question is so clear and credible. Yes, others have expressed similar disappointment in the ending of my book. Let me try to explain how I quit.

First, there were never any periods of more than a few months, more often a few days or at best a few weeks, of being clean in the previous three or four years. So this time was obviously hugely different. How did it work? I’m really not sure. Basically, I reported what happened. The details are accurate. I didn’t have an instruction manual, so I can’t really say what was going on or precisely what I did that time that unlocked a new door.

But here, I’ll try. I had recently endured two particularly shitty events. My girlfriend left me, which broke my heart, and my friends found me, semi-comatose,  on a toilet seat in a public building with a needle sticking out of my arm, which was intensely shame-inducing. I think by then I had built up a lot of rage, not just self-contempt and all that but real rage — toward drugs, I could say, or toward what seemed to be a force or a malevolent spirit, or maybe something like the Greek Orchestra idea of a “fate” that keeps fucking up the protagonist’s chance of getting out of hell. Something pivoted on that particular day, the day I wrote “NO” on a piece of paper, decorated it with the trimmings of a mandala, and stuck it up on my wall. The rage seemed to pivot around and focus on this external entity, rather than on me for a change. And that was a big change. I remember feeling: you have no right! I deserve to live! You can’t do this to me!

That was how it started. There was also the small matter of saying to myself “never again” — rather than never again for at least 2 years, or never again injecting, or other half-assed self-promises. I truly at that moment didn’t want to EVER do it again.

And I just kept going on like that, day after day, telling myself NO fifty times a day….then less and less as the days went by. By the second or third week, I thought it might be really working, but I didn’t know for sure until about two months had gone by. And during all that time, the horror of my recent life kept returning to me in vivid images, and I kept telling myself: I don’t WANT to go there again. This is ME speaking: I DON’T WANT TO. Of course the withdrawal symptoms and the depression and all that were shitty for a week or two, but even within a few days, there were rays of light. Maybe even that first day.

Things like that happen. Big life changes can turn on a dime. How can that be, you may ask, given all the “wiring” that’s already taken place? For one thing, the brain hasn’t lost all its plasticity from addiction. Not at all. It’s just that addiction takes hold through several really fierce feedback loops that continue to gobble up plasticity on a day-to-day basis. I mean the loop of wanting-getting-losing-craving, and also the loop of using/lying/sneaking and shame, which greatly increases psychic pain and makes you want relief at any price. In both cases, there is a massive interaction between dopamine uptake, cue salience, and the potency of desire……that just cuts through the available options — the plasticity — as if there WERE no other options.

I guess another idea is that, while I was building up this elaborate addict network (I mean synaptically), I was also building up an elaborate non-addict network. I never stopped trying. I still wanted to be a regular person with a good life. I went to see a variety of therapists. I remember one who wouldn’t even talk to me (a psychologist, in fact) because he said I was too far gone. In fact, none of them helped much, but it meant (at least to me) that I was trying. Meanwhile, I was applying to jobs in mental health agencies, and getting some, and I was still aiming to get back into school. All that equals a whole OTHER synaptic network. Maybe the pivot point for me had to do with connecting a day-to-day/hour-to-hour sense of self with that second network, long enough for it to “take”…and start sucking up its own helpings of dopamine (I WANT this).

Also, I have no idea if I’d have stayed clean IF I didn’t get accepted into grad school a few months later. I’d like to think so, but I just don’t know.

Since then, I’ve had a number of flirtations with drugs, I sometimes drink too much, but I have never gone back to the hell I lived in before that day.

So there you have it.

And don’t be depressed. Loss of plasticity is relative. There’s plenty left over. Read Norman Doidge’s book if you want to think more about the immense degree of plasticity that’s available, even well into our later years.

Cheers,
Marc

…and how modern society fails to meet them.

Hi everyone. I hope your summer is going smoothly, safe from insects, droughts, forest fires, and other human-assisted calamities. I’m on vacation in France now, after a harrowing trip giving talks, first in Victoria, Canada, and then in Melbourne and Brisbane. Harrowing because I flew across 16 time zones, then back, in just a week. But it was a great trip, the highlight of which was hanging out with inmates, then giving a talk, at a beautiful prison on Vancouver Island. I know the phrase “beautiful prison” is rare, but this was a rare place. It included an area for First Nations rituals (complete with sweat lodge!), a Buddhist meditation parkette, and wild deer running everywhere. The only problem for the prisoners was that they couldn’t leave. The place was a living contradiction, and of course most inmates had been through addiction. A few of them gave me lovely gifts when I left. They spent their time developing craftsmanship in wood and metal. (And yes, I was allowed to leave — but I felt a familiar anxiety at the exit post, left over from years ago.)

Now that the zillions of comments on April’s moving post have finally died down, here’s a “vacation post” — a shortened and revised version of an article I published in The Guardian about a month ago. I’ve been asked many times what I think about the opioid/overdose epidemic hitting the US and Canada in particular but also the UK and other regions. Here are my thoughts.

……….

Most drug-related deaths result from the use of opioids, the molecules that are marketed as painkillers by pharmaceutical companies and heroin by drug lords. Opioids comprise a large family of molecular cousins, some weak, some powerful, all united by their capacity to bond with the opioid receptors all over our bodies, particularly our brains. Those receptors evolved to protect us from panic, anxiety, and pain. But the gentle impact of natural opioids, produced by our own bodies, resembles a summer breeze compared to the hurricane of physiological disruption caused by drugs — opiates — designed to mimic their function. And as if heroin wasn’t enough of a bull in the China shop, most street opiates (including heroin) are now laced or replaced with fentanyl and its analogues, far more powerful than heroin and so cheap that drug-dealing profits are skyrocketing at about the same rate as overdose deaths. People don’t know what they’re getting and they take too much. Fentanyl is recognized as a primary driver of the overdose epidemic.

Society’s response has been understandably desperate but generally wrong-headed. We start by blaming addicts for their self-indulgence or weakness of will. We blame the pharmaceutical companies for developing and marketing painkillers. We blame doctors, for overprescribing opiates, which pressures them to underprescribe them, which drives patients to street drugs — cheaper, home-delivery via the internet, and zero quality control. We say we’re going to rekindle the war on drugs, recognized by experts as a colossal failure from the thirties onward. Dealers will always find their way to consumers if the price is right. We also continue to view addiction as a chronic brain disease, so the benefits of education, social support, and psychological intervention receive far too little attention. Black-and-white solutions are simply inadequate for a problem of such complexity.

There has been some progress: There are pockets of activity here and there where prescribed opiates — like methadone and buprenorphine (Suboxone) — are made more easily available to addicts. That’s a good thing, because increasing addicts’ desperation (e.g., methadone clinic line-ups on the far side of town) often drives them to the street, where they’re most likely to die. The availability of naloxone, an opiate neutralizer, is slowly wending its way through the drug policy jungle, providing a simple resource to combat overdose on the spot. But in most segments of most communities in the US and elsewhere, naloxone is still too difficult to obtain.

I think there are smarter answers at hand — but also smarter questions to be asked. The opioid overdose epidemic compels us to face one of the darkest corners of modern human experience head on, to stop wasting time blaming the players and start looking directly at the source of the problem. What does it feel like to be a human trying to make it in the early 21st century? Why are we so stressed out that our own (internal) supply of opioids isn’t enough to feel okay?

The overdose crisis obviously builds on people’s desire for opioids. But what do opioids actually do? The opioid system was designed by evolution to allow us to function, not panic or shut down, when we are under threat or in pain. Critically, support from other humans also helps us cope with stress, and that support is underpinned by opioids too. Our attachment to others, whether in friendship, family, or romance, requires opioid metabolism so that we can feel the love. Opioids grant us a sense of warmth and safety when we connect with each other. You get opioids (from your own brain stem) when you get a hug. Breast milk is rich with opioids. Rodents play more when given mild doses of opioids.

In short, we need opioids to feel safe and to connect with each other. Then what does it say about our life-style if our natural supply isn’t sufficient? It says we are stressed and isolated. That’s a problem we need to resolve.

To confront the problem of addiction, many have proposed targeted education, community support, and interpersonal bonding through group activities. Johann Hari’s powerful book, Chasing the Scream, reviews how such initiatives have worked in diverse societies. An intriguing example is the compassionate, blame-free dialogue that has naturally evolved among high-school students in Portugal, highlighting the dangers of hard drugs and urging the most vulnerable to abstain — not because they’re going to get in trouble but because addiction is miserable and dangerous! The emergence of this dialogue has been particularly meaningful because it has paralleled the decriminalization of drug use. Portugal had an astoundingly high heroin addiction rate 17 years ago. It now boasts the second lowest overdose rate on the continent. Drug addiction has diminished significantly in Portugal because compassion and social inclusion actually work against addiction, while punishment only fuels it.

But let’s look beyond the challenge of addiction per se. The peculiar appeal of opioids tells us more about ourselves as a society, as a culture, than addiction statistics can reveal. Today’s young people come of age and carve out their adult lives in an environment of astronomical uncertainty. Corporations that used to pride themselves on fairness to their employees now strive only for profit. The echelons of management are as risk-infected as those of the lowest clerks. Massive layoffs rationalized by the eddies of globalization make long-term contracts antique. I ask the guys who come to the house to deliver packages or upgrade our TV box how they like their jobs. They can’t say. They get up to three six-month contracts in a row and then they get laid off so the company won’t have to pay them benefits. People pour out of colleges and universities with all manner of degrees, yet with skills that are rapidly becoming irrelevant. But people without those degrees are even worse off. They find themselves virtually unemployable, because there are so many others in the same pool, and employers will hire whoever comes cheapest. (The absurdly low minimum wage figures in the US clearly exacerbate the situation.) As hope for steady employment fizzles, so does the opportunity to connect with family, friends, and society more broadly, and there is way too much time to kill. Opioids help reduce the despair.

The opportunity to settle into a viable niche in one’s family and one’s society, the bedrock of social and personal security, is being blown away by the winds of unregulated capitalism in a globalized world. As for the intimacy and trust we humans have always sought in each other, in friends, colleagues, and lovers, the bonds are shaky these days. Even if we have the opportunity to connect — if we are not resettling geographically to find employment or staying up late to retool through distance education or simply sitting on the sofa all day long collecting welfare — we’re still too stressed and depressed to get to know each other, to develop trust, to give and receive compassion.

(The links between under-employment, family dissolution, and addiction are beautifully reviewed by Sally Satel. And many of you may know of Bruce Alexander’s explanation of how globalization feeds addiction.)

The early 21st century offers less structure and stability through religion, and through extended family relationships, than we have experienced in thousands of years. And maybe that’s just the way it is. But we don’t have to throw away the basic currency of security and interconnectedness entirely. We can build social structures — governments, corporations, community organizations, and systems of education and care — that encourage stability, hope, and trust in our day-to-day lives. Like the high-school kids in Portugal, we can offer compassion and inclusion as an alternative to heroin. If we fail to do that, many of us will want to hook ourselves up to an opioid pump. Just to endure.

……..

I’m not entirely pessimistic, but that’s the way I see it. Regardless, let’s not give up hope, not even slightly. Let’s do a bit of meditation, enjoy the sunshine, and be good to each other. See you again in September.

…by Eric Nada…

Hello again, and Happy September!  This guest post accomplishes something far too rare: a balanced perspective on the Twelve Steps. They can be a real boon when structure and connection are most needed, and a hindrance when it’s time to keep growing.

………………………

I am 22 years away from heroin and the desperation that it both created and exposed in my life. I didn’t plan on becoming addicted to heroin. I did, however, have a profoundly positive reaction to drugs of all kinds right from the start. My drug use began with alcohol as a young teenager. I added daily cannabis soon afterward and recreational psychedelics as well, although these substances never brought me the deep sense of comfort I was seeking. I left my parents’ home when I was 16 and started drinking heavily daily. I began using cocaine as well, and tried heroin for the first time soon afterward. Apparently, heroin really agreed with me, and I eventually became physiologically dependent, fairly quickly losing the ability to navigate within relationships or the workplace. I was eventually homeless, feeding my habit through hours of daily panhandling and petty theft.

But drugs were not the only way I sought to regulate my feelings of longing. I used romantic connections to the same end. My romantic attachments formed very quickly and intensely and were eventually laced with feelings of desperation and neediness. This pattern followed me well into traditional recovery and abstinence, and would ultimately be as important a part of my recovery story as learning to live without drugs. In fact it wasn’t until I really addressed this foundational attachment problem (after ten years of abstinence from drugs)—through psychotherapy and the right books read at the right time—that I started to grow apart from the 12-step process and from identification with its fellowship.

When I was 24 years old I went to the last of over a dozen treatment and detoxification centers I have attended. I was, and had always been, resistant to the 12-step approach to recovery, and I did not resonate with many of its underlying principles regarding the causes and treatment of addiction. But I followed the lead of some open-minded people at my last treatment center and began attending 12-step meetings voluntarily. And I began to recover. There is much that I learned from my 12-step involvement, the most important being the utilization of some kind of growth modality instead of simply trying to stop using. I also began identifying with others who had attachment wounds like mine, even if these concepts were not discussed overtly. I created some deep and lifelong friendships and learned about the fulfillment that comes from service to others. The Twelve Steps taught me that deep emotional change must be incrementally worked toward with diligence and sustained focus, and gave me a prescribed external structure (meetings, commitments, and step-work) upon which to start building these changes. Finally, in the beginning, it gave me a large group of people with whom I could openly share my struggles and successes, finally building a sense of personal competence and esteem.

But there was another side to all this.

There were some aspects of 12-step involvement that I couldn’t, and didn’t, agree with. I don’t agree with the disease theory of addiction, a concept which is embraced by most members. I am also not remotely religious, and never attributed my ability to abstain to a higher power. Finally, and this became more apparent after I left 12-step involvement—especially after I incorporated moderate alcohol use into my life a few months later—listening to similar messages repeatedly for years created a type of programming that made the idea of leaving difficult. To do so, I had to contend with deep feelings of fear caused by overt messages that leaving would inevitably lead to relapse and the loss of everything that I had spent so many years creating. Leaving also elicited deep feelings of shame and guilt that lasted acutely for months, and their tendrils still infect me two years later.

I am disappointed that there weren’t more nuanced approaches available to me when I first needed help. As a result, I consider myself to be in the process of recovering from the recovery process, from a host of deeply embedded erroneous statements about the causes and nature of addiction, and the cult-like psychological after-effects of having identified with a particular group for so long. But with the options available to me in 1995 when I attended my last treatment center, I understand why 12-step involvement may have been the only viable aftercare option—for a young man without a built-in ability for healthy emotional navigation.

My addiction story is ruled by two deep, seemingly contradictory, truths: first, that deciding to become a 12-step member was one of the best decisions I’ve ever made. And second, that deciding to leave 12-step membership was one of the best decisions I’ve ever made. I wish that it weren’t anathema within the 12-step paradigm to leave either for periods or forever, but I kind of get it. I benefited from the same rigidity within 12-step doctrine that eventually repelled me. I may have temporarily needed that rigidity to counteract the evermore rigid attachment I had to heroin. I needed the external structure offered by the 12-step program and traditional abstinence until I could incorporate my own version of structure, inwardly. I needed form until I could safely find formlessness.

My story is as anecdotal as any other individual story and not proof that it’s safe to simply discard abstinence after a time. But I am convinced that the decision to trust myself has been immeasurably important, as was my decision not to trust myself for a while. I do wish, however, that I had moved on much sooner, that I would have decided to trust myself years earlier. But late is always better than never.

…………

Please see Eric’s less abridged memoir here. And while you’re at it, check out some of the other Guest Memoirs. Many of these stories are truly compelling.