Disease, choice, or self-medication? Models and metaphors for addiction

Many readers responded to my request for different perspectives and insights on the question: Is addiction a disease? I said I’d like to know what others thought before stating my own view. The strange thing is that my own view has changed considerably in light of your comments. Perspective is funny that way: it looks like a solid version of reality until the waves pick up, the boat starts to rock and pitch, and it’s time to set a new course…or jump ship.

Over my next three posts, I’m going to talk about the three most common definitions of addiction, one per post: a disease; a matter of (unwise) choice; and a process of self-medication. And for each I’m going to show the pro’s and the con’s, backed up by theory and data from psychology and neuroscience.

My own model of addiction will come at the end, in a fourth post. Here’s a sneak preview: I see addiction as an accelerated form of learning. I see it as the result of a natural learning process that has gone way too fast and way too far, yielding habits that are extremely difficult to “unlearn”. I explain this in terms of the highly emotional content of what gets learned (associative learning in the amygdala), the processes that connect emotion with action (through the ACC and premotor cortex), and the elaboration of networks (in orbitofrontal cortex and related regions) that give the addictive goal its enormous “value” or “meaning” – all of which feeds back with the narrowed focus of our primary goal-seeking system (the ventral striatum and its dopamine pump).

I’d like to think that my model of addiction is accurate and precise – a scientific model – whereas the other three are analogies or metaphors. So I refute the idea that addiction is a disease, but I agree that it can be like a disease. And I refute the idea that addiction is a free choice, yet I see that it involves choice at every step. Finally, I don’t think that addiction is self-medication, but I agree that it’s based on attempts to self-soothe, to relieve anxiety, boredom, or depression.

So I’m tempted to claim that these three models are metaphoric approximations, whereas mine is the real thing. But wait a minute. If these metaphors help us understand addiction, if they help us to classify it and deal with it, then they must have some value. And maybe my model is an approximation too, albeit a biological one.

And what’s wrong with metaphors anyway? Some scholars say that all our concepts are based on metaphors or analogies – variations on a theme. So if, for example, the “disease” concept works to organize your thoughts, and more importantly your actions, to help addicts (including yourself?) work toward recovery, then it’s worthwhile, it’s beneficial, it might even be the best show in town.

Yet there is one major qualifier: different analogies, metaphors, models, or whatever you want to call them, work for in different ways for different people. And as much as they can be constructive for some, they can also be destructive for others. If you are tuned into the helplessness, the insidious, relentless growth of addiction, if you see addiction as something that takes over one’s body, one’s mind, maybe one’s soul, then the disease model is going to be meaningful to you. And your efforts to quit will take the form of searching for a cure. But for others, seeing addiction as a disease, as something outside the self, foreign to the self, the disease concept may be harmful. Because the implication is that “you” can’t do anything about it – at least not without help. Or, if you are tuned into the choices that fashion addiction, if you focus on those fleeting moments of intention, when addicts jump the gap from let’s-stay-sober to let’s-get-stoned, then the choice model will be most meaningful. And that model can help you to make different choices, because the cause is in you, it’s something you can change. But once again, the choice model is a double-edged sword. Because, for some people, it’s the basis of blame (from outside) and guilt (from inside) – both of which can poison the recovery process.

The way we see our addicted selves or our addicted loved ones is going to determine which model rings true. So experience is going to play a crucial role in how we define addiction. Consequently, I can say that my “learning” model is the most plausible, I can say that it fits best with cognitive science and brain science, but I can’t say that the alternative models are meaningless. They can do a great deal of good, or a great deal of harm, depending on how they’re used.

Stay tuned, for a closer look at each of the three models. And while we explore their meaning, we will also explore their use, their misuse, and their capacity to help or to hinder.

66 thoughts on “Disease, choice, or self-medication? Models and metaphors for addiction

  1. LeonRover June 8, 2012 at 9:39 am #

    That was one of the most thoughtful posts on this subject I have come across.

    Thanks

    • Marc June 8, 2012 at 6:27 pm #

      Thank YOU.

      • LeonRover June 9, 2012 at 1:20 pm #

        Marc,

        I have been reading thro’ blog posts in order.

        Finally decided to buy – onto Kindle – immediate gratification!!

        My second most chosen Wilde quote:
        “I can resist everything except temptation.”

        Slainte

        • Marc June 15, 2012 at 5:25 pm #

          Excellent. And no nasty side-effects that I’m aware of.

  2. Jaliya June 8, 2012 at 11:23 am #

    Can’t wait to continue the conversation :-)

    Learning gone awry … your model can apply to the other three that you’ve mentioned … and some pivotal questions might be ‘How do we learn?’, ‘What do we learn?’ and ‘How can we unlearn … and re-learn?’

    Perhaps addiction is, in a way, our capacity *to* learn — deranged, nullified. After learning (in this way) comes assimilation … and habit … and rote behaviour … and perceived helplessness.

    Too much disease can kill … Too much choice can paralyze … Too much soothing (self-medicating) can suffocate.

    Curious: Marc, what’s your definition/understanding of ‘learning’?

  3. Marc June 8, 2012 at 6:32 pm #

    I’ll talk more about that soon. I do get into it in the book. Meanwhile, the questions you pose are indeed important. Unlearning is almost impossible, so it seems. But we can learn new trajectories, new meanings, and if they’re powerful enough they can supersede the pathways that have already been established. That’s why “giving into a higher power” in the 12-step approach works for some. Not that I would necessarily recommend it. But it works because it taps a strong, homogeneous motivational thrust. It diverts the dopamine flow from long-established habits.

    • Daniel Efford June 9, 2012 at 9:35 am #

      I think I’m most excited for the choice discussion. It really reflects on our ideas of the pivot-point and understanding the perspective through “how is it that I’m choosing to succumb to addiction, rather than turn-away?” When we see the freedom of choice, we have to wonder how it is that in light of information – the negatives of addiction – that we still freely make the wrong choices. I think this really lends to the self-medication model quite well, because it works as the only tool of justification for making the wrong choice.

      Marc, when it comes to the pivot-point, there are different types of justifications that we construct. For myself, the final thought to pass through my head before I give in to an addiction is “I’ll feel better afterwards”. But what happens when I don’t feel better is that I feel guilt, or just pass it off as nothing. Or perhaps I did feel better, but I begin to LEARN that it’s ok to make this CHOICE because it SELF-MEDICATES (feel better), and all of this can be seen as a DISEASE. It might be a stretch, but I think that all of the models really do complement each other.

      Thoughts?

      • Marc June 15, 2012 at 5:32 pm #

        I agree with you about the appeal of the “choice” model. I’m very aware of the pivot point, what it’s been like for me, and especially aware of that moment of….was it you who described it as “free-fall”? It seems we can jump — intentionally — over a small crevice but still land on a different mountain. And yes, we know what we’re doing at that instant, but the jump is small enough to get it over with before we really have time to reflect on it. So, choice, yes. But it’s a particular kind of choice, and I’ll get into that.

        I see the self-medication approach as an extension of the disease model. But it doesn’t matter. You use it in a different way — to justify and reduce guilt, which of course is self-medication once again. I think we all have to do some fancy footwork in our internal dialogue after making the self-destructive choice. Otherwise, it’s hard to continue to inhabit the body and mind that just did that.

  4. Kathleen June 9, 2012 at 8:07 am #

    Hi Mark,
    Just wondering, are you a spiritual scientist?

  5. Kathleen June 9, 2012 at 8:08 am #

    Apologies, I keep spelling your name wrong.

    • Marc June 10, 2012 at 5:32 pm #

      You’re not the first. Apology accepted. The answer is: I don’t think so. But I have some spiritual moments, I guess you might call them…only when I remove my scientific hat. (Unless reading cosmology, when the two often go together) Sometimes, in meditation, I find a place that seems completely “other” — which is good enough for me.

      As a young man, I used to have what they call astral projections, but I gave up trying to understand them years ago. Logic has become my religion, you might say.

  6. China Krys Darrington June 9, 2012 at 9:38 am #

    I like the learning model too. I know many of my early chemical experiments had the best of intentions. Then again “the road to Hell” is paved with those as well.

    • Marc June 15, 2012 at 5:34 pm #

      That’s the trouble with learning. It really is a one-way process. You can never actually reverse it. But at least you can learn to get out of Hell, perhaps once it’s become too damn hot.

  7. Conor June 9, 2012 at 11:08 am #

    Mark, most of the better quant literature I have reviewed) using structural equation models suggests that with booze at least, the self-medication model is bunk. I ran this with the 2011 NSDUH data with logits and found similar results for chronic as well as binge drinking tested against depression and anxiety.

    • Marc June 16, 2012 at 4:43 am #

      I’d really like to hear more about this. Can you give us some details? Are you saying that people with depression or anxiety are not more likely to drink than others? That would surprise me. Does your data set tag only those who have been diagnosed with a DSM-defined disorder, or does it include those who’ve experienced depressive episodes as well?

      Your input it really helpful. Please give us a bit more to chew on.

  8. PersephoneInExile June 9, 2012 at 3:21 pm #

    Marc, your writing on this particular subject is like a breath of fresh air. Thank you yet again!

    I am always fascinated by the social factors I see playing so heavily into the addiction/recovery process, which was enough for me to discount the disease model as an all-encompassing model. I’m also most certainly not a neuroscientist, so I look where I’m experienced. I haven’t seen very many people, however, writing about this from a multifaceted angle. In some circles the idea would be heretical, even.

    This is wonderful, really! If you veer too far from the disease model, you always land (if you’re not a professional in this area, at least) with the choice camp, and on a personal level I have problems with both sides. It’s great to see someone looking at the middle ground at long last.

    • Marc June 16, 2012 at 4:48 am #

      Thanks. I was more rigid in my outlook a few months ago, before so many people shared their ideas on this blog. I see better now that models and metaphors are not so different, so the deciding factor is not just accuracy, it’s how people use the model, what it does for them.

      Now I see some value in all three definitions….though I still have my own pet model, which is “accelerated learning” or something like that. I’ll scope all this out in the next few posts.

      • PersephoneInExile June 16, 2012 at 11:56 am #

        I agree completely. I was mainly exposed to the disease model, which was also heavily infused with the “you’re a faulty, flawed human” model, personally. I have seen many take that in a positive way, but I’ve also seen many with backgrounds that include trauma and/or abuse absolutely crumble under it. That’s not a matter of personality and genetics (that response) as it is life experience.

        I love your “pet model”, by the way, but won’t pretend that the fact that I relate to it so well isn’t a factor. I never realized how much my own experience with addiction was influenced by the things I was reacting against until I removed from my life these negative things, what was causing the reaction. I suppose that falls under the category of accelerated learning as well, an addictive trained response of sorts to handle the negative stimuli followed by a relatively quick unlearning of all of these things.

        • Marc June 18, 2012 at 12:27 am #

          That’s a really interesting story — different from most. Most people talk about how hard it is to quit. You say that your souped up learning module did what it needed to do. Dopamine drives all learning, not just addictive learning. That’s why dopamine-enhancing drugs are given to people with ADHD — so they can concentrate. Maybe there was enough of it flowing to switch targets. Just maybe.

          Also, really interesting what you say about the disease model crushing people. I wonder, was this in a 12-step context? I think that’s very important to understand.

          • PersephoneInExile June 18, 2012 at 1:38 am #

            That’s very interesting, Marc. I did have a remarkably difficult time quitting, mainly for the reasons most do–I felt HORRIBLE being wrenched off of the opiates! Physically and mentally, I just felt awful! Once my nerve injury healed though, I just didn’t want to be on anything ever again, so my mind was made up. I felt like I was in uncharted territory, really.

            The rehab I ended up in was extremely 12 step. Not just 12 step, it was almost entirely AA based. We were told to read the AA “Big Book”, even those of us who didn’t drink. There was little else there but confrontational therapy. That’s not really the best environment for anyone, but even less so for pain patients. We didn’t fit their prearranged narrative. There was enough that was terrible to make me analyze why I was reacting so badly to it, and to identify other negative influences and people in my life. I went into a period of isolation after that, not for long, and all I can describe as what happened afterwards was that my brain seemed to know after all of this what was good and bad for me in areas far outside of addiction.

            My brain somehow righted itself, and when it did so it was irreversible. Enough bad things happened, also, to cause a sustained fight or flight response, and perhaps that is what helped this extremely “accelerated learning” curve I’ve been on since? My understanding is that my dopamine was certainly depleted at the outset, but when it returned to normal (I’m assuming it’s normal now) it seemed to spur me into a state that I’d prefer to stay in. I seem instinctively able to shield myself from the negative now, but that change was almost immediate after post acute withdrawal was over.

            • Marc June 19, 2012 at 6:25 am #

              How fascinating! And also encouraging. I know what you mean about feeling awful without opiates. Do I ever! It felt like the worst kind of emptiness, and life seemed like a cold wind might to someone whose skin is already raw from some allergic reaction.

              But you fixed yourself. Your brain righted itself. I’m reading more and more about “spontaneous recovery”. It’s a lot more common than people imagine.

              But for you, the aversiveness of being on drugs seemed to combine with the aversiveness of a 12-step program. And those nasty experiences gave you new insights, new sensitivity, which you used to care for yourself. Good going!

          • PersephoneInExile June 18, 2012 at 1:45 am #

            Yes, also, about people being crushed. I saw this. I saw people forced to wear signs and told they were doomed to never get better in rehab. It was so dehumanizing and hopeless the things we were told! I can’t pretend that there was no correlation between those who were bullied the most and the suicide/OD rate upon release from this place. They (myself as well) refused to accept that the rest of our lives would be dominated by this “disease” which would force us to attend meetings the rest of our lives and struggle until death with day in day out cravings and mental anguish. It wasn’t true for me in any case, but if you succumb to this line of thinking there seem to be only two outcomes: becoming someone perpetually “in recovery” or losing all hope completely.

            • Jaliya June 18, 2012 at 1:31 pm #

              … and the addiction remains first and foremost in the front of the mind ad infinitum (‘becoming someone perpetually “in recovery”‘ … ). I’ve long wondered about the focus, chronic in itself, on one’s identity in certain programs — ‘Hi, I’m ________, and I’m a/n ________.’

              ‘Is that all you are?’ I want to say in response … I find this approach to be tragic, in a way … I am a person who lives not with drug or alcohol addiction, but with lifetime aftermaths of tramatic injury. Sometimes my focus is on those aftermaths — how can it not be, especially as I get older (am now in my early 50s) — but I am not the aftermaths themselves — there is so much more to me, and I don’t view myself as being ‘in perpetual recovery.’

              I also wonder about the word ‘recover’ — in one way, it means to re-cover: to cover up again. I’ve lost far too much time in ‘covering up again’ all the challenges I’ve lived with — pretending I’m much stronger and more functional; lying to myself (I’m much worse, or much better, than reality shows me to be); considering myself hopeless because I can no longer function in the world as I ‘should’. Etc.

              There’s something of Sisyphus in the ‘perpetual recovery’ model … in the primacy of identity being coiled around that one ‘me’ we can construct — the addict, always teetering on an edge, always at risk of another colossal failure.

              Caroline Myss (a contemporary medical intuitive / spiritual teacher) has done great work with human archetypes … She identifies the addict as one (Link: http://www.myss.com/library/contracts/three_archs.asp) —

              Persephone, you say something pivotal at the end of your post re: ‘there seem to be only two outcomes’ … Another commenter says something similar: ‘either [you] outgrow the addiction or die from it.’ Another still quotes the Gospel of Thomas, ‘If you bring forth what is within you …’ — It does seem to come down to this: essentially, a choice to live or a choice to die. This either/or goes far, far beyond simply ‘I am / am not an addict.’ Perhaps, too, we are all addicts AND not-addicts, given the human condition and (especially) the times we live in now.

              What do we give our power to … and do we believe we have any power in the first place? How can it be helpful to ‘give up’ all our power, all our will, in order to ‘recover’? Is that not a way of augmenting the belief that we already *are* helpless/powerless?

              As a person who nearly died in infancy (very premature birth w/ grave medical consequences and interventions), I’ve had to do the daily, unrelenting work of getting myself UP and beyond my history’s long effects. I don’t think I’m in ‘perpetual recovery.’ I think that the damage has left its marks, and I live *around* it and *beyond* it as best I can. Someone once said to me, ‘To thine own self be merciful’ — that was the wisest advice I ever received, and the most difficult to live by. I can only imagine what it’s like for a person who lives with a constant hankering for ‘that one thing’ that will supposedly relieve the agony of his/her human condition …

              My ‘one thing’, I came to realize, was relation — loving, bonded, safe relation. I didn’t go for a bottle or a drug — I went for love.

              Sometimes I think that love is the ‘one thing’ we are all after …

              P.S. Thank you, Persephone, for your thoughts … :-)

            • Marc June 19, 2012 at 6:28 am #

              Beautifully said, both of you. I mean, both elegantly and powerfully stated, but more than that, really important advice. The self-labeling process — and it IS a process — is so central to how we act and how we feel. Seeing yourself consistently as “an addict” must have very negative consequences for very many people. I’ll remember that.

              Please see my reply to Kathleen on the next post in line, the Strombo one. Lots of negative facts and figures regarding AA. In fact there is much evidence of harm done by 12-step programs. But we should also keep in mind that many people attest to their usefulness. It seems it can go either way.

              • PersephoneInExile June 19, 2012 at 4:01 pm #

                A great many find hope and solace in these programs, I agree. I have never had any desire to take that away from people in discussing addiction issues, if that was the path they took. It has simply become so dominant in the discussions that it almost seems difficult to not address it a little. So many of the concepts, if not the vast majority, have been expressed to so many in treatment centers and the like through the 12 step lens to so many of us. It can be hard to shake!

                It wasn’t my intention to divert any discussion into debate of the worthiness to some people of those programs, though. I personally just had a hard time escaping them and their views!

  9. Donnie Mac June 9, 2012 at 6:32 pm #

    Everyone has such Great ideas it makes wonderful conversation . I think maybe some historical events have been over looked that are seminal to the discussion .
    Addiction as “Disease” is more “Analogy” than “Medical Metaphor” .
    Alcoholics Anonymous co-founder Bill Wilson did not invent a disease perspective of alcoholism but he had been credited with the idea . Much like Calvin Klein didn’t invent pants but literally has his name on millions of pairs .
    In 1960 Bill Wilson spoke at the Catholic Counsel of Churches inquiry into Alcoholism he explained A.A position as :

    “We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease.Instead, there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore, we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore, we always called it an illness, or a malady – a far safer term for us to use.”

    I believe the modern day equivalent would be if I lived on fast food , smoked cigarettes and took no exercise my heart would “Become Diseased ” not be a “Disease ” a major perspective shift ( in my humble opinion )

    Reverend Sam Shoemaker had a great influence on Bill Wilson when he was writing the 12 step and the A.A “Big Book ” . Rev Shoemaker was rector at Calvary Episcopal Church in New York as well as ” The Oxfords Groups ” headquarters where Bill Wilson was sequestered in the 1930 while writing the steps . Shoemaker description of “Step 1 ” as :

    “The gap between man and God which man is powerless to bridge, man having lost the power to deal with sin for himself. As to the unmanageable life ”

    The form of “Disease ” in Bill Wilson analogy was based in the culmination of sin . Sin of your own ( Guilt , Shame ) Sin of other perpetrated on you ( Trauma ) as to the inability to stop an addiction . Steps 4 and 5 are to make a “Searching and Fearless moral inventory ” ( describe Sin ) and “Admitted to God , ourselves and another human being the exact nature of our wrongs ” Confession of Sin that has been going on for Century’s in the Church .

    A metaphor or a “Hole is your Soul ” is bantered around in Addiction quite a lot , the more accurate description would be ” A Heart clogged with Sin ” as to the “Disease” Bill Wilson was speaking about all those years ago .

    Donnie Mac
    Bitches .

    • Steve June 11, 2012 at 12:33 am #

      A disease of the soul? Sounds like the type of language than can prove very dangerous when it comes to real solutions.

      • Donnie Mac June 11, 2012 at 1:37 am #

        I didn’t invent this stuff Steve , just relaying some history . The reference to “God” or “God as we understand him” ( yes Him and We ) are mentioned many times in the 12 steps . Page 64 of the Big Blue Book of A.A Chapter 5 often recited as “How is works ” states :

        “Resentment is the “number one” offender. It destroys more alcoholics than anything else. From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically”

        The sad part is Steve , so far , these are the real solutions . A.A and 12 step meetings occupy “Top Spot ” in collective knowledge of addiction/recovery of anything from Alcohol , Drugs , Soup to Nuts .

        It’s not my cup of tea but in many many many places it’s the only tea being served , lots of folks love this tea and I support them all the way .
        Many don’t people know there is a world of ways to quench thirst .
        I like lemon aide .

        • Marc June 16, 2012 at 6:07 am #

          Hi Donnie Mac, The history lesson is fascinating and important. It clarifies the degree to which the 12-steps philosophy is founded on a particular brand of Christianity. The facts you report, and the general disagreement about what the 12-step program is and does, prompted me to do a little more web research.

          What I found is that the original 12-step (AA) writings and concepts do not seem to include the disease label. I’ve seen “disease” referred to on some of their discussion boards and so forth, but mainstream AA does not go there. Rather, as you say, their emphasis is on the notion of wrongness, misdeeds (or a thinly veiled notion of good old-fashioned sin), helplessness, and of course on giving into and getting help from a higher power.

          It seems from my brief survey that Narcotics Anonymous injected (no pun intended) the disease concept into 12-step literature and philosophy.

          From NA:
          “Based on our experience, we believe that every addict, including the “potential” addict, suffers from an incurable disease of body, mind and spirit.” –NA Basic Text

          This is not surprising, since the disease definition of addiction grew up in response to drug addiction, not alcoholism. And as we know, this definition now dominates professional organizations and institutions such as the American Medical Association and the National Institutes of Health (including NIDA, the National Institute on Drug Addiction).

          Nora Volkow, director of NIDA, proclaims:
          “More than three decades of research supported by the National Institute on Drug Abuse (NIDA) has proven that addiction is a complex brain disease characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist despite potentially devastating consequences.”

          The notion of a brain disease will be discussed in my next post.

          Finally, I’m not sure your statistics are accurate. I’ve read a number of conflicting accounts of how well 12-step programs actually work, especially if you start counting from day 1 of the process. Other more recent programs boast better recovery rates. Hmmm.

          • Jaliya June 18, 2012 at 6:42 am #

            There’s a discomfiting inference in the quoted NA statement that ‘… every addict, including the “potential” addict, suffers from an incurable disease of body, mind, and spirit.’ ~ If that’s so, then it seems that we ALL ‘suffer from [that] incurable disease’ — that incurable addiction is a time-bomb ticking away in all of us, just waiting to detonate into fatal mayhem. What a statement of hopelessness, right from the start!

            If, indeed, we are *that* intrinsically helpless against this inevitable ‘incurable disease’ (presuming a context that every person, then, has a ‘perfect storm’ of factors that will one day blow up into full-fledged addiction), what’s the point of any intervention — it seems a futile effort.

            I can see how easily one might categorize addiction only in terms of “a complex brain disease” … but that would have to presuppose that all addictions arise always and only from the brain — the organ — itself. That I cannot believe.

      • Marc June 19, 2012 at 6:45 am #

        Yup, I’m becoming convinced of that. Please see the comments above by Persephone and Jaliya.

  10. Susan Millar June 9, 2012 at 8:04 pm #

    Hi Mark,
    I am really looking forward to this series of blogs. I’ve got to say that I find
    Gabor Mate’s contention that it is highly related to early childhood trauma
    or at least negligence/abuse as very compelling.
    Cheers, Susan

    • Marc June 10, 2012 at 5:34 pm #

      I agree. The “comorbidity” is really high, probably above 50%, though I haven’t checked recent stats. Gabor Mate does make the mistake, I think, of saying that ALL addiction has causes in early abuse/trauma/neglect. I think that’s overstating the case.

    • Marc June 16, 2012 at 4:38 am #

      I just got a recent statistic to help us out. 60-80% of addicted women (in the U.S.) have been physically or sexually abused. I don’t know what the figure is for men. But…wow!!

      • Jaliya June 18, 2012 at 1:46 pm #

        Not surprised by this … and men are coming out of the horribly shaming ‘closet’ of having been sexually assaulted.

        Quick thought re: treatments/interventions — in my mind, there’s a great deal of overlap for both trauma survivors and people whose primary evident trauma is addiction. I’ve come to see addiction as a trauma in itself –> Eventually, addiction comes to threaten one’s existence. Peter A. Levine (a sage of trauma studies, with 40+ years in the field) understands trauma as (terror/threat + immobilization/helplessness) … and I feel sure that anyone who is in a state of chronic addiction experiences (to some degree of consciousness, but certainly as a biological organism) the terror and the immobilization, again and again and again …

        Essential foundations for trauma treatment include relative existential safety; sustenance/nourishment; moderation of CNS alarm; sanity; rest … and safety, safety, safety (these things in addition to any direct interventions to bodily injury).

        There are lots of overlaps in re: addiction and trauma …

        • Marc June 19, 2012 at 6:55 am #

          That’s the problem with drug/alcohol use as self-medication. These things really do soothe the gnawing anxiety and shame derived from trauma. (And I’m one of the men you mention — I also experienced sexual assault, as well as the trauma of boarding school.) They can also help you overcome immobilization. (I had a friend who could stand up in court every day because he had oxycodone in his blood. Notice I said “had” — he is dead now.)

          But then the addiction BECOMES the central trauma. Now you’ve got that terror to live with as well.

          I sometimes think that people become addicts intentionally, though unconsciously so, because they want to replace one form of self-abuse with another. Hardly an ideal solution.

  11. Jasmine June 10, 2012 at 12:16 am #

    Hi Marc,

    I’ve read your memoir with great interest and appreciate the contribution you’re making to understanding addiction. I can really relate to some of the underlying emotional themes or issues that played out in your struggles and I’m interested in how brain chemistry factors into it. One thing you’ve talked about, in particular, resonates with me, and that is the problem of endurance. We can set a strong intention and say ‘no’ to the craving or impulse time after time, but it can wear you down and catch you off guard in a moment of stress or weakness. Abstinence demands constant vigilance. I was in a 12 step group for years, and I do consider myself a spiritual seeker, but I found the cookie-cutter, black or white thinking demeaning and harmful. For some, it’s a life-saver. For me, it was another way of feeling like an outsider if I deviated from the prescribed order. I’ve always felt it was important to understand the deeper issues behind my addictive urges and to learn how to address these…..not just label myself a ‘sinner’ and repent, so to speak. Recently, I’ve read a couple of books by Lance Dodes, MD: ‘The Heart of Addiction’ and ‘Breaking Addiction’ and have found his take on the subject similar to my own. In ‘Breaking Addiction’, he writes, “When people feel that they cannot act directly against helplessness (usually because it would make them feel too guilty or anxious) they resort to a displaced action—-the addictive behavior. Consequently, in searching for alternatives when you are faced with your addiction, what you are really doing is simply undoing that displacement.” And: “Since there are usually hints of trouble before the final overwhelming event (the breakup of a relationship, a job loss, etc.) these hints can help you to anticipate what is coming. By playing close attention to what is happening at the key moments when you first consider your addictive act–you will notice a common theme behind these moments. You will see that, repeatedly, you are terrified to be left out, or you feel you’re being treated as if you are weak, or you’re infuriated because you feel you aren’t being heard–or it might be you’re made anxious by success, or certain situations remind you of past traumas, or something else that is individual to you. Whatever it is, you can know it. It will be the central problematic theme of your life–an emotional vulnerability specific to you that surfaces again and again, and results in feelings of helplessness and powerlessness (what we have called the “helplessness trap”). Once you become familiar with this theme you will be able to think through these perilous occasions very far in advance….”

    I think knowledge is power, and getting to know ourselves intimately, being closely in touch with the thoughts and emotions that prompt self-destructive urges or actions (in the guise of relieving discomfort) is probably the single most valuable tool available to a person who is willing to undergo a deeper level of self-examination. It’s sort of like that quote in the Gospel of Thomas “If you bring forth what is within you, what is within you will save you. If you do not bring forth what is within you, what you do not bring forth will destroy you.”

    For me, that’s the problem of addiction in a nutshell.

    Thanks for your blog, book and bravery on the journey.

    Jasmine

    • Marc June 16, 2012 at 6:17 am #

      Thanks for your contribution, Jasmine. I like the quote you took from Dodes, and I agree with the main idea. There usually is single core theme or a small cluster of themes that bring forth the anxiety, discomfort, etc, that propel us to take drugs or booze. I know that it is really important to get to know those core concerns. Some psychologists call them “core relational themes”…and they probably originate in childhood. If you see it/feel it coming, you can usually get there before the compulsion starts to build to unmanageable levels.

      Knowledge IS power. But it’s so difficult for people to look at their darkest concerns head-on and come back out the other side. Difficult but not impossible.

  12. Julia June 11, 2012 at 7:23 am #

    Marc, As many of those above have said, and from my own experience of addiction, I am so very appreciative of your wisdom, expertise and personally-informed perspective. I am especially grateful for your embrace of each person’s unique story. I think it’s largely a Western cultural constraint to label people and group them together according to some outward characteristic. A big part of my own growth & healing process has been finding places and the ability to tell my own story. From going to some Al-anon meetings I see that that is also a big part of what the 12 step method offers.

    Even when I was in the depths of my eating disorder behavior I knew somehow instinctively that the problem was not the behavior, that that was just something that was covering up something inside me that I could not yet access. So my search was for how to access what was really going on and how to find some other way of dealing with the pain it was apparently causing and which I was using obsessing about food to distract myself from.

    I have similarly always had a problem with, or at least have not accepted at face value, the term addiction. I think I have had a somewhat addictive relationship with other activities such as reading, thinking, exercise, etc. But those things are not generally thought of as negative.

    I also question the notion of having and then not having an addiction, or being and then not being “addicted.” I think labels or categories and notions of beginnings and endings are constructions we humans place on “reality.” I don’t think there is any absolute distinction between behavior that is “addictive” and that which is not. So much depends on the subjective experience and the effect is has on one’s life, not to mention cultural valuation and judgements. Neither does anything ever begin or end in the absolute sense. Even when life begin or end becomes fuzzier and fuzzier the more we know about their biological mechanisms.

    The story of my own recovery is best described by something I read long ago, that the only possibility for the end result of being addicted is either to die of the addiction or to outgrow it. I think I came pretty close to dying of it before I managed to outgrow it. And that is simply my own unique life story which I do hope to write out in more detail and send to you soon!

    Thanks again for opening up this open forum for discussion. Julia

    • Marc June 16, 2012 at 6:44 am #

      Thanks for your input, Julia. Categories indeed group people in ways that ignore a lot of what’s unique and important within people. Yet they help us think about things…without them we’d be lost. Whether addiction is a useful category is a really tough call. I think it is, but then, as you say, people feel very differently about whether they fit it or not. I do not use the word disparagingly, especially as I see myself as an addict or at least an ex-addict. But I wouldn’t recommend it for everyone. It sounds like it wouldn’t work well for you.

      And what you say about beginnings and endings is especially interesting. I must say it goes well with the way I see “addiction” — as a subset of all the learning processes in life, a progression part-way along the road of life, if you like, during which your habits are out of control in a way that is obviously harmful. So indeed there is always learning that comes before it and hopefully after it…unless, as you say, it kills you. This perspective keeps open the developmental angle, which I think is crucial.

  13. David June 11, 2012 at 3:25 pm #

    Marc,
    You gain my immense respect for having the humility to state, “maybe my model is an approximation too.” Most of us relate to the world through metaphors accurate or not. As a recovering addict who has always been curious about how I perceive the world, having a model of the underlying brain chemistry gives me a new way to relate to craving/caving/release. Both the choice and disease models are inadequate to explain my experiences. I don’t really buy into the victim mentality of the disease model, I did choose to walk my path. However, sometimes I am remarkably weak at choosing sustained recovery. I have often viewed repeated experience as digging deep ruts in my brain, your explanation makes it more likely that I have overdeveloped pathways in my brain and neglected others. Looks like the task now is to balance the pathways by building the neglected ones as I can never undo the development of the past, much like a tennis player may have an overdeveloped playing arm can balance their non playing arm by exercising it.

    • Marc June 16, 2012 at 6:52 am #

      I agree with every word you say, which is unusual. Except maybe about my humility. It was really closer to false humility, since I KNOW my model is approximate. The brain is so damn complicated that that’s about the best we can do these days.

      Yes, we both see the process in terms of overused, overextended pathways. In synaptic architectures, frequency of use actually increases the extensiveness of pathways. It increases their numbers, their strength, the thickness of axonal bundles, the number of connection nodes….it makes dendritic “bushes” bushier, etc, etc. Yes, ruts…ruts that get deeper each time the water flows through them. And your tennis analogy is right on. You don’t undo, you build alternative pathways. And you PRACTISE them!

  14. Elizabeth June 11, 2012 at 5:19 pm #

    Apropo this recent blog entry, I ran across this article in the NY Times:
    http://opinionator.blogs.nytimes.com/2012/06/10/the-hijacked-brain/?hp

    Interestingly, I found myself twisting the “hijacked brain” metaphor to something that is a mixture of “free will” and “choice”. Would individuals find it useful to think of an addiction as something that “hijacks” them, but can be overcome? What about learning “self-defense” strategies…your own “karate”…as a way to combat your hijacker. For me, this captures the overwhelming nature of addictions, but also shows that hard work and skill building can build up effective defenses to kick our hijackers in the groin!

    I also think this ties in with the learning metaphor. I’ve always enjoyed the “addiction as a disease of learning and memory” view championed by Hyman :).

    • marc June 18, 2012 at 7:07 am #

      You got me reading an in-dept interview with Hyman — not to be confused with Gene Heyman, who has championed the choice model with his recent book, “Addiction: A Disorder of Choice.” Hyman definitely backs the disease model, but he does it in an intelligent way. He has a good understanding of the neural foundations of addiction — not surprising given his positions at Harvard and the National Institute of Mental Health.

      I’m going to use his model to present the “disease” view in its best light, next post, coming up.

      Meanwhile, nice work hijacking the hijacking model! Seriously, this is a productive way to have your cake and eat it too. Yes to a hijacked brain, no to the assumption of helplessness.

      • Elizabeth June 18, 2012 at 8:37 am #

        Excellent! This has been such an enlightening discussion and really helps me in figuring out how best to present data in the field of neuroscience for translation to effective therapies. Keep up the work! I wish more of this was discussed in academia.

    • Marc June 18, 2012 at 7:41 am #

      Hi again. I just read the essay you linked to in the NYTimes. And I realized halfway through that I know the author, Peg O’Connor, and in fact had a dialogue with her and two others on The Agenda (TV). Here’s the link to that discussion: http://theagenda.tvo.org/episode/175272/aiming-at-addiction

      Okay, free choice is rearing its not-so-ugly head again. Please see Julia’s comment a couple down from here. And I’d better do some writing!

    • Dave June 18, 2012 at 10:43 am #

      All these metaphors, like Marc, are illuminating.
      I hope Elizabeth doesn’t mind if I accost the ‘hi-jack’ metaphor further. I find my experiences with addiction are like a ‘seductive, seamless takeover’ that often seem to sneak up on one, where the distinction between use and abuse is blurred, especially if, as a ‘functioning addict,’ one ‘manages’ the addiction like prolonging a dysfunctional relationship. Or is that ‘self-diseasing’?
      Self defence strategy? Shed it like an old skin by growing beyond it. Change is hard. Catalysts vary. Reading Marc and co certainly helps.
      Anyway, here’s hoping my attraction to metaphors remains a helpful quality and isn’t becoming a misleading addiction.

  15. Richard Henry June 12, 2012 at 10:37 am #

    Hi! Marc… Addiction, Choices, and options…

    Certain Behaviors, become addictions, when we repeat actions, of an activity, despite the negative consequences!

    When it comes to Drug Addiction, the mind under goes a constant bombardment of options, from the brain, in order to achieve its desires, that being the brains craving for its choice drug of abuse at the time.

    Your brain goes into over drive, in a creative thinking mode, that drives your mind crazy, the brain sends out options, for the mind to make choice in a constant battle for relief.

    Some give up their right for choice, its a battle for control, you fight and struggle endlessly that impulse to follow through with any options that become clear.

    When we do give in to the craving, it brings closure to the torment, and some relief, if only temporary, in most cases its only once all avenues have been depleted and exhausted do we get some peace.

    Its a battle, I will fight the rest of my life, once you cross that line, life will never be the same. Think twice the next time you thing you need something in order to have a good time.

    Life is beautiful, all on its own, help others, think, positive, for its only your imagination in seeing how life is, that will bring you to that happy place, a happy heart.

    Its your right, your choice to a good life! “One Life One Chance, Gotta Get it right”…

    Today I’am “FREE” and I am enjoying life without all those outside influences.

    My Prayers go out to all thoughts who still suffer..

    • Marc June 18, 2012 at 7:13 am #

      Hi Richard. You have a novel approach to thinking about the mind-brain relationship. Indeed the brain is operating in an unusual way, with very powerful goal-orientation to one thing and one thing only. Now, whether the mind can sit on top of that situation and make a choice…that’s a tough one.

      I like your notion that it can, that there’s still choice about what to do with that runaway brain state. As you say, it’s not an easy choice. It’s more like a fight!

  16. Julia June 13, 2012 at 4:39 pm #

    In regards to questions of “choice” it might be worth delving a bit into the discussion going on in the neuroscience world about free will, etc. There are several different points of view jockeying for position, all pretty much defaulting to metaphoric explanations.

    One that is pretty interesting is the idea that we don’t ever really choose to act, that all our impulses and motivations arise from levels below consciousness and that by the time the get to the level where we feel like we have a choice, we basically have only the choice NOT to act. The catch phrase I’ve heard, which I love – kind of a bad news/good news schtick – in answer to the question, do we have free will? No, we do not have free will… but we do have free “won’t.” Meaning we pretty much only have the ability (some of the time) to choose to inhibit an impulse or action. I do think that the more one practices that, the less powerful that impulse becomes the next time it arises, AND the more other impulses are allowed to arise and maybe compete or replace the one that is being resisted.

    The concept that makes the most sense to me is one offered by Michael S. Gazzaniga, whose latest book is “Who’s in Charge?: Free Will and the Science of the Brain.” What he adds to the conversation is that all our actions, ideas, impulses, etc. take place within a cultural context so that the judgements about which ones to allow, to value, to encourage are largely contextual. What we think we should try to resist or encourage depends largely on what the society around us values positively or negatively. Here’s a great interview with him where he explains this much better than I could:
    http://www.brainsciencepodcast.com/bsp/how-mind-emerges-from-brain-bsp-82.html

    Listening to him really helped me open up my thinking. Thanks again, Marc, for this forum! It’s the most intelligent and well-rounded discussion around addiction I have come across. Julia

    • Marc June 18, 2012 at 7:22 am #

      You’re welcome, and thanks for your input. Gazzaniga is one of the most respected neuroscientists in the world. But before I look up his recent stuff, I want to say that (a) I agree that the word “choice” is a Pandora’s box from the perspective of neuroscience, cognitive science, philosophy, and psychology, and (b) I dealt with the debate you mention way back in October in this post: http://www.memoirsofanaddictedbrain.com/connect/not-quite-free-will/

      The compatibelists (not sure of the spelling) want to get free will into a brain that runs according to the laws of nature — that is, according to determinism. That means that the brain just does what it does, based on its inputs and its state a moment before now. So how to we fit in free will?

      Not easily. But the paper I cite by Frijda in the October post does a very nice job of it. I’ll get back to this question soon.

      • Marc June 18, 2012 at 7:26 am #

        Sorry, I didn’t actually link to the article by Frijda after all. Here’s the best I can do: http://emr.sagepub.com/content/2/1/68 That gets you to the abstract, and my post also helps explain Frijda’s position.

        By the way Frijda is an emotion theorist…at the top of his game. Hence the emphasis on passion. He’s also a delightful man.

      • Marc June 18, 2012 at 7:43 am #

        And please see Elizabeth’s comment a couple up from here. She’s also concerned with the issue of free choice, and she links to a great article!

  17. nik June 13, 2012 at 6:26 pm #

    I find myself agreeing, in spirit with Julia.

    Julia//I have similarly always had a problem with, or at least have not accepted at face value, the term addiction. I think I have had a somewhat addictive relationship with other activities such as reading, thinking, exercise, etc. But those things are not generally thought of as negative.

    I also question the notion of having and then not having an addiction, or being and then not being “addicted.” I think labels or categories and notions of beginnings and endings are constructions we humans place on “reality.” I don’t think there is any absolute distinction between behavior that is “addictive” and that which is not. So much depends on the subjective experience and the effect is has on one’s life, not to mention cultural valuation and judgements. Neither does anything ever begin or end in the absolute sense. Even when life begin or end becomes fuzzier and fuzzier the more we know about their biological mechanisms. //

    Hey, theory is neat, and some conundrums intrigue –what’s the relation between an addiction
    and a ‘bad habit’?

    What is a disease? What is an addiction?

    From the first person point of view, I find myself ‘stuck’ in something. I’m doing things that, the next day or next hour, I regret. I seem ‘locked’ in a pattern–even if I can ‘will’ the exception–e.g. not eating for an hour– i can’t muster the resolve to break the pattern; lose an old ‘bad habit’; gain a new one. Maybe I call it an affliction, malady, fuck-up.

    First professional says I have a disease; the second one says, a “psychological disorder”; a third one, a biochemical inbalance. OK. Can you help.? Well, the third fellow says, “Take these pills twice a day.” I say, “For how long?” There, the answers will vary “A couple weeks will usually suffice” “Probably the rest of your life.” The question my be, Will the pills alone, suffice?

    The first fellow may want to discuss a) how it came about, b) changes of behavior involved in a cure/recovery. But even if it’s and STD, and it was “my choice,” he or she gives me the meds; Maybe offers advice “use condoms.” If one thinks of Type 2 Diabetes, perhaps it came about through rampant sweet gobbling. Was that my choice? Doesn’t matter. It’s recommended that I stay off sweets, balance my diet. That’s assumed to be a choice. If I say “I can’t,” maybe a support group will be recommended, or something else.

    Now Marc has this wonderful book; he summarizes it and says,

    You’ve undergone an accelerated form of learning. I see it as the result of a natural learning process that has gone way too fast and way too far, yielding habits that are extremely difficult to “unlearn”. I explain this in terms of the highly emotional content of what gets learned (associative learning in the amygdala),…. And my dopamine levels inappropriate, skewed, not functioning properly.

    OK. I say, about my ‘bad habit”? I imagine I’m told “Stop X, one way or another; learn some new patterns.” This is not different, it seems, from the advice a dr. gives to the Type 2 Diabetic, who he considers to have a ‘disease.’ I have to stop with one pattern (life style) and learn another (healthy lifestyle).

    Perhaps the difference is that Marc, if not now, maybe up the road, can say, “Take these and these drugs to either help ‘dissolve’ the old brain reactive pathways, or facilitate forming of new ones (in conjunction with some learning regimen).” Grof spoke of using LSD to dissolve. Or consider a dr. prescribing bupropion to someone trying to quite smoking; something eases the change, biochemically. Will more drugs be developed to facilitate learning? As to changing dopamine functioning, we do know that the picture is always complex; one can’t alter one biochemical and ‘cure.’ You can’t cure depression simply by a drug raising serotonin levels.

    I’m just speculating of course; spit balling. Some of the basics, though, seem unaltered. Marc says, “Stop.” If I say, “I can’t.” Marc says (perhaps), “Talk to an addiction therapist.” Should I join a group? “Some people find it helpful.” That makes sense in terms of Marc’s model: a group teaches and supports ‘new learning’. Marc, of course, may give me a scientific account the “I can’t”: “Your biochemical pathways are abnormal in these and these respects.”

    The key seems to be, as regular drs. say to Type 2 diabetes patients, “to acquire a new lifestyle” or new, health-promoting habits. If some professional can help with that, one might ask (leaving aside the issue of biochemical intervention), Does it matter if it’s disease, disorder, affliction, culmination of bad lifestyle choices, or a form of ‘accelerated learning.’ ?

    • Marc June 18, 2012 at 7:56 am #

      I wish I did have such a pill. I’d take it myself. But when you say you can’t “cure” depression by raising serotonin levels, I take a different view. The sentence (and I know you’re just spit-balling) assumes that depression is a disease, since only a disease can be “cured”. A “bad habit” can be broken, but not cured, consistent with the rest of your comment.

      But if you call depression (or addiction) a habit, then serotonin “pills” CAN be really helpful. The whole antidepressant industry is based on that fact: SSRI’s, selective serotonin reuptake inhibitors, work. Because if you use the concept of habit, and thus move from medical territory into learning territory, then all you care about is function, not categories. And neurochemical changes certainly do affect function, as is demonstrated by the impact of SSRI’s on depression

      I’ll let you know when I hear of a pill for addiction, one that actually works. I know that people are spending millions in research on such a pill, but so far, no luck.

      • nik June 19, 2012 at 2:37 am #

        I think my questions, here, are rather simple, though possibly obscured by my wordy post, above. Aside from pharmaceutical interventions or pharmaceutical-assisted interventions (e.g. use of Zyban with those dealing with nicotine addiction), what are the practical implications, for someone trying to ‘kick’ an addiction, of the choice of disease, “disorder” (DSM), cumulation of bad/wrong choices, or ‘accelerated learning’ models as the most suitable, scientific account? Don’t the alternatives–stop on your own; find a therapist; find a support or self help group– remain the same? (so long as a model allows for personal responsibility, if not for incurring the habit, for recovering from it). Putting it differently, what light does the accelerated learning model shed on the the available alternatives or on possible new ones?

        Serotonin: The meta study by Kirsch et al (2008) found little evidence of a clinically significant effect for the SSRIs fluoxetine (Prozac) and paroxetine (Paxil) (chosen as among the best documented) for mild to moderate depression. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration
        http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045

  18. billp June 21, 2012 at 11:49 am #

    Just discovered your work through a posting on Alternet today. And in reading through everything here briefly; I must say I am impressed with your openness to your commenters etc.

    I noted one thing that stands out in your story: at the age of thrity you ‘chose’ to stay clean and sober….this brings me to what I would like to say about all this.
    When AA was first organized….and I believe ‘organized’ is probably an incorrect word to use; as the beginning members; I do not believe set out to ‘organize’ anything. I believe they were just trying to ‘survive’. And they took some information from CGJung, the Oxford movement and writings from Blake, coupled with some personal experiences and the AA 12 Steps and program evolved. What most modern folk do not understand is that those 12 Steps relate very much to ancient Spiritual Alchemy from the Babylonians, Greeks, Eygptians etc…

    With that said; let me get back to your choice/decision to finally give up the drugs etc at age thirty. Although I did not read it said; it seems I can assume some sort of BOTTOM” was hit at that point in your life; where what ever had ‘worked’ and ‘got away with’ in the past was no longer working. The first AA members only worked with those people who were at those ‘bottoms’ in their own life. And AA pretty much stayed that way for many years. Throughout this period however; research and education was developed in attempts to further understand and educate folk about addictions and ‘create’ ways to intervene and ‘raise those bottoms’.

    However; everyone seems to overlook one of the basic elements of Spiritual Alchemy, and that is the necessity of pain and henceforth enduring pain in this process.

    I am curious what your pain was that you endured at age thirty in order to succeed?

    Local rehabs do not teach this element of choice. Everything is labeled as being an cognitive and effortless choice without furnishing tools to enduring the pain process…..so most when they ‘hit’ the barrier of pain will resort to the old habits; and attempt to get by with it one more time….in other words; go back to the old addictive habits which worked in the past; instead of accepting and enduring the pain of change.

  19. Marc June 25, 2012 at 7:26 am #

    Hi, and welcome to the blog. Very interesting what you say about the initial premises of AA. I didn’t know that. I do see the connection with ancestral forms of treatment. For example — jumping to a modern analogue — taking ayahuasca in a shamanistic setting causes people to face their pain, no matter how awful it is, to endure it, go through it, and then, as a result, they may come to the other side of it. That’s my understanding of how ayahuasca can be successfully used to alleviate addiction (see Gabor Mate’s clinical work).

    Anyway, yes, I had hit bottom. I was in a great deal of pain. My girlfriend, whom I loved very much, had just ditched me. She couldn’t handle my drug-taking any more. But more than that, I was so disgusted and horrified with myself that I just couldn’t tolerate it anymore. That helped me make the “choice” to stop.

    I don’t think anyone says that the choice is “effortless”, but you point out, correctly I think, that it really does help to hit bottom before you claw your way back up.

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    The non-addicted person, in my experience of talking with them, wouldn’t consider other means of eating that chocolate bar they are “craving” if their lives were being threatened, they would be thinking about their families, their careers, their friends, loved ones, ect.

    • Marc July 21, 2013 at 10:45 am #

      Exactly. That’s the big difference between being addicted and being “non-addicted” — i.e., how people deal with their cravings.

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