Substance (not just substances) in addiction

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

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

woman with nothing to doA substance is what fills up a space. The lack of substance equals, well, nothingness. When people talk about their addiction they often talk about a sense of profound emptiness, a psychological void, that gets filled by a something they can only get from what they’re addicted to. To replace a sense of nothingness with a sense of somethingness (what else to call it!) is more powerful than words like “pleasure,” “relief,” or “satisfaction” can possibly convey.

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

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

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

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

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

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

 

24 thoughts on “Substance (not just substances) in addiction

  1. Mark January 11, 2019 at 7:30 am #

    “…wanting, not liking, a drug or other reward, and this has been a major contribution to our understanding of addiction.”

    Things get REALLY interesting – not to mention complex – when you consider the Buddhist perspective that a human incarnation is the underlying “wanting” we are all fundamentally addicted to.

  2. William Abbott January 11, 2019 at 9:54 am #

    Some time ago I heard a talk about addiction to etoh as a progression from liking to wanting to needing.

    All this before you and Berridge and the DL /

    But to me most of the language used around this like ” substance” or ” addiction” or ” recovery” is sloppy and slippery . Until the ” scientists” clean up the terms, well have trouble dealing with the problem .

    Neuroscience and not medicine or psychology , must lead the way

  3. Carlton January 11, 2019 at 11:38 am #

    Marc, Yes, agreed:

    “To replace a sense of nothingness with a sense of somethingness (what else to call it!) is more powerful than words like “pleasure,” “relief,” or “satisfaction” can possibly convey.”

    To add to that, and in hindsight, replacing this is something that “occurs” just like love “occurs” to a person.. it is not something a person “does”.

    In all seriousness, here is food for thought:

    From the current point-of-view of the addiction field, would Romeo and Juliette be considered “Addicts” that could have benefited from treatment, perhaps even
    by prescription?

    • April January 13, 2019 at 6:59 am #

      But of course! They were classic love addicts. Where is Stanton Peele when we need him? Dopamine drove them to unfortunate ends. If only they had had access to heroin, they could have used that instead of becoming so obsessed with each other. I may seem to be joking, but if you imagine a world where medical heroin is legal and can be prescribed, it might not be such a bad idea.

      These days, I imagine they’d be given drugs intended to calm people down, ironically either benzos or versions of speed like Adderall. Their obsession with each other would definitely been pathologized and someone would have attempted to get them into a 12 Step program to make them obsessed with the group and pleasing their sponsor and Higher Power, or to medicate them. Or both.

      If only they had lived in a society where natural urges can be acted upon without social death (if not physical death), they could have just had a nice fling and gotten on with life, as most of us did in college and so on. The repression of desire opens to door to all sorts of addiction. Sometimes, I think, it’s better to just have a slice of chocolate cake or a beer than to spend your life obsessing about the idea that you can’t. And believe me, I’ve tried both.

      • Carlton January 13, 2019 at 12:13 pm #

        But people universally believe that experiencing such an endlessly deep and unbound feeling of love like that is what we all aspire too.

        ( in their case, it was the hate and confrontation of the families that tragically ended their lives indirectly, but that is not a point here).

        A point I am trying to make is that people outside of the Addiction Field have a different point-of-view than people inside the Field of Addiction.

        It is probably why the Field of Addiction rarely hears from the addicts that have recovered on their own, or who leave recovery programs.

        Answers to ongoing and puzzling questions, and a truer understanding of Addiction and Recovery could occur is this large number of addicts.. or ex-addicts, was researched and considered.

        April, although you were being a bit lighthearted, I bet a-lot of people in the Addiction Field would readily agree with your post ! 🙂

  4. Helen Meline January 11, 2019 at 12:44 pm #

    Marc,
    Putting the anticipation of
    “wholeness” into a perspective. Words that describe the visual landscape in US today. From food to video games, and tied to the reward system of “Fill me up…please”
    Thank you for this article. Sharing with my colleagues.
    Helen

  5. Katie January 11, 2019 at 1:44 pm #

    Nailed it, again. Thanks for making me feel understood. I wish I could find a therapist up for ‘going there’ with me.

    • Marc January 11, 2019 at 3:24 pm #

      I’m up for “going there” with my clients in online psychotherapy. It’s a place I’m familiar with, as you can tell. Let me know if you want to try connecting this way, by contacting me through the far-right tab at the top of the page.

      • April January 13, 2019 at 7:04 am #

        If only I had known about people like you and Adi Jaffe who do online psychotherapy when I was in crisis. Later on I found such people, who made a tremendous difference in my life, but the money spent on rehab could have much better gone to treatment that would not have left me scarred with fear. In the end, I found people who treated me completely for free. A list of trauma therapists provided by some of the top people in harm reduction psychotherapy were too expensive, and when I finally found a group that would have residents treat people with little money, they did a two hour phone interview intake and assessed me as too severe a case to be seen by anyone less than their most senior person, who cost $500/hour. And yes, I’m still mad. Of course people need to make a living, but it’s such a tragedy that money is thrown at rehabs that unnecessarily lock people up when it could be spent on less invasive, more effective treatment.

  6. Teresa Rodden January 11, 2019 at 4:44 pm #

    “The substance common to drug addictions and behavioral addictions may be the feeling of wholeness, once lost, now regained…Hundreds of studies have shown that dopamine release in the “craving centre” (the ventral striatum or nucleus accumbens) corresponds with effortful action, not with pleasure per se.”

    I have found this to be true with my clients and for my own sobriety. My next book (The Primed Drinker) shares two case studies that the above two paragraphs (really much of the post) could have been used to explain how they learned to misuse alcohol. Both women had lost a sense of self. It wasn’t so much the drinking (alcohol) that gave them a sense of power but in TAKING the time to drink. They assumed alcohol was the problem, but as we explored their life as a whole we discovered it was the claiming of time, space, self, that they craved.

    One trying to figure out how she can squeeze a drink in between wife and mother duties and the other escaping from aging parent duties.

    Both were able to take charge of their relationship with alcohol.

    Thank you for all you contribute to broadening the view of addiction.

    • April January 13, 2019 at 7:05 am #

      So very true – I must read your book! I dislike the term “sobriety” and don’t see that as the only goal, but definitely have seen how especially women use alcohol as a way to claim one tiny sliver of life to ourselves.

      Adi Jaffe writes quite a lot about that in The Abstinence Myth as well.

      • Teresa Rodden January 13, 2019 at 11:51 am #

        April, I didn’t like the term sobriety for most of my abstinent years, but that’s because I didn’t understand the true meaning of ‘being’ sober. The true definition of sober boils down to is to be clear of mind, not abstinence. I go much deeper in the book. But when we take abstinence off the table and focus on how you really wish to live your life, I mean with all your heart identify your true desires, to go after that life requires a clear mind. Shifting your energy and focus from not drinking to filling up on life. It may seem simple, but I’m living proof, and it’s been remarkably effective for my clients.

        Marc touches on this in the Biology of Desire, “addiction can only be beaten by the alignment of desire with personally derived, future-oriented goals.”

        Sober is freedom for me to go after life, intentionally. I have swung the full pendulum with all the language around this challenge. Language matters.

    • Carlton January 13, 2019 at 9:55 am #

      “I have found this to be true with my clients and for my own sobriety.”

      r.e the term, “sobriety.”.

      A life-changing realization can be that sobriety is a default-by-nature…it does not need to be maintained.

      What a person is actually actively maintaining is a deliberate effort and control of doing something to NOT be sober.

      This is not just semantics.

      To deeply realize that if you do nothing, you are sober, is one of the ultimately liberating realizations a person can have during the recovery process.

      • Marc January 14, 2019 at 11:48 am #

        Fascinating point, Carlton. It seems obvious. And yet.. So much energy devoted to REcovery seems to drown out the idea that sobriety is actually just settling into the here and now. Of course, we don’t always like the here and now, which is why we spend so much energy trying to get away from it. And then we seem to have to spend just as much energy, maybe more, to get back there. Seems like a terrible irony.

        Some of the “unpleasantness” of sobriety, of just being here, comes from tangible sources of suffering, as we’ve all talked about. But there’s also a belief or attitude, lying deep within our culture, that says that suffering is NOT okay and we’ve got to paper it over — viz, get loaded.

        The Buddha had a few things to say about that.

        • Carlton January 16, 2019 at 9:04 pm #

          The “Sword of Damocles” of Addiction can disappear when a person realizes that they can be doing things and be anywhere again..and only by their specific actions and effort can they NOT be sober.

          To truly realize it was the ADDICTION that required maintenance, not Sobriety, can be part of a persons life-changing experience.

  7. April January 13, 2019 at 7:15 am #

    Another excellent piece – no surprise there!

    I’ve been thinking lately about how repression of two natural drives drove me to drinking. I was a very late blooming drinker – I didn’t really start to drink seriously until 27. I had been a super over-achiever, overcoming difficult economic circumstances and various childhood traumas to go to an Ivy League school, excel, and rise to the top of my field by the age of 27. I was supervising 10 people and running a campaign with a budget of $1 million that turned out to be the biggest success in the country in that field that year. I was also supervising a group of female bullies who treated me so cruelly that I went into what I would now recognize as PTSD.

    The two drives targeted were:

    a: ambition/power: I was the supervisor, and very good at it, and they hated authority
    b: sex: I was having a completely consensual relationship with someone I worked with, but who was not in a supervisory role over me. He also happened to be the most attractive man in the state (it was a small state, to be fair, but he was its most eligible bachelor) and they attacked me brutally over it. I was literally called a whore in a staff meeting. They attacked my clothing, my long hair, the fact that I get my nails done (you’re probably starting to guess the small state by now, as it obviously was not New Jersey). At one point I was physically threatened by a woman whom we later found out had a record of assaulting people.

    I came back fragile, unable to keep down food, and a shadow of my former self. I also started drinking… led down that path by a huge drinker who was quite confident that both he and alcohol could make all these difficulties go away.

    Women are still punished for wanting power and sex. I repressed those desires by drinking. Many repress them by eating.

    This is why I recommend watching Game of Thrones as therapy for the woman suffering with shame from drinking. It has strong female characters who overcome trauma by seizing power. “There’s no justice in the world unless we make it,” says one character, right before she slices off the head of the person who sold her to a sadist.

    I don’t recommend chopping off heads, but perhaps finding ways to satisfy the needs for intellectual growth, mastery of topics, competition (women can be hunters too! and also very competitive gatherers) and sex would be a good part of therapy.

    Instead, most therapy tries to convince us to fit the mold, repress the desires, and become good little girls again.

    • alison lewis January 13, 2019 at 2:03 pm #

      April- I very much agree with your comments that we need to stop spending more and more money on rehabs, this system sucks, sorry…. I go to two different rehabs weekly…it doesn’t work for a lot of people….
      And then people are “blamed” when “rehab doesnt work” and told they don’t have “an open mind”… ugh!

      And I agree with what you said about the “intakes” that therapists or tx providers do that determine someone is “too complex” to be treated…..I deal with this almost daily, as an advocate and I scream with rage! WE ARE ALL HUMAN. There is way TOO much judgement in the treatment field. Labeling and diagnosing people creates this environment of “us and them”.

      Counseling is not about judgment, this is why people aren’t finding what they need. And counselors have to be risk takers, they have to be willing to get into the messy…but everyone is so afraid of “liablity” that they don’t treat people….

      I finally started my own foundation to build community, and promote acceptance cause my heart was starting to break…and I felt like: how can I keep working in this field, that is itself in denial…..I feel like I’m apart of this sickness..

      Recently, I had 2 doctors say they would not authorize more time for rehab, that a person asked for, unless the person took medication assisted therapy! And the doctors said they weren’t being “coersive” ….WHAT IS YOUR DEFINTION OF COERSION?
      The doctor’s argument was “Statistics state that addicted people can ONLY get better on medication assisted therapy”. No meds no rehab time…..yeah your own made up statistics…..! Fantasyland!

      And, on your women comment: I totally agree that women are suppose to fit the mold and repress desires, about power and sex. I was raised in catholic schools. As a senior in high school, I was a terribly shy kid with a repressed nun teaching that any thought of sex was a “sin” and sexual engagement of any kind was sending you to hell. One day, as a shy kid who couldn’t open her mouth to say anything in class, I quietly but forcefully said, “No” out loud in class. (….I was recently sexually active and feeling so confused by this nun sending me to hell)
      The nun was shocked, and took me outside the classroom asking what I was doing, an “nice quiet” girl like myself. Too shy to say more, tears about to come from my eyes, I just remained silent with a dead stare on my face. She said she would give me a warning this time, but if that happened again it would be dealt with.
      I have finally turned my back on the Catholic church, I find it ironic that they were the ones repressing desire, and that ended up hurting thousands and thousands of children sexually abused…..I know that nun damaged me…cause her “teachings” sent me on more of a path of rebellion…..

      And I agree we are suppose to be the “good little girls”, but society expects women and men to repress desires all round….it makes me angry.

      AND LASTLY MARC, I love this piece you did…my favorite quotes “to replace a sense of nothingness with a sense of somethingness”. and “it’s the feeling of an empty day that can’t be filled”….so so so human….thank you for your pieces they keep me hopeful…

  8. Percy Menzies January 13, 2019 at 6:18 pm #

    A brilliant piece Marc. I am going to share this article with my medical and counseling staff. The word ‘drug’ was replaced by ‘substance’ to reduce the stigma associated with ‘drug’ addiction and ‘addiction’ was also replaced by the word ‘disorder’. Drug addiction is commonly called SUD (substance use disorder). There is a common parallel between substances and behaviors. Let’s agree that ‘substances’ encompass ‘chemicals’ like drugs, food, gambling, sex etc.

    The human biological instincts of survival is very vulnerable to substances and the environment. For the vast majority of us, the frontal lobe (the ‘wizard’ brain) keeps the primordial brain (the lizard brain) on a straight and narrow path. The access or availability of substances is major contributing factor to the development of addictions. The fact that 40% of the US population is overweight or obese is due to the easy and cheap availability of junk food. Over 120 million people in the US have exually transmitted infection (STI) and about 48 million people have a drug or alcohol addiction which includes nicotine. All three of these impact the survival instincts and sensitized by Pavlovian Conditioning. For humans the ‘bell’ rings in the form of people, places, things, time of day associated with the substance use.

    A further complicating factor is the behavior associated in obtaining substances like heroin, meth or cocaine. The subject is forced to develop unhealthy ‘connections’ like lying, cheating, stealing etc. to obtain the drugs. This behavior can be even more ‘addicting’ than the substance.

    Recovery is not an easy process. For the vast majority of patients the recovery has to occur while they continue living in the ‘swamp’. There is no easy way to drain the swamp. Indeed, it is filling up faster with newer and more potent drugs like fentanyl. Patients going away to residential treatment return home often to an bigger swamp. It is easier to reconnect with the unhealthy connections than make new and healthy connection. Bruce Alexander’s Rat Park does not exist – patients have to make their own ‘recovery’ park! Small wonder, the overdose rates have increased every single year since 2000. The number one goal is to keep patents alive by distributing opioid reversal drugs like naloxone and hope they get into treatment.

    We have finally realized that taking patients out of the toxic home environment is a good strategy. At our clinics in St Louis, the state is paying for housing these patients. Patients are offered a range of medical and psychiatric services and the housing component is a critical for long-term recovery. As usual, we do not have the funds to provide treatment and housing for everyone. Recovery is much more than palliative care with anticraving medications – we have to create an environment for healthy attachments or connections.

    • Marc January 17, 2019 at 12:27 am #

      Hi Percy. It’s good to hear from you. I’m noticing that your insights about addiction and recovery seem to be broader, more inclusive, and less formulaic than in the past. I think you see the big picture admirably. It’s important to emphasize that most addicts have to recover within the “swamp” or their home environments, which makes it all the more difficult to succeed. You also recognize that returning from residential treatment, back to the swamp, presents an even more challenging scenario. Most of all, it’s good to hear that your clinics offer choices in several domains, including the all-important domain of housing, as well as the different pharmacological aids that really can help people through the rough times. I’m glad that your focus on naltrexone seems to be less extreme. While naltrexone certainly can help some, there are many for whom it is not the preferred treatment strategy, as recently highlighted by Maia Szalavitz in Vice: https://www.vice.com/en_us/article/7x9ypq/how-safe-is-americas-hottest-heroin-addiction-treatment

      Anyway, we both seem to be discovering and exploring new horizons, strategies, and harsh realities that are crucial for progress. Congratulations to you for your continuing contributions and your open-minded attitude.

  9. Carlton January 14, 2019 at 1:36 am #

    However, Romeo and Juliets’ endlessly deep and unbound feeling of love is what people universally all aspire too.

    A point I am trying to make is that the general point-of-view in the Addiction Field can be very different from point-of-view of the general society.

    Extremes of any type can be described as sick, diseased and needing treatment.

    This point-of-view is probably why the Addiction Field rarely hears from the addicts that have recovered on their own, or who leave recovery programs.

    Answers to puzzling questions, and a truer understanding of Addiction and Recovery may occur if the full spectrum of ex-addicts was researched and considered, including ex-addicts that no longer maintain sobriety through strength, control, therapy or pharmaceuticals.

    April, although you were being rather lighthearted, many of the people in the Addiction Field would readily agree with your post ! 🙂

  10. matt January 14, 2019 at 7:12 am #

    Brilliant post and keen observations by everyone…that capture the fact that substance use and survival behaviors (overcoming or prevailing-over-risk, risky behaviors, like gambling and bungee jumping) are adaptive responses to stress in a world full of innumerable and unknowable stressors that our wizard and lizard brains can’t keep up with. Then the behaviors can become maladaptive given the right array of circumstances. That’s why many find vacationing on a deserted beach or camping in the woods actually relaxing.

  11. deborah j barnes January 14, 2019 at 11:19 am #

    Hi Marc, thanks for helping bring addiction out of the Dark Ages. I am intrigued with nuance and relativity here, as i tend to see the “what is” as a platform of perceptions pressing to grow past the designated boundaries. Maybe the urge for a “something” is the “black hole” in the center of self, the culture, the universe! The urge to seek that which is “other” can be satisfied for a while, can be avoided or temporarily filled and yet eventually the quest for “more” starts up again. Maybe this is the call of evolution, is that something -drive, life force- that is always going towards the true and/or rmetaphoric light. Maybe the goals and story of the world we inherited do not satisfy the needs of a greater growing awareness, of who we are as human beings, how relativity and spectrums of choice and gender create necessary diversity, how to hold the sum and the parts as equally valuable, etc. I tend to mingle many disciplines as core commons is human thought, expression and the like. Anyway, this points to a new story of being and doing human. Maybe its something more in tune with the feminine side of the spectrum, i am my own “experiment” 🙂

  12. John McDowell January 17, 2019 at 12:27 am #

    I love your You Tubes-just discovered him, and would love to connect with you or how to find out where I can get further information that Marc follows or gets his information. I think he is brilliant.

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