Author: Marc

Hi all. The reason you haven’t heard from me for a few weeks is because I finally had that surgery I’ve been waiting for. Cervical spine surgery, bone growing where it’s not supposed to, I’ll spare you the details.

But what I’ll tell you about is my revisiting the land of addiction. This happened to me a little over three years ago too. Then it was lumbar spine surgery. Jeesh. I hope they’ve covered the whole thing by now. At that time, I published a piece about getting into, then out of, opiates, in a popular magazine called Toronto Life.

Here’s the sequel.

The story line is pretty straightforward: pain — painkillers — surgery — more pain — more painkillers — struggle with self because opiates still feel like opiates to me: and do I or don’t I need them for one / two / three more weeks? — and then quitting. I’ve gotten very good at quitting. But haven’t we all?

Here are a few lines I wrote the other day when I was still pretty spacey and feeling the pseudomagical draw of the pills:

The old cravings come shooting up through cracks in the sidewalk like weeds growing too quickly via time-lapse photography, pulling you, your attention, your focus, the thing that you want to be moving toward, that picture frame waiting for its picture, the pull, the pull that hasn’t really been absent all morning, you just forgot to remember it for a few minutes, that pull toward….toward what? Toward nothing. That’s the irony, the stupidity of it. Especially on this dose, enough to soften the pain quite nicely, but you’d think there wouldn’t be enough rope to hang myself. I mean, would there? With the tolerance I’ve built up in the last few weeks, I’d have to take a lot more than the prescribed amount — and I have cheated some, scoping out the territory — to….to….get to….where was it I wanted to get to again? In which case, I wouldn’t have enough left to override the pain for a couple more days, until it was time for the refill. But it would be worth it because everything is worth getting that feeling again, now, this afternoon. You know: that feeling that…that you both can’t forget about and can’t think about. That, once you’ve got it in you, you have to keep telling yourself is special and different, even though the fact that you have to keep reminding yourself implies that maybe it’s not so special. And after a few days of this stuff, let’s face it, it’s not different at all. It’s boring.

These are the strange meanderings of an ex-addict touring the past in the present. What’s valuable about it is that I can see, with vivid clarity, that the addictive urge is a pull toward nothing. Just the same tired replay of an illusion I know so well. It feels now like it did then, but with the addition of perspective, a life, a whole different set of habits of thought and feeling, a meditative warmth that allows me to exist wherever I am. And all that really puts a different slant on things. But there’s still the urge, there’s still enough of a memory of something beyond just okay. There’s still this synaptic freeway, this massive roll-out of holiday traffic, lining up, frantically checking the time, in order to get to a playland that’s been closed for years. And then realizing that it was already closed when I used to go there,  regularly, way back then, because even then, the brief fizzle of fun was like some sprinkler they forgot to disconnect at the entrance. There just wasn’t anything to do once you got through the gates.

Whether you want to call addiction a disease, a brain aneurism, a satanic possession, or whatever, the way things feel to me now, the same as before and yet so different, is the bedrock experiential proof that it’s a developmental process. Addiction and recovery that is. I’ve actually ceased seeing any value in talking about them as separate processes. It’s all development. Because, as with everything else that develops, you lay down habits — synaptic configurations — that don’t ever go away completely. Yet they change with time, the nature of  “the reward” changes with time and so does the way you deal with it. The configuration continues to transform itself. As the Muppets so sagely captured it: That’s good enough for me.

I’m okay now. The cravings came, they’re still there sometimes, other times not. I’ll be off the drugs in another couple of weeks, after some pretty conscientious tapering. (Thanks, Doc) And the pain is going down day by day. I can sit. I can type. The sun is shining. There’s a lot to do.

 

 

 

 

 

 

Hello all. I have to admit I’m becoming addicted (again!) — this time to addiction memoirs. I’ve read four in the last four months, all written by alcoholics:

Drinking: A Love Story — Caroline Knapp.

Drunk Mom — Jowita Bydlowska.

Drunkard: A Hard-Drinking Life — Neil Steinberg.

The Couch of Willingness — Michael Pond & Maureen Palmer.

I’m still finishing the last two. I pick them up in my spare time, packed up on my Kindle for train rides and class breaks, or late at night when I’ve got time to myself. I really like them. I find them delightful, suspenseful, fascinating, epochal, and redemptive — redemption seems to be a big word in this genre.

But really, why do I like them so much? First, I’ve written one of my own. I know how the story goes from inside out. Second…okay, let me reconsider the list of adjectives I just used:

Delightful. Really? These are without exception intimate portrayals of people who are living horrific lives, cutting out hunks of flesh and soul without knowing how to stop, committing reprehensible acts and then choking on shame, guilt, and remorse. Why is that delightful?

Suspenseful. I already know that they are going to keep drinking until they finally quit. And then they’re going to feel better. Where’s the suspense?

Fascinating. Ditto. The stories are remarkably similar, as though they are simply variations on a theme — sitcom formulas. I mean, right down to the details. They hide bottles all over the house. They get rid of empty bottles in the neighbours’ trash cans. They feel embarrassed going back to the same liquor store day after day. Then they go to another store. How is this fascinating?

Epochal. That’s a word used to describe Greek myths, classic tragedies, and so forth. These folks just get drunk a lot. How epochal is that?

Redemptive. Well, they do finally quit. (I’m still not sure about Neil Steinberg, having not gotten to the end. But I’d be surprised if he didn’t). But “redemption” seems like a pretty strong word for finally behaving in your own best interests rather than continuing to torment yourself and everyone around you.

 

So here are my best guesses at why those words came to mind:

Delightful. They are such human beings. Such an unpredictable, ever-changing mixture of strengths, weaknesses, suffering, defeat, pride, shame, and even humour. A fair bit of humour in the last three for sure. Because you have to laugh if you’re not going to cry. Or at least get some of each. These memoirs epitomize the complexities and virtues of humans facing and eventually overcoming astonishing challenges.

Suspenseful. When are you going to quit?! How are you going to do it?! You have tried so many times without success (often), I just can’t see how you’re going to pull it off, and I’m waiting for it with every page turned.

Fascinating. See “delightful”. But let me add that these are war stories, dramas, tragedies, and they describe unimaginable extremes of human desperation, depravity, creative problem-solving, and determination. So you really held an airplane bottle of vodka to one nostril, blocking the other, to inhale the fumes?  Snorting booze? You poured your wine into baby bottles as camouflage? You really grabbed that bottle off the bar counter while the bartender turned her back? Unbelievable!

Epochal. But they really are epochs. Each and every one. Just as Shakespeare’s tragedies all followed the same formula, and yet each came across as unique, profound, one of a kind. Each one (at least each good one) carries us effortlessly along classic story lines constructed from the basic components of suffering, self-deception, and the inexplicable capacity — the heroic capacity — to come back from the jaws of defeat with your dukes up. Or to reshape your personality until that becomes possible. Addiction memoirs seem an obvious extension of classical drama into our modern age.

Redemptive. Well, what is redemption, anyway? I think it must presuppose the idea of sin, moral failing, finally overcome through some sort of penance that one endures voluntarily to become clean or whole once again. In his recent book, Lance Dodes mentions this assumption as built into the AA-inspired notion that you have to hit bottom before you’re ready to quit. But very often, you do. People fight like crazy to quit. And the most agonizing part of that fight is turning your back on the one thing that provided relief, support, and comfort. As Steinberg puts it, “attending the autopsy of someone you love.” That’s pretty damn courageous.

 

Addiction memoirs seem to tell the same tortuous story, often starting in the same place and ending in the same place, but with the incredible diversity, the unexpected creativity and novelty, the unanticipated twists and turns, partial victories, temporary failures, redoubts and stupidly courageous counterattacks, that derive from being one of an infinite variety of suffering humans. We are so different. And though addiction pulls us through roughly the same line-up of torture instruments, like those tours you can take through torture chambers in medieval castles — adults, 18 euros; kids, 8 euros — it does so in ways that never cease to surprise me, mesmerize me, and make me proud.

 

Here’s most of an email I recently received:

 
> Subject: why does the addiction resurface when we least expect?
> Marc,
>
> I really enjoyed your memoir. In so many ways I feel I can relate….
>
> So… Here’s my question…
>
> Why, after being sober for 7-months, did my craving for alcohol become
> that much more intense? Gave up alcohol in August 2013… Started
> drinking again in February 2014… It’s like….. thought I was on my
> way toward a happy peaceful sober life, and then, BAM! Drinking more
> and in ways that I see are perhaps more self-destructive?
>
>
> What’s up with me?

 

Here’s most of my reply:

Hi  _____, Thanks for your note. I find it thought provoking, and really very moving, partly because I had similar experiences when I was taking drugs. Also, your note goaded me into writing this long-overdue post.

This is what happened to me: In 1979 or so, after several years of struggling to abstain and remain abstinent, I finally quit “successfully” for a few months, and then BAM! — I fell back in. Just as you describe. I had quit taking any and all opiates in late December, at the same time as extricating myself from an extremely painful marriage — many strings, much guilt — and making binding promises to myself. Now I was living in my own apartment, I’d given up trying to influence my wife’s state of mind, I was getting good grades in my first year (of graduate psychology), and I was thoroughly delighted to be “unhooked” physically and, so it seemed, psychologically.

Then I went to a party at someone’s home in April, about four months later. I went to the bathroom to pee, and while standing in front of the sink I impulsively opened the medicine chest. And there, staring me in the face, was a large-size bottle of Tussionex — about 1/4 used up, so…. ideal for taking a few sizable gulps without anyone being the wiser. (Tussionex is a cough medicine whose main ingredient is hydrocodone.) Soon after that night, I began using again regularly, and breaking into medical offices again regularly. I guess I was so upset with myself for ending my fast that…well you know how that one goes. Then, one night, three months after that, I climbed out of the basement window of an enormous medical centre, my pockets stuffed with drugs and needles, and walked directly into the waiting arms of several officers of the law. Ironically, I was working as a psychology intern at the time. In other words, I was supposed to be one of the healthy ones. Six weeks later I was given a suspended sentence. But far worse than that, I was kicked out of graduate school, essentially black-listed from all psych departments in Canada, at least for a few years, and I ended up washing windows and house painting to make ends meet.

So what goes on when we are sailing, in the clear for months, and then BAM! — we suddenly find ourselves in the throes of our addiction, as bad or worse than ever?

I figure the two most important brain changes that go with addiction are (1) the rewiring of the striatum, from ventral (nucleus accumbens) to dorsal striatum, and (2) the rewiring of prefrontal areas responsible for self-control, decision making, and so forth. The striatal change takes drug-seeking from an impulse to a compulsion, so that the behaviours we engage in to get/take substances or engage in other addictive acts become at least partly automatic. This is an example of classical (Pavlovian, i.e., stimulus-response, i.e., S-R) conditioning. Stimulus now leads directly to response. The prefrontal change blunts our capacity to think flexibly and switch goals as needed, so that addictive goal-seeking is no longer harnessed by cognitive control.

If those two brain changes are central to addiction, then ongoing brain changes in both systems — essentially in the opposite direction — are probably central to recovery. We recover some cognitive control, and those prefrontal networks become more efficient once more, but slowly, and mostly because we work on it like hell. We practice cognitive control daily, and thereby awaken the synapses that got too sleepy. In fact, a study I recently reviewed on my blog shows that we grow extra synapses in cognitive control areas after several months of abstinence. These function like a suit of armour that protects us from addictive impulses….until the automatic S-R response finally weakens.

But here’s the problem: On any given occasion, the cognitive control network is slower to power up than the impulsive/compulsive network, and this is especially true while the cognitive control network is still being “tuned up” (so to speak) during the recovery phase. So the synapses in the striatum and its close neighbour, the amygdala, get activated extremely rapidly by drug cues — even during recovery — compared to the prefrontal control networks. Approximately one-fifth to half a second faster (my speculation based on EEG findings). So these “control” networks (which Kahneman refers to as System 2) are not only intrinscally slower to begin with, they’re even slower (and more deliberate) than usual because they’ve gotten rusty with disuse.

So when I opened that medicine chest, my slow deliberative control mechanisms did not have a chance to act BEFORE the rapid, automatic, Pavlovian-style response took effect — as soon as I saw that bottle. Stimulus = Tussionex. Response = Grab and drink. Reflective self-control doesn’t even power up until half a second after the sight of the bottle. And that’s another important point:  action tendencies break off and have a life of their own. My whole brain was already set into a response mode (triggered by the stimulus) that was extremely hard to interrupt once it got started. All those striatal synapses were already singing in choral unison: “fuck it”, “just do it”, “I have to get this inside me”, “do it now before anyone (including myself) can stop me”. Those synapses were still functioning as a coherent, efficient network — the net result of all those yeas of addiction.

I don’t know if this explanation works for you. You mention increased craving. But that could be a sort of byproduct. I’d say that many people slip because they’ve let down their guard, they’ve stopped concentrating very hard on beating back those action tendencies (and maybe even imagined they could experiment a bit) — simply because they’ve been sober long enough to believe they’re out of danger — at a time when they actually need extra effort while cognitive control networks are just beginning to blossom again. They figure they’re safe. They open up medicine chests on a whim, or sip a glass of bubbly at an office party. And, as you say, BAM! Down you go again. And this ride really is more self-destructive than the last, because you are terribly angry at yourself for letting it happen. What an ideal time for a self-destructive feast!

 

 

In the comment section following the last post, a fruitful dialogue sprang up between Matt (the author of the post) and Cheryl, a reader. In a comment following his post, Matt admonished us (addicts, ex and otherwise) to remain aware of our vulnerabilities (like fluctuating willpower, loss of perspective), to not get too cocky, to continue to remind ourselves that we still think and feel and even act like an addict. Cheryl’s response was a sort of call to arms in the other direction — an invitation to shut down the voices of self-doubt and take stock of our strengths instead. To trust in those strengths, to dive into that pool of self-trust without looking back. These approaches to recovery sound almost diametrically opposed. Yet it seems to me there is  some crucial truth in the space between (or stretching to include) both of them. In fact, this could be one of those magical tensions. Like wave-particle duality, or the impossibility of life without death, or the fact that humans are both totally selfish and totally altruistic — the kind of tension that gets you thinking more deeply about a topic than any one perspective ever could.

The sort of self-trust that Cheryl mentions is, I think, similar to what I was trying to emphasize in several posts, including this one, nearly a year ago. I was pointing to a special kind of power in self-trust that turns up its nose at the reminders of past failures, to the shame and guilt that go with them, and to the moralistic (and sometimes, hate to say it, but realistic)  judgements of others, those judgements that bounce round and round inside our minds in self-defeating rumination. That kind of total self-trust is a lot like hope, in that it’s at least partly irrational, maybe even deluded in the grand scheme of things, but absolutely essential to moving forward, potently, effectively, without looking back, eradicating that massive tangle of self-defeating habits in one giant twist rather than a bunch of little adjustments.

And yet — hey, we’re not idiots! — after what we’ve been through (i.e., addiction) we’ve learned a thing or two. We know the value of staying on top of the little things, continuing to evaluate just how vulnerable we might be in certain contexts (like the aftermath of rejection or loss, driving past a particular neighborhood) and situations (like parties, especially when things get a little late) where the dangers lurk. Even little dangers, because they can easily blow up into big dangers. We’ve learned to remain cautious so that we can avoid those dangers before they spring up in front of us. Like a dog suddenly caught in the headlights of a speeding car, it’s too late for the dog, given that we didn’t start slowing down half a block away. This view has a lot in common with the concept of “self-programming” that I got into a few posts ago, and that Jeff Skinner and Shaun Shelly have also remarked on in different ways.

I quote my esteemed self from that post:

Proximal intentions don’t matter. By the time you are getting close to the point of action, the dye is already cast. Setting up intentions in advance is called “self-programming” by [a philosopher named…] Slors, and I think that’s a great name for it. You are indeed programming your own future, by changing contingencies, determining circumstances, setting up non-negotiable outcomes. You are programming your life, and your brain, and your environment…

As Matt says, it is really crucial to stay ahead of the game, i.e., to adjust your speed, or pick a different route, before you hit the dog, before the urge (and/or the opportunity) to use is staring you right in the face.

Come to think of it, both those strategies — total self-trust and vigilant self-monitoring — so seemingly opposite, are resolutions to the fundamental problem of delay discounting…or to put it more colorfully, the problem of being stuck in our over-the-top attraction to the IMMEDIATE FUTURE, at the expense of long-term contentment. If you’ve followed this blog, you might remember how I went on about the role of dopamine — which geysers in our nucleus accumbens when addictive “rewards” become present, possible, available. I claimed that an unfortunate side-effect of dopamine is to exaggerate the (perceived) value of immediate rewards (e.g., a few lines of coke in half an hour; a chocolate cheese cake for dessert) while “discounting” the importance of future outcomes (e.g., being broke, fat, and/or increasingly addicted).

So….isn’t that cool? These opposites — whose tension feels creative, productive, maybe even necessary — are both good answers to the same question: how do you free yourself from the fierce and unpredictable tug of the immediate future? Do you trust yourself and thereby project yourself directly into the future you really want, or do you slow down and turn up the vigilance dial by remaining painfully aware of your past?

I could try to collapse this tension by saying something like: trust yourself to be exactly as cautious as you need to be… But some tensions are more creative when left alone.

A LOT of you replied to my brief ramblings on Harm Reduction. Some of you see it as almost poisonous — a kind of quicksand making it more difficult to quit using. Others see it as a valuable perspective for helping people “where they are,” without imposing conditions or restrictions. Some of you see it as an expression of kindness, others as short-sighted or even lazy, and some note that it does more good for the society at large than for addicts trying to recover. It’s good for all of us to be aware of this diversity of opinions.

I don’t think I can help provide unity, but here are a few more impressions I got from that conference.

I mentioned in one reply, last post, how struck I was by a speaker who looked like he was about to collapse right there on the podium. A slender young man who spoke in a halting voice, sometimes unable to find his words. He talked of being a young gay man from a traditional Chinese family. He was rejected by his family and peers with such vehemence that he ended up wandering around Toronto like a stray puppy, looking for anyone he could follow home. Not surprisingly, sex was part of that equation, and, apparently not uncommonly, so was crystal meth. Clean needles and condoms were the furthest thing from his mind. Until he got sick. Now, HIV-positive and who knows what else, he stood there, quavering, clearing his throat, telling this group of strangers all about his shameful deeds. And everybody’s heart went out to him. There wasn’t one person in the room who didn’t wish they’d gotten to him first, not to put a halt to his experimentation but to help him survive it. When he told us he’d been clean for almost four years, the room erupted in waves of applause. But it didn’t seem he’d be a poster-child for HR or anything else for very much longer.

From that moment it was clear to me that harm reduction and abstinence were not opposing goals. And I was sold. I don’t think you can fully buy into harm reduction until you stare straight into the totality of harm.

Karen, a syringe program coordinator talked with me for awhile. Big heart, yes. Weird ideas? Maybe not.

“All I want to do is house them,” she said, “give them somewhere they want to go back to. You want to make it cozy for them, help them furnish it, make it their safe place.”

You’d think that might make it more comfortable for addicts to keep on using. But that wasn’t her view.

“When that happens,” she said,  “their using levels out and the risk-taking all but disappears. They stop sharing any equipment, they stick to one dealer, they tend not to use in groups, and the quantity goes down: crystal meth, Dilaudid, old-style oxycontin, you name it.”

Okay, you might wonder, but don’t you try to get them to stop? Apparently it’s hard to do both at the same time.

“If clients fail to stop using something they said they’d stop using, then I never bring it up again,” Karen said.  “You never shame people, because shame is the hardest emotion, in my opinion. Kindness — that’s what you give them. You thank them for coming in.”

Others felt that way too. One heavily tattooed man who looked like he could bench-press his Harley told me, in the mildest voice: “The client is the boss. I’ll plan whatever you want…and at any point you want to change it, we’ll change it. Because it’s their life, not my expectations, that matter.”

I never stopped wondering whether this was precisely the right approach. But I became convinced it was a lot better than nothing for seriously down-and-out users. If you met them with restrictions, rules, shame or disapproval, they would simply disappear. Disappearing was one thing they were particularly good at. That and destroying themselves.

My talk was well received. Almost everyone there wanted to understand how addiction works, and the neurobiology was a lot of what they were missing. But policy is not my thing. And all the biology I could offer seemed a pale wand to wave at the pain that surfaced in that room.

I left feeling that harm reduction was a desperate response to a desperate situation, bound to help those who needed it most.

 

P.S. Check out this recent discussion forum in the New York Times. See if you can tell the good guys from the bad guys.