Author: Marc

Those first puffs of pot were so rich, so sweet, so…promising. And that first hit of smack. Granted the needle stuff was a little rough, but can anything that feels this good actually be…um, bad?

One of the most universal characteristics of drug use is the chimeric quality that’s almost always present, especially the first couple of times. (And by the way, just so you know, “chimeric” is a real word: “relating to, derived from, or being a genetic chimera or its genetic material <a chimeric cat> <chimeric genes>” from Merriam-Webster.com.)

Well it should be clear that I have nothing of substance to write about tonight. But I’ll share this bit of fluff.

A few posts ago  I commended Bhagavan Das to you. I called him: “that wise / spiritual / contemplative / meditative dude with a huge beard.” This was in relation to the problem of self-control.

Well apparently he’s not so wonderful after all. In fact, self-control seems to be way down on his list of attributes. I recently learned that B.D. can be a real shit. One of my most effective double-agents had this to say:

“He can be quite magnetic, but you might be shocked by reading and viewing some clips/articles here:  http://karmageddonthemovie.com/”

If you click on this link you will find yet another mirage: a guy who came across as wise and spiritual, but who looks, on closer inspection, to be a bit of a self-serving, devious shadow puppet. Someone who is not even close to what he appears to be.

Ah well, so it goes. Perceptions are by their nature misleading, and maybe the only way you ever get to know the reality of something is to be smacked in the face repeatedly with the stupidity you showed by missing it up until then.

Happy Easter.

A few people commented on my last post that addiction was not the same as OCD. I agree: they overlap, but they’re certainly not synonymous. What I’ve been ruminating about is a related matter: the implication that substance addictions and behavioral addictions are the same. No, I don’t think they’re the same either. I called them cousins, not twins.

There are important things to say about differences in brain mechanisms and other physiological matters. I’m not going to deal with these much here, but the main point is this: Substances such as drugs and alcohol “talk to the brain in its own language,” as I say somewhere in my book. What they provide for the user is immediate, even intimate, in that they directly alter what’s going on in your synapses — the physical medium through which you experience…everything! Their effect does not need to be mediated by actions or events. They affect the brain directly. The implications are huge, but greatest among them is the certainty they provide. Without the middlemen of actions and events to pick up some of the slack, you can be pretty sure you’ll get what you paid for.

In this post I’m going to look more closely at what it is you get — what I got — by examining my own experiences. In doing so, I hope to pinpoint what I think is unique about substance addiction.

My addiction was mostly to opiates, though I also had a great fondness for cocaine at times. And though that was 31 years in the past, I managed to revisit my addiction about two years ago. I don’t often talk about this, but I don’t hide it either. In fact I wrote an essay about my partial re-addiction,  published in Toronto Life (one of the most popular life/culture/news magazines in Canada), and that essay is available for all to see on this website.  I had been through some pretty serious back surgery, and I was in a lot of pain for about 6 months. Which meant 6 months of painkillers. Which meant I got to experience the joys of QUITTING all over again.

It wasn’t nearly as bad as it was the last time. I hadn’t broken any laws and I hadn’t compromised my life. But it was…a potent reminder of what it’s like to have a substance play an unduly prominent role in one’s psychological life, and the step-down I went through with my doctor was a reminder of the ferocity of withdrawal symptoms — this time properly managed, thank goodness.

In any case, my memories remain pretty fresh.

Being a substance addict always meant the same thing to me. It meant putting a huge amount of value in a thing or things. Pills, for example. The substance was hard currency. You could save it up, you could collect it at the back of your drawer. You could sit up at night and count it. I don’t suppose you can do that with internet addiction or sex addiction, though I could be wrong. But for me, the substance, the thing itself, the currency, had enormous symbolic value — as currencies generally do. And the value was that I could cash it in for a feeling any time I wanted.

Most important, the exchange rate was pretty reliable, given a certain amount of slippage — inflation — due to tolerance. So this currency gave me instant and predictable access to a feeling, just by putting something inside my body. Unlike gambling, where you have to be lucky, or like food addiction, where what you feel is a complex blend between calories, flavour, and your distance to the nearest Seven-Eleven, drugs gave me reliable access to a warm feeling that itself was (at least partly) symbolic. A symbol of a symbol? Sounds complicated. In fact it was very simple. The warm feeling was a version of some fundamental state of calm, contentment, peace… But it was really just a version. It was a nice feeling, but not quite the real thing.

Certainly other addictive rewards are symbolic: winning at cards, beating on-line opponents, having sex with…let’s not even go there. So I don’t think that’s the main difference between substance and behavioral addictions. The main thing, for me anyway, was that I had possession of these things, these pills. That gave me total control of the cascade of symbols and feelings that I had become attached to. Substances are….there. They’re objects, in three dimensions, solid, liquid, or even gas, I suppose, if you count nitrous oxide. You can hold them in your hand and take them when you want to. (Until they run out, of course.)

And what that means, dear friends, as I’m sure most of you know, is that you don’t have to get good feelings from other people or other activities. You don’t have to get good feelings from being at one with yourself, from loving yourself. You have this direct access to good feelings — sitting in your drawer. That gives you control. And control is the one thing we simply don’t have with other people, or with life in general. In fact the opposite of control is helplessness, and I believe that helplessness is the fundamental state we spend most of our time and energy trying to get away from. Brain-altering substances are just a little more efficient than anything else — at turning our backs on our helplessness.

I think that the bottom-line value of all addictive acts is that they give us access to feelings that are not accessible without them. I think that must be true of gambling and sex and the internet and crack, speed, booze, and everything else. But behavioral addictions don’t affect your brain directly. They require you at least to DO something — which involves more work, more symbolism, more uncertainty. Substance addictions simply require you to open your mouth, your nose, or your veins.

I said I’d use the next few posts to share what I learned at a recent conference on behavioral addictions. I should emphasize that the conference, held in Budapest, was billed as the the First International Conference on Behavioral Addictions. The idea that gambling, hypersexualized behavior, eating disorders (including obesity), and internet addictions are in fact addictions is quite new, and even today there are many professionals, policy-makers, and researchers who bristle at the thought.

Think for a moment about the implications. If the medical world accepts, say, internet addiction and eating problems as addictions, requiring treatment, then insurance companies in the U.S. will go bust within weeks. Not that they don’t deserve it. If internet use is an addiction, then how do parents and teachers moderate kids’ internet use? Almost nobody would claim that internet use should be forbidden, yet, if it’s addictive, then shouldn’t it be tightly controlled? These are just a few of the problems society will face when behavioral addictions are acknowledged as addictions.

I say this as if the matter is resolved. Well, it is for me. I saw enough evidence in those two days at the conference to convince me, beyond a doubt, that behavioral addictions not only resemble substance addictions in “real life” but also arise from the same brain processes.

The most convincing parallels between substance and behavior addictions start by recognizing their common denominator: compulsion. When gambling is considered an addiction, it’s called compulsive gambling. Eating disorders including binging and bulemia are often discussed as compulsive. The same goes for sex addiction and a few other things. Then we cross the line into substances. Smokers smoke compulsively, alcoholics drink compulsively, and as for drug addiction,the National Institute on Drug Abuse defines it as characterized by “compulsive drug seeking and use.” In my last few posts, I’ve described a set of stages in the onset of addiction (and addictive acts), and the final stage is compulsion. So, if we are seeing evidence of a common denominator underlying both substance and behavioral addictions, both in people’s behavior and in their brain mechanisms, then the defense rests.

Interestingly, the most fundamental behavioral addictions are the individual actions people perform repeatedly when they suffer from OCD (obsessive-compulsive disorder). When you wash your hands or check the stove 50 – 100 times a day, that’s a behavioral addiction! So a number of speakers at the conference directly compared the behavioral and neural portrait of OCD with both/either drug and/or behavioral addictions.

Naomi Fineberg, a well-recognized researcher in this area, sees OCD as the archetypical compulsive disorder: People with OCD can’t inhibit impulses, they show low cognitive flexibility, and narrow, limited goals. She uses a button-pressing task in which the “reward” is turning off a mild electric shock. After training on the task, the reward is withdrawn. From that time on, pressing the button accomplishes exactly nothing. Yet compulsives keep on pressing the button. Ordinary people do not. Compulsives report that they keep on pressing simply because they feel the “urge” to do so. Sound familiar? Sound like addiction? She concludes that OCD is not about repeating a behavior to get a reward — nothing good is anticipated. Rather, actions are performed to avoid “punishment” — the negative consequences of not doing something. And the negative consequence may simply be the build-up of anxiety. I’d say it’s very much the same with addiction.

Dr. Fineberg also talked about her neuroscience research. OCD “patients” (I hate that term, but that’s what they call them) and stimulant (e.g., coke and meth) addicts show a host of similarities in the scanner. The ventral regions of the prefrontal cortex (such as the orbitofrontal cortex) are where emotional meaning grows and solidifies over time, and these regions show reduced connections with more dorsal areas involved in self-control. So the brain becomes less capable of exerting self-control.

Giacomo Grassi, from the University of Florence, talked about OCD and addiction as caused by “reward dysfunction” — a condition that starts out with anxiety but ends up as a behavior problem, becoming “addicted to compulsion” as he calls it. Dr. Grassi’s brain scan images showed that OCD patients have higher activation of the amygdala (the centre for emotional conditioning) and lower activation of the nucleus accumbens (or ventral striatum — the brain centre for motivated reward-seeking) — a pattern repeatedly shown in addicts as well. He also demonstrated a shift in activation from the nucleus accumbens to the dorsal striatum as compulsions set in, just as I discussed two posts ago as the final stage of addiction.

So we could say that OCD is the pure form — the grand-daddy syndrome — in which people fall into loops that are no longer rewarding, just difficult to turn off. Substance addictions and behavioral addictions are two derivatives or variants of that form. Two lines of descendants — its offspring. Substance addictions and behavioral addictions look the same, sound the same, smell the same — common sense suggests that they are, at least, very close cousins.

Hi from Hungary. I’m at a conference on behavioral addictions. Two days of talks by experts — psychologists, neuroscientists, psychiatrists, clinical researchers, etc. — who want to understand behavioral addictions. These include compulsive gambling, eating disorders, hypersexuality or sex addiction, and internet or gaming addiction.  And I am really high on the flood of information, insight, commitment and good intentions, knowledge, creativity, blah blah blah, not to mention that I happen to be in Budapest, which looks like a magical kingdom from some angles and a Communist-bloc relic from others.

I knew so little about Hungary, I actually forgot the name of my destination when checking in for my flight in Amsterdam. I was standing at one of those automatic check-in terminals, had entered my passport information, and then when the prompt asked me for the first three letters of my destination, I blanked out. I asked the guy next to me, which was kind of embarrassing as he was deep in a conversation with someone else: What’s the capital of Hungary? He thought about it for awhile and then said “Bucarest”. I typed in BUC, and then realized that’s where my wife, Isabel, was born — and she’s Romanian, not Hungarian. It finally came:

Budapest

Coming in from the airport by cab, we crossed into another dimension. Mile after mile of hulking, dilapidated rectangular buildings, looking like they were last used 70 years ago to make bomb parts for the war. There was this stale ghost of leftover Communism everywhere. Everything looked shut down, grey slabs of concrete under a grey sky. This was Budapest?

My first surprise came when the driver demanded 5,450 for the ride. What? This could be trouble. But it turned out that 5,450 whatevers translated to 20 euros. Whew.  My next surprise was how beautiful the inner city turned out to be. At some invisible line the Communist-era shabbiness rolled back to reveal a land of Oz: Enormous but gorgeous monuments to a thousand years of changing architecture — churches, castles, museums, fountains — with elaborate arches and elegant turrets, tapering to slender needles pointed at the sky. All connected by wide avenues, full of shoppers, and bridges that appeared to be held up by steel lace. History oozing out of every stone in every facade.

The third surprise was that the talks were so riveting I was hardly tempted by the marvels just outside the door. In two days I learned so much, met so many amazing people, discovered new research strategies, new devices, new recovery tools. For example, today I chatted for an hour with a man named Robert Pretlow, who spent two years — full-time — developing a cell-phone app, and a couple of decades studying child and adult eating disorders. This app (displayed on the right — so far only available for research) lets you chat with other recovering individuals, warns you about addictive triggers, reminds you about your own effective coping strategies, records your progress day by day. It’s like having a treatment centre in your pocket. Dr. Pretlow is using it to study eating disorders, but it seems that it could be applied to many other addictive problems as well. Bob agrees, but there is a lot of work to be done.

I learned about the hidden dangers in sex and gambling. This was not one of those conferences where you have to douse yourself with coffee to keep awake. I learned about the diversity of eating disorders — from binging, which looks a lot like substance addiction, according to Marc N. Potenza at Yale  — to anorexia — which looks more like over-control. A lot of talks focused on OCD, obsessive-compulsive disorder, and quite a few speakers connected the compulsive nature of OCD with that of addiction. People talked about stages in the development of addiction (not far from the stages I listed the last couple of posts), and compared them with stages in the development of OCD. One guy showed how the addictive progression of stages coverged with the OCD progression — starting out in different places but ending up almost completely overlapping.

And these people weren’t just talking about behavior. There were neuroscience data in half the talks. The striatum was the overwhelming star of the show — the ventral striatum and its role in craving, and the dorsal striatum responsible for compulsion. It appears that OCD sufferers talk about their compulsions a lot like addicts talk about their addictions. I don’t want to stop it. I know it’s bad for me, but it makes me feel better. And their brains light up in almost all the same places! In fact, their brains show changes in synaptic density (some areas getting more connected, other areas getting less connected) that look exactly like what you see in addicts, over the same time frame, as they get worse — or better.

In just two days I learned so much, met with so many experts, exchanged email addresses, got books and papers handed to me…enough to keep me busy for quite a while.

And to keep you busy! In the next few posts I’m going to try to synthesize what I’m learning about behavioral addictions — gambling, sex, food, and internet — how they develop, how they stabilize, and most of all how the same or at least overlapping brain changes underlie them all.  And here’s the clincher: I’m going to show you, as I continue to digest it myself, how similar ALL addictions are. When it comes to substance addictions versus behavioural addictions, there’s just not much difference in what the brain is doing.

So, it might seem counterintuitive, but heroin addicts, codependent partners, gaming addicts, and sex addicts are very, very much alike. In other words, you don’t have to be a heroin addict or an alcoholic to wreck your life. You can wreck it just as well by spending 18 hours a day on the internet, while the bills pile up, the unemployment cheques fizzle out (and you didn’t notice), and your wife starts packing, not only her stuff but the kids’ stuff too. You might reply: yeah, sure, but substance addiction can kill you! Behavioral addiction? That’s pretty wimpy in comparison. If you believe that, as I did until yesterday, I’ve got news for you. According to the stats, obesity (a result of food addiction) causes 4 – 5 times more “preventable deaths” in the U.S. than the number caused by alcohol.

The conference just ended. I’m going to go out and check on Budapest now — gaze at statues and absorb some culture. But stay tuned for a deeper look at the core processes underlying  behavioral and substance addictions — in other words all addictions. Coming up next.

Hi again. Last post I argued that the growth of addictive behaviour takes place at several scales. A “real-time” scale of minutes or hours, approximately, and a much slower scale that we can properly call “development” — something that takes place over months or years. And perhaps other scales as well.

I realize now, as then, that the picture I painted was not only dense and abstract but also incomplete. I fleshed out the real-time scale, but not the others.

Since most of us have been or still are “addicts,” the real-time scale is probably the most familiar and the most upsetting and frightening to contemplate. Here’s how I summarized it last post:

Attraction leading to craving, leading to pursuit, leading to…a brief period of pleasure or relief, followed by more attraction and craving. In other words, wanting leading to getting, leading finally to loss or emptiness, which leads once more to wanting.

I didn’t cover it last post, but I think there is an even faster scale of addictive cycling, which we particularly see with certain drugs (e.g., cocaine), with binge eating, and probably with gambling. For these addictions, the “reward” is not long-lasting, so the whole cycle of craving, doing, and loss can repeat itself every 10-20 minutes. This may also describe addictive drinking, when the satisfaction of the last drink rapidly fades and the urge for the next one rapidly grows.

We’ve also talked about the rapid brain changes that take place when we are in the clutches of this spiralling pattern — for example the shift from default mode activation to the rapidly rising activation of the ventral striatum (v.s. or nucleus accumbens), fueled by dopamine from the VTA (the ventral tegmental area in the midbrain), and accompanied by lots of action in the prefrontal cortex (PFC, especially orbitofrontal/ventral regions) and the amygdala (that almond-shaped repository of emotional associations).

But what about the developmental scale? That’s where the big picture of addiction gets drawn, first in broad brush strokes and then with the details more and more fleshed out. What changes over months and years, as we become addicts? Does this process really show the same sequence of states we can trace in real time? Do brain changes really follow the same pattern? The answer, I think, is yes, and this is a very important issue.

Many prominent addiction neuroscientists theorize about developmental changes in the brain. And many of them point to those changes as evidence for the argument that addiction is a disease. As you know, I don’t call addiction a disease, but it is like a disease in some ways, and the slow, insidious sequence of brain changes bring us face to face with this perplexing definitional challenge.

So here’s a rough sketch of the developmental changes in brain and mind that take place as we become addicts:

1. At the start, like most other people, we spend a lot of our time in the default mode network, daydreaming, rehearsing things we’d like to say and do, imagining our lives, past and future. In other words, our brains start out “normal,” except that addicts spend more and more time in the default mode, as focused attention gives way to fantasy. Over weeks or months, we find ourselves indulging in fantasies of getting or doing that one special thing. We find ourselves floating away more often on unbidden thoughts — “what if…?” — while we’re  supposed to be reading, writing, calculating, buying, selling, or whatever it is.

2. As time goes by, and we keep going back to that special “pastime,” we find that the drugs, drink, food, or gambling isn’t just fun anymore. It’s more than fun. It makes us feel better than we could have felt doing anything else — so it seems. Now the fantasies — the thoughts, memories, images, and stimuli related to our thing of choice — become more and more compelling. They take on unprecedented power to switch our thinking from a daydreaming mode to a highly focused mode, where sharp attention and motivational thrust join forces, and we start to crave and to make plans.

The brain change associated with this stage is called incentive sensitization. Our brains become more and more sensitized to specific cues and reminders that rapidly trigger the incentive to go, do, get, score, acquire…. I’ve written about this in detail elsewhere. In a nutshell, a whole lot of cells in the nucleus accumbens  (NAcc, or ventral striatum) are getting more and more strongly linked to the the cells in perceptual (posterior) cortex that represent coke, or sex, or booze, and many of those linkages run right through the amygdala, which records the hot flush of emotional potency that goes with them. Now those specific synapses in the NAcc, and between the NAcc and the prefrontal/orbital cortex, and between the NAcc and the amygdala, start to multiply. Those synapses, those hundreds of millions of connections, are all shouting “cocaine!” or “sex!” or “vodka!” more and more loudly as they grow fatter and stronger — by sucking up the dopamine that was designated for alternative synapses, representing other goals, other wishes, now fading in comparison.

3. The period of increased craving/planning and procuring, of increased desire and demand, may continue to grow for weeks, months and even years, before impulse turns to compulsion. It’s not that I really want to, it’s that I really have to. Now the anticipation of the “drug reward,” or “drink reward,” or whatever, is actually replaced. Now what’s driving our thinking and behaviour is the enormous anxiety of a need that has to be fulfilled. Attraction, anticipation, planning, and behaviour have already been set in motion, and now any doubts or drawbacks feel like temporary obstacles — “temporary” because they have to be overcome. It becomes paramount to complete the behavioural sequence. To leave it hanging feels like being trapped in suspended animation: nowhere else to go, nothing else to do.

The brain changes that takes place when impulsive turns to compulsive have been worked out in animal research, and powerful new models are appearing in the literature. The striatum — whose job it is to initiate behaviour — has a dorsal region and a ventral region, which you can imagine as a northern region and a southern region. The dorsal region is in charge of automatic behaviour sequences triggered by a stimulus. This is not where new learning takes place. Rather it’s where old learning gets packed into habit, and habit gets triggered by cues or stimuli, from inside our heads or from the outside world. As synapses in the dorsal striatum start to become sensitized to addictive cues, they join in a network with the nucleus accumbens/ventral striatum and the amygdala. They suck up additional dopamine — now from another little dopamine factory called the substantia nigra — a factory designed to power behaviour directly, without having to wait for the rest of the brain to come on board.

So you see? There is a direct parallel — a self-similarity — between the developmental changes that take place in the structure of these systems and the real-time progression that takes place as these systems get activated, one after another.

Kinda scary. These brain changes are real, at both scales, and the underlying structural “wiring” may never be completely reversible. But we do have the power to overcome these biological processes, along with the feelings and actions they generate. Next post, I’ll show how self-control, and the brain changes that power it, also evolve with time, changing our lives for the better.