Author: Marc

Let’s return to John’s driving metaphor and fit it with what we know of the brain. As per my last post, let’s look at choice as a blip, a flash of intention, that rides on the momentum of underlying habits. Skillful drivers have built up a repertoire of good habits, like alertness, sensitivity, self-monitoring, and flexibility. So, even though they can’t promise to never have an accident, they can minimize the risk.

“Driving responsibly” like “drinking responsibly” sounds like Big Brother claptrap. In fact driving well is very Zen. Today I took the car out on the winding roads at the foot of the French Pyrenees. I thought about John’s metaphor and became more aware of what I actually do when I’m driving. I took the curves gracefully, skillfully, even though the skill wasn’t something I could put my finger on. It wasn’t something I possessed. Rather, it felt like a moment-to-moment balance between assertion and surrender, focus and flexibility. It had to be that way, because I was moving fast through complex terrain, and I was thinking with my head but also with my body, my instincts, and that vast unconscious part that puts it all together, moment by moment.

This view of choice fits well with brain mechanics. Sensory input pours in from the retina to the occipital area at the very back of the brain. That’s the primary visual cortex. Then it gets passed forward toward the centre of the brain, and it becomes more holistic, more comprehensive, along the way. Stage by stage (but very quickly) it joins with other sensory information (e.g., the feeling of the wheel in my hands) as well as memories and feelings. By the time it arrives at the orbitofrontal cortex, it is a gestalt with a familiar meaning.

At the same time, motor output cascades from the centre of the cortex outward toward the periphery, going through stages in the opposite order. It starts in the dACC, or a region just north of the dACC called the supplementary motor area. That’s where plans seem to emerge. From there the output stream gets increasingly articulated, as it passes through the premotor cortex, where plans are translated into global action patterns, and finally to the motor cortex, where the actual muscle movements are orchestrated.

These streams, input and output, flow at the same time – the output stream doesn’t wait for the input stream to finish before it starts up.(If it did, we’d respond to our environment at the pace of a slug.) So a special trick is needed to coordinate these streams. The brain connects the input stream to the output stream at each level, from detail to gist, with multiple connecting links, like rungs on a  narrowing ladder. At the bottom rung, concrete sensory details connect with concrete action commands, so the visual details of a sudden curve in the road are coordinated with the movements of my hands on the wheel. The rungs continue to connect the two pathways, as they get closer to the centre of the cortex, where a meaningful visual scene connects with a meaningful motor plan: I’m driving this narrow winding road, which feels good, but a car could come around the corner at any moment so I’ll downshift to second gear and slow down. Which I do.

Intention – where “I” make a voluntary choice – is a difficult thing to locate in the brain. But our best guess is that it happens near the centre of the cortex, where orbitofrontal meaning connects with emerging plans in and around the dACC.

So choice takes up a rather small part of the whole sensory-motor process. Think of it as the top rung of the ladder, with all the other rungs stretched out below it, doing their business of integrating perception and action. Was it a choice to change gears just then? Certainly. But that choice was the cream at the top of a dark, frothing mixture of perception and action at multiple levels. And what about those links below the level of choice? They are automatic, unconscious, and they are shaped and refined through repetition, through learning. Those links are where habits get built, by way of synaptic shaping, and those habits determine a very large part of our behaviour.

Driving is a great metaphor for how we negotiate the attractions and hazards of life, which is also complex and difficult, and which also comes at us around each corner with great speed. Driving relies on something like flow, but flow depends on smoothly running habits. Being a good driver requires good habits, to give choice a chance (paraphrasing John Lennon). Being a good ex-junkie or ex-drunk also requires good habits, if you’re going to stay on track. First we try to build up those habits, then we simply do our best to make good choices, whenever the road takes an unexpected turn.

A comment by John Becker, near the bottom of the page two posts ago, gave us this automotive metaphor — for steering through a thicket of addictive possibilities and staying on the road:

“…you drive defensively, paying attention. Not too tight; not too loose. You’re not so afraid of having an accident that you’re all frozen up…not so tight you can’t take in the wider picture, but not careless either, you keep your eyes on the road. You’re not alone in the car; [you’re] responsible for your family, you want to be skillful.”

That was a therapist’s response to an (ex?) addict who wished it were possible to say “never again” and be absolutely certain.

I love it. You can’t be certain you won’t have an accident, but you can drive well — flexibly, with awareness — to minimize the chances. John used this metaphor to reflect on the nature of choice. To call addiction a “disorder of choice” merely scratches the surface, he says, and I agree, because we don’t really know what choice is. We don’t know how it works, and therefore we can’t avoid the uncertainty surrounding addictive choices, present or future.

Right now I’m in this “villa” (not such a villa) in the south of France, and it’s hot, day and night. So I’ve been spending a number of hours in this semi-meditative state, rather than sleeping, which I would prefer by 2 AM. In this state I sometimes focus on my breathing, in and out, in and out, and I discover for the umpteenth time that breathing is fascinating. When you focus on your breath, you seem to be right there, present, at the moment when each breath begins. You say: ok, I’m going to inhale now, and you do. But when you relax a bit more, or when your mind wanders, you find that the breath comes anyway. Of course it does.

What’s most interesting is the place where the choice and the automatic reflex converge. There you find that the choice to begin another breath coincides with an impulse that’s already gathering. Like froth on a wave – the wave being an underlying biological rhythm that senses the world and responds to it. The breath happens on its own even when you’re doing it intentionally. So what proportion of the “decision” to inhale is actually coming from you? Or, to put it differently, how much of that inhale was actually your decision?

I think choice is like that most of the time, maybe always. Certainly the “choice” to reach for that bottle or that phone (to call your dealer)  is only part choice. It’s also part impulse — the gathering and then discharging of an underlying urge or plan — mixed together with conscious volition. So your moment of intention rides like a little boat carried by a wave.

The trick then would be to work on shaping the wave – to become “skillful” in order to help protect you and your family from disaster.

Making good choices requires good habits — skillful habits. Driving habits, like addictive habits, are not built in like breathing habits. But that’s what permits us to work on them and improve them. Through effort and practice. Good habits allow the spark of choice to flair in the right direction, the way you want it to, the way that keeps you safe.

This little breathing exercise is a great way to study choice, from the inside — a start toward understanding it. But we can go further. In a couple of days I’ll post Part 2 –a look at what your brain is doing when you make a choice.

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

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

Here’s a quick guide:

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

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

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

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

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

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

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

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

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

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

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

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

Notice, first, that I say “resulting from” choice. Nobody choses to be addicted. But as people become increasingly hooked, they may increasingly choose to take the pill or the drink, or to gamble or purge, and that’s the thing we need to examine. What is the role of choice in the onset of an addiction? What is its role in recovery?

The voices that oppose the “choice” model often argue that addictive behaviour is nothing like free choice. It is like a compulsion. There is a feeling of need and desire, and perhaps not just a feeling but an actual need, that compels them to choose to use, each and every time. From the “disease” camp, this argument is further bolstered by our understanding (as described last post) that addiction really does change the functioning of the dopamine system. Since our organ of goal-pursuit (the NAC, or ventral striatum) is thus compromised, how could we possibly make free choices. Finally, opponents of the “choice” model argue that framing addiction as choice just invites the humiliations and accusations, both from within ourselves and from others, that become so unbearable. “If it’s a choice, then you damn well need to choose differently, and that’s your responsibility!” That usually makes things worse, not better.

The problem, I think, comes with the phrase “free choice”. Who said choice is free? I’ve covered this topic in two previous posts. In the first of these, I argued that choice comes from the brain – obviously – and it specifically springs from a contest between the striatum’s goal seeking and the role of the anterior cingulate cortex (ACC) in monitoring probable outcomes. In the second, I described how neuroscientific data places the moment of choice in a stream of brain activity, occurring seconds before we’re even aware of making a choice. But I also claimed that we can insert “reflection” into that stream and nudge it one way or the other.

With addiction, the ACC is increasingly weakened by ego fatigue, and the v. striatum responds ever more strongly to gouts of dopamine triggered by addictive cues (including thoughts and memories). So choice becomes increasingly irrational, increasingly spontaneous, and increasingly uncontrollable. Then should we still call it “choice” at all?

One of the most persuasive advocates of the choice model is Gene Heyman. For Heyman, addiction is a result of choosing what is most rewarding in the moment at the expense of long-term gains: choosing ‘‘locally’’ rather than ‘‘globally.’’ He cites studies of delay discounting that investigate these effects. Remember the marshmallow test? Same idea. Rewarding events are much more attractive if they are expected “now” rather than “later”. But this poses a problem: repeatedly choosing the immediate reward makes both immediate and long-term rewards less desirable. In terms of the immediate benefits, heroin becomes expensive, boring, and smeared with self-rebuke. It’s never as good as it was at the beginning. But the value of long-term rewards goes down as well. Once your marriage is shot, you’ve lost your job, and/or you’re deeply in debt, the future doesn’t hold much attraction at all. It becomes less and less rewarding, in fact it becomes painful to contemplate. So the immediate reward, a shot of heroin, remains the best option.

On any single occasion, says Heyman, the local choice continues to be valued above the global choice. In other words, an immediate reward—‘‘one more time,’’ as addicts often tell themselves—is always more attractive than waiting for the long-term picture to get brighter. In this way, addictive choices are like normal choices. You choose what you want based on its expected value. But, unfortunately, the expected value of things gets shifted by the self-perpetuating nature of addictive behaviour.

What’s wrong with the “choice” model? It sounds pretty rational. Just a problem of behavioural economics, as they call it. We keep choosing what feels best. And that also means that we can choose differently, providing a gateway to recovery. Once the future backs right up to the present moment, then the immediate choice, the addictive choice, loses its attraction, and we can choose to stop.

What’s wrong is that the “choice” model ignores the brain. Big mistake! The brain that houses the famous dopamine pump, and its eagerly awaiting customer, the v. striatum, is the same brain as the one we use for making choices. From a brain’s-eye view, the reason people choose the immediate reward is that dopamine highlights immediate possibilities. That’s its function, and has been throughout evolutionary time. Research shows that dopamine rises proportionally as the goal gets closer and closer at hand, driving motivation with it. Now, if that’s the case for marshmallows and other normal rewards, imagine how powerful the dopamine surge is in response to addictive substances or acts! (See recent posts and comments.) That swelling wave of dopamine, announcing the availability of a supremely attractive reward, recasts the balance between present and future appeal — more quickly and more thoroughly than anything else could. To choose future gain, over immediate reward or relief, becomes incredibly difficult when every synapse in the striatum and frontal cortex is resonating to the “neural now”. Especially once ego fatigue sets in.

So, yes, the addictive act is a choice. Each and every time. That means that there is always the possibility of saying No. Yet, saying No is incredibly difficult, and that’s a problem the “choice” camp can’t solve…

…without the help of neuroscience.

I’ve generally felt critical of the “disease” label for addiction. But having read your many comments and looked up some recent literature, I can now give it its due. In my last post, I argued that models and metaphors are not intrinsically different. A metaphor is a kind of model. And I commented that the different metaphors/models of addiction work differently for different people. So the way a model functions should be a criterion for its acceptance.

But what about the “disease” model? Psychiatrists – because they are doctors – rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem fits a label, a medical label, from borderline personality disorder to autism to depression to addiction. These conditions are described as tightly as possible, and listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases) for anyone to read.

The idea that addiction is a type of disease or disorder has a lot of support. I won’t try to summarize all the terms and concepts used to define it, but Steven Hyman does a good job (thanks to Elizabeth for the link). His argument, which reflects the view of the medical community (e.g., NIMH, NIDA, the American Medical Association), is that addiction is a brain disease. (Also see this piece in the Huffington Post.) Addiction is viewed a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Specifically, the dopamine system is altered so that only the substance of choice is capable of triggering dopamine release to the nucleus accumbens (ventral striatum), while other potential rewards do so less and less. The nucleus accumbens (NAC) is responsible for goal-directed behaviour and for the motivation to pursue goals, as I’ve described in detail in my book.

Different theories propose different variants. For some, dopamine means pleasure. If only drugs or alcohol can give you pleasure, then of course you will continue to take them. For others, dopamine means attraction. Berridge’s theory (which is the one I follow) shows that cues related to the object of addiction become “sensitized,” so they greatly increase dopamine and therefore attraction…which turns to craving when the goal is not immediately available. But pretty much all the major theories agree that dopamine metabolism is seriously altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all.

What’s wrong with this definition? Not much. It’s pretty accurate. It accounts for the neurobiology of addiction much better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It explains the incredible persistence of addiction, its proneness to relapse, and it explains why “choice” is not the answer (or even the question). That’s because choice is governed by motivation, which is governed by dopamine, and your dopamine system is “diseased.”

So, do I buy it? Not really. I do think it’s often very helpful. It truly does help alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and if I follow my own words, then a good metaphor and a good model aren’t much different. Their value depends on their usableness.

Then why don’t I buy it? Mainly because every experience that has some emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get when you’re on your way to visit Paris, or your favourite aunt, a disease. Each rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s true of Paris, Aunt Mary, and heroin. In fact, during and after each of those experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, sex, music…they don’t turn you on that much; but coke sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.

So how well does the disease model fit the phenomenon of addiction? How do we know which urges, attractions, and desires are to be labeled “disease”, and which are to be considered aspects of normal brain functioning? There would have to be a line in the sand somewhere. Not just the amount of dopamine released, not just the degree of specificity in what you find rewarding: these are continuous dimensions. They don’t lend themselves to two (qualitatively) different states: disease and non-disease.

Thus, addiction doesn’t fit a specific physiological category. But what about the functionality, the useability, of the disease model? That’s disputable. It works well for some, not at all for others. And I think that’s because addiction is an extreme form of normality, if I can say such a thing. The function of modelling addiction as a disease is limited because “disease” and “normality” are overlapping, not mutually exclusive, when it comes to the mind and the brain. Yet we sure recognize addiction as distinct from “normal” in our everyday lives. That’s the problem.

My solution will come several posts from now. Meanwhile, I hope readers will comment on other aspects of the disease model that fit, or that don’t fit, the phenomenon of addiction.