It’s been a while since my last post. I did some relaxing, hung out with my kids, but mostly I spent my time writing a long, dense article summarizing my book — an invited article for a journal. I found myself back in the ring, fighting the Disease Model of Addiction… Round 17.

Is this some imaginary nemesis? Am I some demented Batman doing battle with hidden enemies? My dear cousin, Karen, who’s given me advice on all matters of personal deportment, diplomacy, table manners, and proper toilet practices since the age of three (she even instructed me to wipe after peeing, which turned out not to be necessary for boys) …Karen tells me to put down my slingshot. Goliath is more imaginary than real, and I should try to be nice and get along with others.

And then my knowledgeable email buddy, Sally Satel, sends me an issue of the New England Journal of Medicine, published only last month, in which the disease model is centre stage once again. The title of the article is…

Neurobiologic Advances from the Brain Disease Model of Addiction

The second sentence says it all:  “In the past two decades, research has increasingly supported the view that addiction is a disease of the brain.” Nothing new there. In a nutshell…

Addiction is a chronic, relapsing brain disease, evidenced by changes in the brain, especially alterations in the striatum (the brain part that underlies goal-seeking) and in the prefrontal cortex (responsible for cognitive control). These regions become partially disconnected with ongoing drug use. (my summary)

The argument hasn’t changed in years. (For a detailed account, read my book.) But the next sentence takes a new tack: “Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…”

Indeed it does, more and more, and the appendix to the article spells out some of the criticisms leveled by writers such as Maia Szalavitz, Carl Hart, Sally Satel, Bruce Alexander, our cantankerous and relentless Stanton Peele, and yours truly. (Gabor Maté and Johann Hari will agree if you ask them.)

As you might expect, the appendix also includes a brief counter-argument posed against each of these criticism. Here I’m going to review just two of these arguments/counterarguments and tell you why I think we should keep the slingshot loaded.

“1. Most people with addiction recover without treatment, which is hard to reconcile
with the concept of addiction as a chronic disease. This reflects the fact that the
severity of addiction varies, which is clinically significant for it will determine the type
and intensity of the intervention. Individuals with a mild to moderate substance use
disorder, which corresponds to the majority of cases, might benefit from a brief
intervention or recover without treatment whereas most individuals with a severe
disorder will require specialized treatment.”

So are they saying that most people with addictions don’t have a disease, and only those with severe addictions do? But you wouldn’t say that people with mild cases of cancer, pneumonia, tuberculosis, malaria, or even diabetes don’t have the disease. You’d say they do have the disease but it’s not too bad…yet. So maybe they’re saying that most people with a mild to moderate level of the brain disease of addiction don’t need intensive treatment? That might make sense, except that it doesn’t. This majority of addicts start using more than they should for a few months or even a few years, and then most of them just stop, without treatment. (The statistics on that are indisputable, so it’s good that the disease folks are finally acknowledging it.) But that doesn’t sound like a disease at all. It sounds like a bad habit that most people recognize is unhealthy and learn how to control. Then is there a threshold at which addiction goes from an overlearned habit to a disease? If there were, it would be measurable. But no one has ever succeeded in measuring it. Few would even try.

“3. Gene alleles associated with addiction only weakly predict risk for addiction, which
is hard to reconcile with the importance of genetic vulnerabilities in the Brain Disease
Model of Addiction. This phenomenon is typical of complex medical diseases with high
heritability rates for which risk alleles predict only a very small percentage of variance in
contrast to a much greater influence of environmental factors (i.e., cirrhosis, diabetes,
asthma, cardiovascular disease). This reflects, among other things, that the risk alleles
mediate the response to the environment; in the case of addiction, the exposures to drugs and stressful environments.”

My last post covered the genetics issue in some detail (and I’ll get back to it in a later post). But here’s the crux of the issue. Yes, weak genetic predictors may be typical of many diseases with high heritability. But they’re also typical of a bunch of other stuff…like personality! Personality outcomes fall into distinct categories: extrovert, anxious-neurotic, sociable, suspicious, dependent, etc, etc. (Should we add “addict” to the list?) And all of these “types” have weak genetic predictors (though high concordance between, say, identical twins). The reason is because people become the way they become based on what happens to them in life — the environment shapes them while they shape their environment. So the whole “genetics issue” — which has been a holy cow for disease model advocates — ends up saying nothing at all about whether addiction is a disease.

I’ll end by saying that holy cows get my goat (that actually means something in American). Next post, I’m going to tell you why I think it’s so hard (though it would be nice, Karen) to actually reconcile the disease and learning models of addiction.

Hi all. I haven’t written anything since New Year’s, and I guess it’s time to crank up the blog machine. I can see that we have a lot of new readers. I want to welcome you newcomers as well as ye olde and faithful — I hope there’s something here for you and I hope you’ll join in the dialogue with comments.

I just got an email from someone confused about the genetic roots of addiction. I get questions like this all the time. It’s a big issue that nobody’s very clear on. To be honest, I’ve been somewhat confused about the heritability of addiction too. One of the things I’ve found most confusing is that the heritability estimate keeps showing up in the 40 – 60% range, for drug addiction and alcoholism. How can it be that high, when most experts agree that the idea of an “addictive personality” is just plain wrong?

Over the past month I’ve been reading an advance copy of Maia Szalavitz’s latest book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction (St. Martin’s Press, upcoming). Maia is one of today’s brightest, most insightful commentators on addiction and related issues. She’s been writing articles for the popular press (e.g., The Fix) as well as scientific publications (e.g., Nature) for years. In her new book she explains addiction as a learned style of thinking, a coping style that isn’t working, or a developmental disorder — a rigid system of behaviours and beliefs cemented together over development. Her focus is mainly on trauma — hurtful, often devastating events impacting on the lives of children/adolescents and/or their families. Yet despite (or maybe because of) this emphasis on environmental forces, her explanation of genetic factors is as smart and as accurate as they come.

The Big Three.

There are really just THREE things to keep in mind:

1. Yes, heritability can be in the 50% range for many different addictions. That means that identical twins (with the same genetic makeup) share a strong inherited tendency to become addicted. Specifically, if one twin becomes addicted, there’s a 50% probability that the other one will too, and the commonality has to come from their parents’ DNA (and possible “epigenetic” influences too). The rest of that 100% is made up of environmental factors.
2. This 50% figure is actually very typical of personality traits in general, such as the famous “Big Five” traits, like sociability or extroversion.
3. And yet the 50% figure for a genetic influence on addiction does NOT come from any single trait. There is no such thing as an addiction trait or addictive personality!!!

So how do we explain that 50%?!

Let’s say you and your brothers have big noses, or bad teeth, or muddy coloured eyes… And let’s say that this tendency comes from your shared DNA — which would not be surprising if it’s a trait you all share. Because you all carry the “big nose” gene, your chances of getting hot dates in college are diminished. You each have a strike against you.

Now let’s say that another set of brothers (or sisters) is congenitally shy, or has poor colour vision and thus poor taste in clothes. These are other genetic factors that might increase the risk of sitting home alone on Saturday night.

So we’ve got at least two radically different genetically-loaded traits that predict the same outcome. If we were doing a study on genetic factors that contribute to a diminished social life, both traits would show up as predictive. And if each one correlated 50% with its appearance in a twin brother, then it wouldn’t matter that we pool them together in our study, because genetic studies always pool individual traits and add up how much of any outcome is shared by family members (specifically,  family members living apart, since that’s the only way to isolate the contribution of genetics).

The last thing to note is that, if you were unfortunate enough to carry the colour-blindness gene and the big nose gene, then you and your sibs would have an even higher chance of a disappointing sex life, unless these traits happened to work together in a particularly charming combination (Leonard Cohen?) And even though that’s very possible, it wouldn’t matter much. Genetics is sort of a dumb science and all it cares about are averages.

So what traits predict addiction?

Several. The strongest predictors are (1) an impulsive or antisocial personality style, and (2) an anxious, overly-sensitive, perhaps OCD personality style. Note that these personality clusters are almost perfect opposites: the brash, uncaring person vs. the anxious, neurotic person. In fact, they may be based on opposite extremes of certain ingredients in the chemical recipe of personality: too much dopamine or too little serotonin for the anxious kid; too little dopamine or too much serotonin for the impulsive thrill-seeker (who needs to try harder to feel excited). Yet both these traits increase your odds of becoming an addict, and both are (partly) heritable. Which is to say they are shared between parents and children and between siblings (who carry much of the same DNA).

According to Maia Szalavitz in her new book, there’s a third heritable package that strongly predicts addiction: a combination of  reckless drive on the one hand and sensitivity to failure or loss on the other. Maia says that this disposition was her royal road to addiction, and I believe it was mine too. And by “royal road” I don’t mean a direct cause but a causal contributor — one variable among many. Like me, Maia is a developmental thinker, and she sees these genetic predictors as early conditions that can lead down many different roads, depending on environmental circumstances.

Next post I’m going to go into a lot more detail on how these very different personality styles can make one more vulnerable to addiction, and how other personality (and environmental!) factors can make one more resilient. And I’m going to remind you that these factors can interact with each other in all kinds of interesting ways.

Hello my lovelys! I’ve been thinking of you. Actually I thought of you mostly last night, New Year’s Eve, when my own addictive tendencies and my self-concept as someone who can drink alcohol safely (and socially) growled at each other for a little while.

I feel grateful that I’m no longer at the cliff edge that once defined my existence. We’re all at various distances from that scary place, some on the brink, caught by sudden vertigo when we look over the edge, others living on the flatlands, far from the escarpments that were so familiar. But we recognize each other as members of the same tribe, connected through experiences that others view as ugly, perverse, or mythical.

I feel particular empathy for those who are torn by temptation and confusion at a time when everyone around you seems to be having a good time. If there’s anything I can say to all my readers, some kind of ad-hoc post-modern blessing that would make sense to all of you no matter where you’re at, it’s this:

Accept and forgive yourself for wherever you are. You got to where you are through a sequence of events and experiences that no one else has encountered. Wherever you are and whatever you’re doing, enjoy, be safe, and see who you are now as a natural product of where you’ve been, en route to where you’re going. If sadness and loneliness are part of the picture today or tonight, take them in stride, with some humour and some optimism. If you’re with others, take stock of that magic — it doesn’t all have to come from you. This is probably not the last day of your life, but it’s an important day — the bridge between where you’ve been and where you’re going. Give yourself a warm hug whether or not you’ve got others to second the motion.

Happy New Year to all of you!

…by Matt Robert…

This will be our last post of the season. Not only is it smart and sensitive but it’s also warm hearted and optimistic. An ideal note to end on — until January. In the meantime, I wish you all an incredibly happy or at least reasonably happy holiday, however you define “holiday” and however you define “happy.”

Most people know the word “trigger” as a cue that can initiate a negative behavior. It can be a person, a place, a familiar situation—anything that may compel somebody to return to a behavior they are trying abstain from. Common triggers include seeing a familiar bar or liquor store, running into a using buddy from the old neighborhood, something that causes undue stress… These are things people spend a lot of time avoiding in early recovery and figuring out strategies to manage more effectively.

But what do we call the things that help re-engage a person in life—that give life meaning? Exercise, meditation, walking the dog, going to church—the things that help us hold on to sobriety, not threaten to wrench it away like triggers do. We don’t have a word for things people try to learn or rediscover in recovery, to fill the gap once filled by using. These things are specific activities or events, just like triggers are, and they vary from person to person. Yet there is no general, generic term for these restorative habits and activities. “When I’m tense, I visit my grandchildren. That helps me stay sober and not want to drink. That’s a real (blank) for me.” That’s a real anchor? Refuge? A lifeline? A solace? That’s a real safety? The thing that stops the trigger? The diversity of what “trigger” connotes would be mirrored by its positive counterpart, although a widely accepted term doesn’t exist.

“Trigger” is a useful term mostly because it is a salient metaphor for the particular experience of being influenced to do something reflexively that you are trying to avoid. So what are some metaphors for a scenario that aids, or protects, or bolsters one’s recovery? Does it restrain you? Does it shield you? Does it protect you? Does it free you? Does it ground you? Does it support you?

One possibility is the word “tether.” It has several shades of meaning, all related to connection, protective restraint and safety. For example, a boat tethered to the dock is safe because its mooring prevents it from being carried out into the open sea. A tether can be a lifeline followed to safety in a blinding blizzard. A tether is the air hose of a deep sea diver, connecting him to the surface, to air, to safety. A tether connects a novice to a more experienced mountain climber. A tether keeps a spacewalking astronaut from floating off into the darkness. A tether keeps a dog close to its home, so it doesn’t run off and harm itself or others.

A tether can be used by an addict to stay attached and close to sobriety, not venturing past unsafe boundaries. And with time, the tether can be lengthened more and more, until it is no longer necessary. A tether is a metaphor for a connection to safety and sobriety. “After work, I always take a run to ease the stress of the day. That’s been a real tether for me.” Having a generic term for these activities or states could facilitate productive, forward-looking dialogue. And it could reinforce the primary importance of this aspect of recovery.

“Trigger” and “tether” are words that describe the two most important states in recovery—the urge to use and the capacity to abstain. They can be natural partners in our discussions, because they highlight both the negative and the positive aspects of recovery. What to pursue and what to avoid. Such discussions can support a healthier balance and move the focus toward the positive, not just the negative—from the prohibitive to the productive—and eventually the freeing.

The world of recovery has plenty of negative terms for relapse and its causes. Wouldn’t it be helpful to have a reliable, generic term for the positive stuff we do to keep it together?

Please contribute to the blog with any preferences, suggestions or recommendations for something to fill this void and enhance our discussions of recovery.

Since well before the War on Drugs, we’ve been taught to “just say no.” Today we know the pitfalls of pure prohibition and denial. We know the value of “just saying yes” to sobriety instead. Still, especially during the period of craving that follows quitting, we do have to say No to ourselves. Perhaps many times a day.

What I’m interested in is the tone of voice we use to say it. And how we feel as a result.

I’ve written and spoken a lot about ego fatigue (ego depletion). It’s a well-studied psychological phenomenon: the loss of cognitive control that comes when we continuously try to inhibit an impulse. Ego fatigue is one form of emotional dysregulation. Other types of emotional dysregulation have been studied by psychologists and neuroscientists, and they pretty much all involve losing the capacity to inhibit impulses. Many regions of the prefrontal cortex are designed (by evolution) for inhibition. Some forms of inhibition are rapid, automatic and unconscious, some are at the borders of consciousness, and some are completely conscious. Ego fatigue may strike at several of these levels. But let’s think now about conscious inhibition: saying to yourself, “No, don’t do it!”

So there you are, craving to get high “one more time,” and saying to yourself over and over again: No, don’t do it! Then ego fatigue creeps up on you…some part of your cognitive hardware gets tired and gives up the battle. The impulse takes over. Each of the five biographical chapters in my book shows exactly how that plays out in the life of someone addicted to something. But here’s the double whammy, the Catch-22: Psychologists have shown clearly that suppression (just saying No) makes ego fatigue worse. Suppressing the impulse gives it more power. The only way to stay on top of ego fatigue is to reinterpret or reframe the situation: “that’s no fun, that’s not what I want.”

Okay, all fine in theory. But in real life, you simply can’t reframe the wish to get high every time it pops up in your brain, especially during the period of “incubation of” craving, in the weeks or months that follow quitting (see last post). You have to say No to yourself some of the time, maybe even most of the time.

But what’s the tone of that internal message? What’s the tone of the “No, don’t”? I haven’t heard much about this from other addicts or researchers, but my impression is that the tone of the internal prohibition is often one of parental authority. It’s often a tone that’s warning, disapproving, judgmental, perhaps accusing, almost menacing. “You’d better not!” it seems to say. “Or else!” it implies. It’s easy enough to dredge up images of the disaster you’re about to visit on yourself, but that might just strengthen the scolding, authoritarian voice.

So how do we feel when we receive this stern prohibition time and time again? We feel frustrated, obstructed, denied the thing we want. And what’s worse, we may feel put down, misunderstood, and unfairly punished. Don’t I deserve to get high, today of all days? No, you don’t! Be quiet!

This internal dialogue may be playing out in your head, just on the fringes of consciousness. Or maybe you are quite conscious of the sense of being denied something, the sense of being suffocated or oppressed. I know this was frequently the case for me when I ran around breaking into medical centres and stealing drugs. I felt that oppressive edict like a dark, overhanging cloud bank.

So what I would often do is rebel. I’d finally say, Fuck you, I will if I want to! And there was a palpable sense of relief, a sense of lightness, the straps of a harness being peeled off. And then I would get high for a few days. And then I would suffer.

This scenario is surely a case of ego fatigue. But it’s more than that. It’s not just a neutral signal telling you to inhibit an impulse, and then wearing thin with time and repetition. It’s also a voice that makes you feel frustrated, alone, put down, anxious, and probably angry. An ideal circumstance for going back to drugs or drink.

Our minds are full of internal voices. We are fundamentally social creatures, and our interpersonal relationships are constantly playing out, both in the real world of other people and in the private world inside our minds. When we realize this, I think we acquire the power to shift the dialogue, to make it more friendly, less hostile.

The tone of voice with which we say No to ourselves makes all the difference. It’s very possible to link the No with a Yes. To make it a message of support and hope, not just denial and obstruction. We can take on the voice of a critical parent. Or we can take on the voice of a friend, ally, loving parent, big brother or sister… Instead of saying “You’d better not…” (for which there’s a clear script inscribed on our auditory cortex), we can say, “Let’s not do this; let’s do that instead. This isn’t what we want.” Even just by making the voice say “we” instead of “you” we shift the dialogue. We make it supportive rather than punitive.

That’s one key to reframing the addictive impulse, which reduces or eliminates ego fatigue.

That’s when there’s no one there to defy.