Category: Connect

I recently came across a paper in Addiction Biology called “Recent updates on incubation of drug craving: a mini-review.” The studies summarized here show that drug craving increases progressively for weeks after we stop using. And by “we” I mean rats, mice, and humans, all experimental subjects in this review.

Since many of my readers are “in recovery” — and maybe I am too — this may not come as a big surprise. But rats? What’s the story here? And what does it tell us about how to help ourselves get through this difficult time?

Well, we’re all mammals and we share a lot of the same neural hardware — in particular the amygdala and the nucleus accumbens. I’ll remind you what those do in a minute, but for now let’s just call them the motivational engine of the brain. What I want to emphasize here is that, besides these similarities, humans have other problems that make rodent life look like easy street. We have this enormous cortex (linked to a hippocampus that fills it with zillions of explicit, linked memories), and so the cues that trigger craving often come from, and are magnified by, our own ruminations. That can be a real drag.

Most of the studies in this review involve rats. In a typical study, rats get themselves addicted to cocaine, meth, or heroin (with considerable help from humans), and then once they start taking it reliably, on their own, their supply is cut off. After the withdrawal period is over, they are given cues that are associated with the drug they were on. These are called “conditioned stimuli” in Pavlovian conditioning. And then the experimenters measure how much they crave the drug  (based on how much they take it, or how much they hang out in the place where it gets delivered) in the days and weeks that follow. The craving goes up, not down, as time goes on. And then finally it peaks and diminishes several weeks later.

The first thing to note is that the craving is always “cue induced.” It is literally triggered by a sight or sound — a green light or a buzzer — that previously meant “Come and get it!”

The second thing to note is that the incubation period, the period of increasing craving, is longer than we might like, but it’s not forever. Typically 10 days to a few weeks for rats. For humans, undoubtedly longer (in one study, it peaked at 60 days abstinence for alcoholics; in another, it peaked at 3 months for meth users).

It’s very important to realize that craving in the absence of cues decreases much more quickly, often beginning almost immediately after quitting.

What’s going on in the rat’s brain that makes it vulnerable to cue-induced craving? The amygdala is the main culprit, and the nucleus accumbens (ventral striatum) is its partner in crime. The amygdala registers rapid emotional significance. If something is emotionally meaningful, whether the emotion is fear, anger, desire, or whatever, the amygdala will increase its firing. This is where the cue starts the process of emotional arousal and readiness. Then the nucleus accumbens takes over (stoked as it is by a tide of dopamine, thanks to the amgydala’s output). As you know from my writing, the nucleus accumbens is the part of the brain that produces an urge go after a goal: it narrows attention to the goal, gives you that feeling of “I really want it”, and then activates behaviours…like prancing to the part of the cage where the coke gets dispensed, if you’re a rat, or picking up the phone and calling your dealer, if you’re a human.

If you’re a rodent, that’s all it takes. Craving is the emotional response to something you have learned. You’ve learned that something felt really nice, and it might be available, and because your brain is efficient and determined, you’re going to go after it. I should mention that rats on a high sugar diet show very much the same response once they’re cut off. So we’re not just talking about drugs.

But what if you’re a human? — and I assume you are if you’ve read this far. Then you’ve got a whole other set of problems. The initial cue can be the hands on the clock, telling you it’s about that time. It can be a mental image, a rumbling in your gut, the ragged touch of rising depression. It can be a baggie, an email, a neon sign, a dream. So far, you’re just a very intelligent rat. Your amygdala just sent a surge of dopamine to your nucleus accumbens — you’re alert, wanting, wishing… But you’re also thinking, and that’s where things get much worse.

You’re thinking that the day feels so empty without it. What am I going to do with my time? Thinking that there’s really nothing that can fill that gap. Thinking maybe that you deserve it, or you deserve how shitty you’re going to feel tomorrow, or both. One thought leads to another leads to another, and these thoughts fill your head. The amygdala and accumbens both connect to many many parts of the cortex, and they literally unleash these thoughts, which then trigger other related thoughts through direct synaptic connections. That’s rumination.

The problem is that the habit you’ve developed isn’t just a learning and feeling habit — it’s a thinking habit. And until you start to become accustomed to living without that thing, those habits have little to replace them.

So, it would be ideal to avoid cues, but that’s just not entirely possible, since they can come from anywhere (including your own brain). In which case, you have to work on your thinking habits until the cue-trigger starts to lose its force (this can take weeks or months for humans) and until thought patterns readjust substantially.

But how do you work on those ingrained habits of thought? There are many ways. Two come to mind immediately:

1. Shift your thinking as soon as you start to ruminate. Don’t even wait ten seconds. You can turn off cascades of thinking far more easily before they build momentum.
2. Fill your days with other attractive, compelling activities. Provide your day with contour: a beginning, middle and end, so that the rumination habits don’t have so much traction.

But there’s one more highly valued strategy, and in this you’re no different from a rat. Get connected to others when you quit. Cue-induced craving is greatly reduced by “environmental enrichment” for rats and for humans. (Remember Rat Park?) From the journal:

In 2012, Thiel et al. (2012) demonstrated that environmental enrichment reduces incubation of cocaine craving. They first trained rats to self-administer cocaine for 15 days (3 hours/day) and then either housed rats individually or exposed them to an enriched environment (group housing, toys and running wheels, etc.) during the withdrawal period. They found that environmental enrichment reduced cue-induced cocaine seeking on both withdrawal days 1 and 21.

And one more thing: Be brave.

 

Here’s a brief Q&A hosted by a website called 52 Insights. It’s quite a spiffy site, with interesting authors and speakers presenting their views on popular culture, science, politics, and so forth. My piece is about my personal history, my book, habit versus willpower, and a bit about the War on Drugs.

Here’s a longer Q&A, done as a podcast, conducted and beautifully annotated by Barry Daniel for The Middle Way Society. This is a fascinating group in the UK that takes the Buddhist concept of “the middle way” and translates it into philosophical and practical ideas for thinking about and living in our own paradoxical era. My interview is, not surprisingly, entitled Why Addiction is Not a Disease.

The founder (I think) of the Middle Way Society, Robert Ellis, reviewed my book in an essay offering several unique insights into the role of the brain in overcoming addiction. This is where philosophy, neuroscience and addiction studies come together. Ellis says many nice things about my book, but he challenges my claim that addicts lose touch with some of the most critical functions of the left frontal cortex. Namely, the capacity to see one’s life as a linear progression, a trajectory or narrative, extending from past to present to future. I think that addicts have to rekindle that capacity before they can move themselves toward a future they choose for themselves. Ellis says I pay too much homage to the left hemisphere, and it’s really the right hemisphere that goes dim when people lose themselves to addiction.

What do you think? (See my reply for what I think.) The two hemispheres of the brain are responsible for fundamentally different human capacities. Which side of the brain needs to do push-ups to help us acquire the strength to overcome addiction?

 

…by Lynn K. Thorsen…

Out of the blue I found this poem in my inbox this morning. I contacted the author, Lynn, and she gave me permission to publish it here. You will see why I had to share it with you.

………………..

Top Ten

(Reasons I Addicted Myself to Heroin)

 

Because when I was nine and we moved away and my grandmother died,

I thought I killed her because I didn’t write often enough.

Because having to move every three years and say Goodbye to everyone,

even my dog, was so unbearable

That I pretended that anyone I said goodbye to didn’t actually exist.

Because when my parents sent me away when I was Thirteen and just starting

to develop breasts,

I thought they sent me away because I was just starting to develop breasts.

Because when they sent me away I had to pretend

That they had never existed so I wouldn’t miss them.

Because my mattress couldn’t fly out of the

Window and fly me away.

Because when I found out I was pregnant at seventeen

And thought I was in someone else’s play,

I wasn’t.

Because I lost track of who I was and who I wanted to be.

Because I didn’t care about myself, or care for myself.

Because the pain I carried cut me off from

Everything, even my own childhood.

Because Penny said, “It takes away the pain.”

And it did.

I got back Saturday from a 3-week extravaganza: first the Nobel conference on Addiction, then two weeks as a visiting prof at Gustavus College, and then a week in Toronto, catching up with relatives and friends, hanging out with my daughter, and doing about one talk per day on…you know, addiction not being a disease, that sort of thing. We’ve got a lot to catch up on.

Let’s start with the conference. The Nobel Foundation (yes, the big guys, and no, I did not get a prize — they’re often awarded posthumously so I should be grateful) has been hosting this annual event at Gustavus Adolphus College. I’d never heard of it either, but it’s a high-ranking liberal arts college near Minneapolis. This year “addiction” was the topic. So I was pleased to be invited and especially glad that I’d be meeting Carl Hart.

He was easily the most dashing speaker at the conference — a tallish, slim black man with long dreads, handsome, friendly, cool, and collected. His book, High Price, is one of the most popular books on addiction of the past few years. Carl’s talk came on day 2 of the conference, and the crowd of 4,000 present (and supposedly another 10,000 online) were ready for some meat. Yesterday’s talks had generally tiptoed around what many considered the main issues.

So he gets up in front of an audience of rosy-cheeked, blonde midwesterners and proclaims that 80 – 90% of recreational drug users are not addicts and never will be. And most people who use drugs don’t need jail and they don’t need medical treatment. Even the addicts — especially the addicts — are the last people one would ever want to put in prison. Massive applause. The most important thing we can do for drug users, young or old, is to educate them. Just like with sex and driving — other activities that are potentially fun and potentially harmful — users need to know how to stay safe. The crowd likes this guy, and so do I. There’s laughter and applause. It makes sense.

He provided an example of drug education specifically targeted to this audience: when you eat cannabis it takes a long time to feel the effects. So don’t keep eating brownies until you know how strong they are! More laughter, more applause, some clearing of throats from the elders. Everyone is transfixed. Hart is deliberately opening a rift between the beliefs and sensibilities of young people who are presumably experimenting with drugs and the stodgy older generation who are starting to fidget in their seats. Fascinating to watch.

But things got a bit weird when he got onto methamphetamine. He showed some footage designed to scare people away from meth: a clip of a man writhing on the floor as though possessed by demons. He said he could not even imagine what symptoms this man was expressing — in other words, he was ridiculing the kind of “drug education” that has become status quo in the U.S. Good point.  But then he went on for a long time about meth being chemically similar to Adderall, a stimulant used for ADHD. He showed slides of two molecules that looked the same except for a methyl group and apologized for speaking over the heads of the less scientifically inclined. I thought that was a cheap trick. I wasn’t convinced that Hart knew much about methyl groups to begin with. He’s a psychologist, not a chemist. In fact, methamphetamine is not the same as Adderall, which is a mixture of dextroamphetamine and levoamphetamine. Meth is far more powerful, especially given its conventional modes of ingestion, and far more addictive. So what was the message here?

I’d read Hart’s book, cover to cover, in the month preceding the conference. What made him famous was his research program, conducted at Columbia University, showing that crack and meth addicts didn’t have to lunge for a hit of dope every time it became available, if they had other choices. He kept self-identified addicts in a residential setting for three weeks at a time, and he gave them choices between monetary (or other) rewards and various-sized hits of crack or meth. And since they didn’t get the money until they left the residence, they couldn’t go out and spend it on the street. Sure enough, meth and crack addicts often chose the money instead of the drug, especially when the money offered was at the high end of the scale and/or the dosage was at the low end. According to Hart, this demonstrated that addiction is a choice, not a disease. Addicts don’t lose their free will, as Nora Volkow might insist. They can make choices when choices are available.

I really like Hart’s argument in one respect. He is trying to show that inner-city kids who don’t have much to do except take drugs are more likely to take drugs — as a choice, not a compulsion. And I fully concur with his message about the disadvantages faced by minority members, both when it comes to choosing drugs and when it comes to the vastly disproportionate jail sentences they’re hit with — because of the built-in racial bias in laws that, for example, punish the use of crack (a “black drug”) 20 – 50 times more harshly than the use of powder cocaine (a “white drug”) despite their chemical similarity. Johann Hari gave us the same message, loud and clear. And it needs to be heard.

But I find other aspects of his message highly questionable.

First, does anyone, even Nora the Terrible, really believe that addicts cannot control their addictive impulses, even for a little while? I doubt it. That seems like a classic straw-man argument. It’s an exaggerated claim, so it’s not that hard to rebut. Second, how much crack or meth is he offering these guys? The dosage information is in the book and related papers, but if you are offering crack or meth addicts smallish doses many times a day, day after day, surely their tolerance will soon override the potential high. Mightn’t the drug offer become just a tease? Hart doesn’t seem to care about these issues. He does not use self-report to evaluate the level of the high. And he doesn’t show how the choices might change over time (within the residency period), potentially reflecting a day-by-day build-up of tolerance.

Carl Hart got the only standing ovation of any of the speakers. Hooting, whistling, on-your-feet cheering coursed around the auditorium for several minutes. Especially from the young people — the undergrads and high school students. Indeed his message was powerful, both courageous and outrageous: the middle-class, middle-of-the-road masses (young and old, expert and novice) needed to be confronted with the distortions, in fact the lies, that have been beamed at us through every conceivable media channel from the overlords of the War on Drugs.

I liked this Carl Hart. I stood up and applauded with the rest. But I wanted there to be another Carl Hart as well: one who addressed the 10 – 20%, the ones who suffer, the addicts.

When someone from the audience asked him what he would say to his kid, if the kid told him he was thinking of trying meth, Hart said he would try to educate the kid about how to stay safe, whatever drug he was taking. That’s not the answer I would have given. I would have said: smoke weed, try mushrooms, and here are some tips about doing it safely. But stay away from meth.

 

 

 

 

 

 

 

…by Matt Robert…

“If your mind is empty, it is always ready for anything; it is open to everything. In the beginner’s mind there are many possibilities; in the expert’s mind there are few.” Shunryu Suzuki

A friend of mine has a son who had to present at Show-and-Tell. He came up to his dad with a conundrum. “I don’t know what to talk about — this really cool rock I found, or about my stuttering.” He chose the latter to his parent’s surprise and his teacher’s chagrin. Jason started to talk about his stuttering to a rapt audience of 3^rd graders. A lively Q&A followed:

“Is it fun to stutter?”

“Does it hurt to stutter?”

Jason put his stuttering out there as a thing, an object that he had. Just some thing like his cool rock or a broken bone that he got treated. He put it out for the class’s examination, and it lost the stigma, emotionality and embarrassment usually associated with stuttering. He helped his audience approach the situation and the object with beginner’s mind.

In early recovery, we lose beginner’s mind when we need it more than ever. We lose it for two reasons. First, for many of us, the stigma of addiction, the shame of association with it, overcomes our ability to see freshly. We shut down because each possibility for new learning is blurred by shame.

Second, we are experts in our addiction, and in the expert’s mind there are few possibilities. We have done this so many times — relapse after relapse, rehab after rehab. We’ve tried the same thing over and over again expecting different results — in relapse and recovery. We’ve listened to the confident voices of so many counselors, judges, and group leaders laying out exactly what addiction is and how we must treat it. We are experts of the most hardened kind.

Because we can’t access beginner’s mind, for one or both of these reasons, we can’t see recovery as the learning process it is. And it is a learning process, just like our addiction was. We lose sight of options. “It’s a disease, treat it like one. Keep taking the medicine.” The problem is that the same “medicine” doesn’t work for everyone. We need to see all the options.

Try to hang on to your beginner’s mind. It’s not something we are, it’s something we can do at any time. Go to your “first” recovery meeting, not closed off in fear but open to the possibilities that are all around you. Find your way around a problem, instead of stubbornly trying to solve it. Recovery is a process, an experiment. Try what feels right for you. You can always let it go, come back to it, or incorporate it into your satchel of helpful tools.

There’s a familiar story of how many tries it took Edison before he got his light bulb to work, until he found a metal with just the right amount of resistance and the right amount of flow to get the electrons to behave in the way he was looking for. In beginner’s mind there are many possibilities. We need to be open to them so we can light our path to a new life and not give up till we get there.