Category: Connect

…by Peter Sheath (lightly edited by Marc)…

Here is a more detailed account of the community-wide treatment approach being implemented in Birmingham. Thanks very much to Peter for stepping up to the plate. Note that this post is a response to the questions and concerns raised by blog members following my last post.

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I’m pretty much overwhelmed by your positive messages and support. It’s taken some time to get to this point. Now we are about to take the quantum leap of helping people begin to deal with addiction problems within their community — as a community. The program has much in common with policies implemented in Portugal, where there have been dramatic reductions in almost everything negative associated with drugs. If it works, and many of us firmly believe it will, it will be a real game changer for the way we approach health care in general. It will help move us away from the “deficits approach” — needing an “expert” for just about every problem we encounter within our societies — to a more co-productive community-based “expert by experience” model, whereby people can take responsibility for resolving their own problems.

Jasmine makes some great points, and we have thought long and hard about almost every one of them. The only one I don’t get is her query, “how the heck could this not create a sense of stigma, othering, and sense of hierarchy?” Much of the model is already happening in a very informal way all across Birmingham.     The city is probably the most diverse city in the UK, with lots of communities where English isn’t the first language — communities that just wouldn’t dream of looking for outside help. Part of my role has been to find out what goes on in these communities, how they deal with addiction, and if there’s anything we (ROR) can do to help. Most of the time all I’ve found are very dedicated people doing it for themselves, having developed some astonishing networks involving community elders and local businesses. Far from stigmatizing addiction, these networks have served to normalize it and, in many ways, make it the responsibility of the community.

Note that the start date of our project is March 3, and the leaflet that Jasmine is referring to is intended for interested parties, professionals and commissioners. Once we launch, we intend to consult with service users to develop a pamphlet that’s both user friendly and accurate.

Most of the people we will be working with are already engaged with community resources on a daily basis. Nearly 5000 are in receipt of opiate substitute prescribed medications, which they pick up most days of the week from a community pharmacy, and around another 1000 are accessing the various needle exchanges delivered by community venues. Most people with alcohol problems presently go to either their general practitioner or a community pharmacist as a first point of contact. But most of those professionals have little or no support, supervision and/or training, so they simply refer them on to the alcohol team. That usually causes further delay in getting the necessary help — a problem that could have been resolved at first point of contact.

We have gone to great lengths to ensure that professional help, when needed, is easily accessible and readily available. Clinicians, keyworkers, and structured group activities are never more than a short bus ride away and available within community centres, libraries, etc. The ROR outlets, pharmacies, retail premises, eventually taxi drivers, and many other participants will know exactly where and at what time help is available. All sorts of on-line/telehealth support will be available as backup. We are hoping that, as the community develops and community champions come forward, professionals can begin to focus on people with complex issues and those who have become dependent on the treatment system for years. Anyway, as you can no doubt imagine, I have work to do, please watch this space for further updates.

Thank you very much, Richard, for your support. I agree with everything you’ve said, and your words resonate with my experience, both as a person who couldn’t deal with life without substances and as a person who has dedicated his life to try to make things better. I believe the answer lies just where it always has, in the community. We, the treatment industry, have in many ways created a monster: we have persuaded people that they are sick and they need professional help to get better. Just as the great Bruce Alexander, Carl Hart and Marc have been saying, addiction is what happens when people try to soothe away things like dislocation, marginalization, poverty, and dissatisfaction. Yet these come about because of the systems or communities people come from. If we create an environment where communities can begin to heal themselves and their members can take responsibility for each other, then maybe change can happen. Up until now, focusing on individuals, isolating them, and treating them as sick has not taken us where we need to go.

Some of the comments following my last post asked the same question — and it needed to be asked: How might you apply this perspective? What kind of treatment program would embody these concepts? Let’s get concrete…how would it work?

I more or less ended that post with the following proclamation (copied here, in part, from that post):

Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because…there is no line-up at the door… Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future…[while the desire knob is turned up to max.]

Or, to put it in terms of the biology, “what will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change.”

But you often need other people — either one person or a group of people — to hold those elements in place, to help make it happen. Which is why treatment must be interpersonal if it’s to have any chance of working.

So, at the end of the book, and here in today’s post, I provide an example that captures the critical importance of striking while the iron is hot — when desire is turned up high and synched (for the moment) with the vision of a future self free of addiction. It’s a radical treatment initiative that uses “other people” at the grass roots level, to hold the pieces together before the iron cools. And it’s been inspired and shaped by my friend Peter Sheath, a former addict and senior associate of a consulting group for service delivery in the U.K. Thank you, Peter, for inspiring me with your description of this exciting venture.

The city of Birmingham (the second largest in England) is investing massively in this pilot program, designed to provide help for addicts at the very moment when their desire for change is ignited. Treatment nodes are distributed across the community, through sites that are most available to addicts in their day-to-day lives. Shopkeepers, including newsagents, bakers, butchers, and pharmacists, are trained in brief interventions. Participants’ shops display an ROR (“Reach Out Recovery”) sticker on the front window, so that addicts immediately see that they are “recovery-friendly” and ready to help. People come in off the street, perhaps buying a loaf of bread at the same time, and say “I’ve had enough! I’m ready to quit!” Then the shopkeeper tells them they’ve come to the right place, takes a quick inventory, and advises them on what to do next. “Hey, reduce your drinking a bit, and then pop by and talk with me this afternoon or tomorrow.” Or, in more severe cases, “I won’t be able to work with you but I know somebody who can.” People can be referred to “peer mentors” who will show up the following day to help them with difficult issues such as detox and other medical matters. Even taxi drivers have been recruited, so that someone en route to score can throw up his hands and call it quits without that incentive getting lost in translation.

Obviously the community needs to be motivated to make this happen. But that’s a boon in itself, because it recasts the problem of addiction as everyone’s problem, not the burden of the individual alone. (Shades of Rat Park!) So the support is there, the immediacy is there, and the infrastructure is built and organized without any religious or medical axe to grind. And it’s free. The funding comes from the city, not from the addict’s already-stretched family.

I see this as a highly creative approach. Whether it will work as well as we hope remains to be seen. The project is inspired by intuitions about the mercurial nature of desire and the power it bestows on our most essential plans — an intuition that fits what we know of the neurophysiology of addiction. More generally, the project exemplifies the innovation and insight that can sprout when the disease model is retracted and a fresh perspective, free of orthodoxy and special interests, is allowed take in its place.

As promised, here’s Part 2. But note that this section (on implications for treatment) is based on eight and a half chapters you haven’t read yet. To distill some of the main points is tricky, but here goes:

Addiction is maintained by an entrenched set  of connections between the striatum — the part of the brain that generates goal-directed desire and thrust — and regions of the prefrontal cortex (e.g., the orbitofrontal cortex) that hold the goal in mind, embellish it, imbue it with value, and “remember” it as the salvation you hoped it to be. My argument about recovery is that you can’t turn off the striatum — the motivational engine. You can’t turn it off because it’s at the very center of who you are, it is the pulse and drive that moves you from one moment to the next. So, if you can’t turn off the “biology of desire”…then you have to connect it with different goals, goals that can also be consolidated by synaptic networks in the prefrontal cortex. But to do that, you need to engage yet another part of the prefrontal cortex that is critical for perspective change — the part of the brain that can make choices (the dorsolateral prefrontal cortex) — what I call “the bridge of the ship.”

Sounds simple—re-engage the bridge of the ship, and get it to take on a new set of goals, goals that will synch up with the motivational engine.

Only two problems:

Problem #1. These goals for future wellbeing can only be achieved through long-term plans, not the short-term plans for immediate relief that have been central in addiction. And these long-term plans are supported by a different set of synapses than those that supported your addictive goals. Different but overlapping! As with the webbed fingers example, goals for future wellbeing and immediate relief have become fused together in addiction — but now these two synaptic patterns need to be allowed to separate. This requires thinking and feeling differently — a shift in perspective — at least for awhile. What fires together wires together, and what fires apart wires apart. The long-term plans and goals have to establish their own distinct connection with the motivational engine, with desire.

Problem #2. The goals for achieving short-term relief are highly compelling, very much in your face, hard to disengage from, because the dopamine pump continues to activate them — rapidly! I call that “now appeal” (technically, delay discounting)– and it’s a well-known obstacle to quitting. And by the way, it completely bypasses “the bridge of the ship,” the part of the prefrontal cortex necessary for perspective change.

So how do you shift the beam of desire from highly practiced short-term goals to much less practiced long-term goals — what might be called the assembly of a future self — and then reinforce the new roadwork? First, you need to avoid killing the motivational thrust that comes from you and only you. Yet becoming a “patient” (in a disease-model-based treatment environment) is very likely to squelch that motivational thrust…. I mean, doing what you’re told is not the same thing as doing what you really want. Second, you need to act fast, strike while the iron is hot. Because the brain gets so quickly caught in the dopamine-powered pursuit of short-term relief — in now appeal — you have “catch” it when it’s looking toward something different. In other words, you have to catch it just when the “bridge of the ship” gets activated — so that desire and future wellbeing make contact. That’s when a different synaptic channel between the striatum and the prefrontal cortex can open up. Like an arc of static electricity leaping to a new target. And that channel is there, and it does light up.  At least sometimes. Like when you wake up feeling zonked, shitty, shaky, with withdrawal symptoms revving up, looking at the deterioration of your face in the mirror, and running to the toilet — and for the next half hour you want like anything to quit. You want to choose a future. Right then, you want to quit.

So there’s a condensed lead-up. Now I wish I could provide a brilliant new design for optimizing treatment for addiction — one that sits like a crown on this neuro/experiential modeling. But I can’t. I don’t know enough, and I think that job really belongs to people within the treatment world, not “science writers” like me. But here are a couple of paragraphs, from the last section of my book, showing where this kind of logic might lead us. And again, my thanks to Matt Robert and Cathy O’Connor, who helped me see things from this perspective.

 

What alternatives might stem from a developmental approach to treatment, applying the power of momentary desire to a personal time-line for quitting? Most important, there is no single strategy, organization, method, or philosophy that commands center stage. Any approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because there is no fortress wall that needs to be scaled, no line-up at the door, and no financial minefield that needs to be crossed. Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future.

Community-based groups, including SMART Recovery and progressive AA groups, can provide a kind of narrative scaffolding, a concatenation of stories about addiction and recovery, that can help addicts work on their own future “stories” — their personal narratives — addicts who are ready to move on. Group meetings are frequently inserted into institutional treatment as well, but whether they’re available when addicts really need them and can use them is entirely hit-and-miss. And while group processes can be helpful, they are certainly not always helpful, nor are they the only way forward. Treatment only requires the attention of one other human being who can hold, possibly distill, and hopefully extend the vision of a future self energized by an individual’s desire to change.

What will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change. This can be the presence of a friend who accompanies you to your first 12-step meeting, as was the case for Brian at the very point when he’d had enough. Or the attention of a therapist who really gets where you’ve been and where you want to go, as was the case for Donna at the fulcrum of her despair. It can even be the horrific embrace of a jail cell where you see your options with brutal clarity, as was true for Natalie. (To read these hair-raising accounts in full, I’m afraid you’ll have to wait for the book.) It can be a month on your uncle’s farm, a book that captures your heart when you think you’ve lost it, or the stuck window opened by meditation, romance, or antidepressant therapy when you’ve been buried in your cave for too long a time.

Quitting requires a merger, perhaps a collision, between desire and perspective­ — again, what fires together wires together­ — yet it doesn’t demand any particular brand of intervention.

Nevertheless, next week I’ll describe a radical treatment initiative that I think exemplifies a right-minded approach to recovery. And I hope that, through your comments, you might also provide some ideas for how to awaken the treatment world.

 

 

 

 

 

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Our sponsor is the brain, of course. So, before getting to Part 2, here’s an important message, also excerpted from the final chapter:

 

The term neuroplasticity has been bandied around a lot in recent years, but it’s been understood for at least a century. In Donald Hebb’s (1940s) memorable words: What fires together wires together — neurons that activate each other become more strongly connected — through adjustments (increased efficiency) in their synapses. Neuroplasticity is the brain’s natural starting point for any learning process. This includes the development of addiction. But is it also the springboard to recovery?

Neuroplasticity is strongly amplified when people are highly motivated. Which is why all learning requires some emotional charge, and entrenched habits like addiction grow from intense desire. Clearly, the desire to recapture a potent experience of pleasure or relief is the motivational on-ramp to addiction. But does desire also cultivate recovery?

In The Woman who Changed her Brain, Barbara Arrowsmith Young describes the many cognitive exercises she devised for herself, in order to overcome her very severe learning disabilities. She practiced these exercises prodigiously. As a result, she went from a high-school student who could not comprehend history, who even had a hard time understanding simple sentences, to a writer and teacher who has set up roughly 70 schools for learning-disabled children across North America. I met this remarkable woman in Australia, at a book fair, and I became convinced that her intuition, creativity, and determination to triumph over her learning disabilities were precisely the means by which addicts recover. I also learned her delightful phrase for the neuroplasticity needed to replace bad habits with good ones: What fires together wires together, and what fires apart wires apart. In other words, new mental patterns can fashion new and divergent synaptic avenues.

In 1993, Mogilner and colleagues looked at the brains of people plagued with webbed fingers. That means that some of their fingers were connected and could not operate separately – they functioned in total unison. After surgery was performed to allow the fingers to move on their own, these authors looked at changes in the (somatosensory) cortex. What they found was that clusters of neurons that had always fired together now fired partially independently.

The presurgical maps displayed shrunken and nonsomatotopic hand representations. Within weeks following surgery, cortical reorganization occurring over distances of 3-9 mm was evident, correlating with the new functional status of their separated digits.

So the brain adjusted its wiring, breaking down the coherent habit it had assumed, based on the details of repeated action patterns, and replacing it with new habits, based on novel action patterns. In fact these changes were observable just weeks after the change in action patterns took place! Might recovery work the same way?

Just in case you think the webbed-finger analogy is far fetched, you should know that it’s not an analogy. That’s exactly how neuroplasticity works, whether dealing with severe learning problems (which no doubt involve the prefrontal cortex) or reversing a physical anomaly that took hold during prenatal development (involving the sensorimotor cortex).

When people recover from strokes or concussions, the same sort of rewiring takes place in many regions of the cortex. Even language, one of the most basic human functions, can be relearned after it has been demolished by brain damage, through the synaptic rewiring of cortical regions that previously took care of other business. Thus, neuroplastic change can and does occur, in real life, with a speed and vigor we rarely imagine.

Back to addiction. People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of that plasticity. As if their fingers had become attached together, they can no longer separate their desire for wellbeing from their desire for drugs, booze, or whatever they rely on. Then, when they recover, whether in AA, NA, SMART Recovery, or standing naked on the 33rd-floor balcony of the Chicago Sheraton in February, their neuroplasticity returns. Their brains start changing again—perhaps radically. Just as in Mogilner’s study, their brains begin to grow new synaptic patterns to allow for those distinctions, to hold onto them over time, and thereby acquire new vistas of personal freedom and extended wellbeing.

The take-home message here is simple: Recovery involves a major change in thought and behavior, and such changes require ongoing neural development. Without developmental adjustments in synaptic patterns, we would stay exactly the way we are. Which raises the question: If the high-beam of desire is what drives the synaptic shaping of addiction, is it also the necessary ingredient for finding the road out?

So I got the manuscript back from my main editor (who works for the publisher), and to my horror the right margin was swarming with little purple boxes containing suggested revisions. This was only for Chapter 9, mind you. Everything else was pristine by now. Still, I really thought there would be little left to do…and I was just starting to sink into a warm pool of mindless oblivion. (yes, I know how that sounds)

Besides little phrasing issues, there was one serious omission, in her eyes: I had not identified the implications of “my model” for treatment. Duh. She had a point. Shouldn’t that have been the grand finale?

So I dragged my ass back to my computer and immediately sent cries of distress to Matt and Cathy, my two informal (but brilliant) editors, and then thought about it for awhile, and this is what I came up with. No, this is what we came up with —

(I’ll quote the relevant sections in two installments. Here’s the first:)

Part 1. What’s wrong with conventional treatment — i.e., treatment that fits the accepted definition of addiction as a disease?

The medicalization of addiction has provided certain benefits. Foremost among them has been the development of pharmaceutical agents that can diminish withdrawal symptoms and ease cravings. Even if these are temporary measures, they can make a real difference during the darkest of times. The disease model has also led Medicine and society to a more enlightened view of addiction, as a very human phenomenon with clear biological underpinnings, while encouraging humane treatment for those who suffer. But treatment approaches based on the disease model are too often ineffective. Addicts continue to suffer. Medicines that help people cope with symptoms do not ignite the desire to change or light up new pathways for life beyond addiction. And worse, rigid, cookie-cutter methods and institutional and monetary self-interests too often turn “treatment” into a dead end or a revolving door for people who seek help. The premise of this book is that medicalization and the disease model have outlived their usefulness.

To bring the drawbacks of medicalization to a point, consider my claim that addiction can only be beaten by the alignment of desire with personally derived future goals. Does medically-based treatment help with that agenda? On the contrary, such treatment is almost always institutional treatment, and institutions are famous for eroding the self-direction that addicts may have mustered to get them to the door. Typically, those seeking treatment are told to call back, unless they are ordered into treatment by the legal system, which obviously trounces self-direction from the outset. Then they are given a date to come in for an assessment. And any delay can be easily justified: “We want to make sure you’re really ready.” Finally they’re scheduled to begin treatment, weeks later. That is, if they’re lucky enough to bypass the notoriously-long waiting lists for state-sponsored care or afford the swank offerings of a private setting. They are assigned a bed. Ironically, their beds are the hallmark of their claim for help, but beds are where people sleep and where sick people lie when they can’t walk around; they are hardly platforms for initiative and empowerment. Then, if the waiting time for service delivery hasn’t completely undermined their incentive to change, the philosophy of medical care may do so. Addicts become patients, and patients do not participate in decisions about their care. Patients follow the regimens of authority figures who understand the workings of their disease far better than they do. So personal intention has no place in the cure.

If you think this depiction is too extreme, you need only listen to addicts who have been through institutional care (or read Inside Rehab by Anne Fletcher). They often feel overwhelmed by the weight of depersonalization, passivity, and submission to authority, the disinterest of staff in their personal views, and their exclusion from evaluations of how they’re doing, what they’re doing, and when they’ve had enough. At the outset they are told, “We’ll have to break you down so we can build you back up again”—a phrase commonly heard in institutional settings, according to Matt Robert, a friend, former addict, and group facilitator in both institutional and community-based programs. It’s not that such policies are borne of ill intent. It’s just that they’re wrong-headed. Disease model advocates like David Sack despair that “a large portion of addicts continue to use in the years following treatment regardless of the particular drug involved.” They view this as evidence that the disease of addiction is terribly serious and needs all the ammunition society can muster—which often translates to more money and more institutional beds. Yet the obvious conclusion is that mainstream treatment for addiction just doesn’t work. And since it is founded on the disease model, that model is likely to be flawed.

 

Note that many of these conclusions derive from the sincere and sometimes devastating stories shared by you, dear readers.

Part 2 — what’s the alternative? — coming up next post.