Category: Connect

I am finally finished the tapering period, finished getting off the oxycodone I was on pre- and post-surgery. It took about four weeks to go from 100 mg/day to zero. Nice and gradual, and I suffered nothing worse than a runny nose, some diarrhea, some insomnia, and a few twitches. Oh, and that sense of impending loss, depression, and despair. Did I mention that? The old circuits carrying that old message, because that’s what old circuits do.

So there I was, flickering into my “addict self,” as people like to call it, and thinking, I like this stuff and I’m not eager to stop…

I don’t remember who gave me this line — one of you, I’m sure: Quitting drugs is like going to the funeral of your best friend. Funny how it still feels like that. That’s what I anticipated. Not as intense as in the old days. But qualitatively pretty much the same.

What I wasn’t anticipating, what I’d forgotten about, was the relief I’m feeling now. An unexpected flush of freedom, breathing in lungfuls of fresh air. And feeling strong again. I feel centered, and focused, and strong. I feel like me again. It’s been awhile.

But…freedom from what? That is the big question, don’t you think? Freedom from the sense of impending loss, the sort of cowering that goes with ingesting something you imagine is enhancing your sense of okayness, knowing it’s not going to last, and putting off the inevitable. Freedom from the compulsion, the greedy hording (mentally, at any rate) of the crumbs of wellbeing that I was still getting from these pills — even on a medically supervised, perfectly legal, moral, and even necessary detox regime. I was still getting the crumbs. And the freedom I feel now is from the anxiety — pure and simple: anxiety — about losing those crumbs.

My last post addressed how it might be possible to make the future seem as good or better than the present, by adjusting the subjective value, the sense of value, of the immediate reward (drugs, booze, whatever) versus the long-term reward (that list of seeming abstractions) and/or changing their timing. And then you guys asked, and I asked myself, how exactly do you do that? How do you do it for yourself (if you’re the addict) and how do you do it for someone else (if you’re the helper, sponsor, therapist, partner)? If we’re not in some artificial experimental setting, and it’s not just a matter of changing the numerals on a computer screen (e.g., from 10 to 45 euros in the “next week” column), how do you get the future to feel like it’s worth it?! Worth whatever you have to go through to “just say NO.”

And here, ladies and gentlemen, is the answer. At least one answer.

Remind yourself or your addicted friend, lover, client or patient about this sense of relief! This feeling of being a whole person. Of being strong. Make it palpable. Get it back on the radar. Bring it to mind (hint: that’s the first half of the word “mindfulness”). This is what it feels like to finally be free of this shit! Remember? Do you get it? There is peace here.

Certainly  there are twinges of wistfulness. Yes, some kind of magical sheen, winking on and off like an old neon sign, has gone missing. Craving still bunches up in your throat like a reflex, a need to swallow — or  cough. But the place you land in, after these dust devils have passed…that place feels like home.

Now, as to the details, how exactly to do that, I’m going to turn the floor over to someone in the treatment world. First up is my friend (through this blog) and long-time contributor (to this blog), Matt. And if anyone else would like to help us out here — anyone, but especially those of you in the treatment community — please do: get in touch about writing a guest post. Soon! I think we could all use some concrete ideas about manipulating awareness, about expanding awareness beyond the upcoming delivery of today’s lollipop, about shifting your focus…away from the siren call of the moment and back to the main voyage.

Hello! I recently heard a talk about something called intertemporal choice, which is a fancy label for delay discounting, which is a fancy label for people’s tendency to value immediate rewards over long-term gains, even though the latter are objectively more valuable. Here’s a simple description from the first few lines of a scientific article:

Humans and animals prefer immediate over delayed rewards (delay discounting). This preference for smaller-but-sooner [SS] over larger-but-later [LL] rewards shows substantial interindividual variability in healthy subjects. Moreover, a strong bias towards immediate reinforcement characterizes many psychiatric conditions such as addiction and attention-deficit hyperactivity disorder.

—Peters and Buchel, Trends in Cognitive Sciences, May 2011, Vol. 15, No. 5

So addicts go after smaller-but-sooner (SS) rewards more than larger-but-later (LL) rewards…more than “normal” people do. You probably knew that, especially if you are or were one. And I’ve posted about it and talked about it ad nauseum.

One interesting question: were we already like that and that’s why we became addicts? This SS/DD overdrive is related to other personality traits, like, oh, impulsivity. Or does being an addict gradually wear away our cognitive controls, reflective skills, etc? Until there’s nothing holding us back from I want it now! I think both are true, in different proportions for different people. I’ve seen some pretty well controlled people fall into addiction, and they weren’t so well controlled after a year or two.

In this talk, a colleague named Bernd Figner (I know, it sounds like Burnt Finger — how else do you think I remember it?) talked about an experiment using transcranial magnetic stimulation (TMS).  Basically, you put an electromagnet right on the person’s scalp, over the part of the brain you’re interested in, and turn it on. And the effect is that that part of the brain becomes discombobulated. The magnetic field causes it to become disorganized. Temporarily.  So he put his TMS device over the top-side (dorsolateral) part of the prefrontal cortex. And when he did that, people’s tendency to go for the SS reward increased significantly. Especially when he did it on the left side of the head: the left hemisphere does a lot of our thinking for us. Cool. Cognitive control helps us keep those SS rewards at bay while we work toward the LL rewards, like having a life, a wife, a bank account, etc. And the finding might pull for explanation #2: that addiction itself (which depletes cognitive-control on the spot) increases delay discounting. A vicious circle if ever there was one.

Another interesting thing: look at the graph: the effect disappears 30 minutes after the TMS application. In other words, your brain can go back to normal within 30 minutes of whatever it was that interrupted self-control. Which might include drug cues, thinking about drugs or booze, craving, driving toward the liquor store or your dealer’s house… Turn around and drive home, and you should have your brain back within half an hour.

Then Dr. Figner reported on experiments in which they adjust two parameters: The first is the value of the SS and LL rewards. They often use money with adult subjects, so all they have to do is increase the amount you receive after waiting, or reduce the amount you receive in the short term. The second is the time interval. If you can increase the waiting time for either the SS or LL rewards, people’s choices will change also. So some researchers look for the break-point for their subjects. Let’s say you offer me 10 euros today vs. 20 next week. I’ll take the 10 today, thank you. But you increase it to 45 euros next week, and I’m willing to wait. Or if the immediate reward gets less immediate, and I have to wait for the SS payoff for a few hours, then I’m more likely to wait for the bigger payoff next week. But a month? Maybe not.

So by adjusting the value and the timing, you can find the point at which any person will switch from choosing the sooner payoff to choosing the later payoff. Now if you’re an addict, or you’re working with addicts, think about whether this might help. Make the long-term benefits more valuable. Not only will your wife give you back a key to the house, but she will make you your favourite dinner on Tuesday evening, if you don’t get loaded tonight. Or make it sooner. She’ll do that for you tomorrow. Or delay the “immediate” reward. You can do this with self-programming (see recent posts). Get rid of all the booze in the house, so you have to walk four blocks to get some.

See my point? An important strategy for overcoming addiction might be to fiddle with these parameters: how much, how high, when’s it coming? Versus how good will it be, how long do I have to wait? Fiddle with them until the value of the future matches and exceeds the value of getting high today. It’s like saying: Everyone has their price. But instead you’re saying: Everyone has a point at which sanity returns.

My recovery is going well. The pain is nearly gone, so all I have to do right now, besides a fair bit of physio, is get off the damn painkillers.

The post-op pain was bad for about two weeks, so, given the tolerance I’d already built up before the surgery, my dose of oxycodone was about 100 mg per day, spiced up with a side of morphine while I was still in the hospital. There wasn’t much follow-up care. Okay, I got a call from the ward doctor about a week after the operation to make sure I wasn’t paralyzed from the neck down, and I’ll see the surgeon for a check-up in another month. The health-care system here is a bit spotty when it comes to individualized care. My family doc couldn’t even remember what was wrong with me, five days after I left the hospital. It was a herniated disk, right? Um, no, wrong. It was a stenosis, which means extra bone growth impinging on the spinal cord, and the solution was to take out the trash and then fuse three verterbrae. A pretty hefty operation. So, not having a clue as to the specifics, he simply asked how much pain medication (oxycodone) I needed and gave it to me.

But now comes the delicate matter of getting off the oxys — delicate because I lived (and came close to dying a few times) for these very drugs (or their cousins) a mere 33 years ago. So where am I at now? Should I have shaken my head, with a manly chuckle, and Just Said No? A lot of ex-addicts find this decision more agonizing than the pain. Check out some of the comments to my last two posts. They ask themselves: Is the pain relief worth the chance of going back to that terrible place?

Last week my post highlighted the glories of self-programming — both as a principle and as a concrete solution to an existential problem. I still think it’s a big part of the answer. But, as some of you cautioned me, the dividers in a pillbox are not exactly bullet proof. So I sometimes found myself taking a couple of Thursday’s supply on Wednesday, and compensating by borrowing from Saturday to Friday, and so forth. Why? Because I still like the feeling. Because the line between pain relief and the soothing calmness provided by opiates is impossible (at least for me) to pinpoint. In fact it’s not a line at all. It’s a space, a zone. And my self-control is good…but it’s not perfect.

So I took self-programming a step further. My agreement with my doctor about a weekly reduction (20 mg per week — about the fastest you can go and still avoid withdrawal symptoms) was already signed and sealed. (And by the way, that plan came from me, not him.) But for the day-to-day, I handed my neatly organized pillbox to Isabel and said, please give me the daily amount, as indicated, and put the rest away somewhere. I cleverly set up a system in which I have no control, and I did it as the ultimate expression of self-control.

Suggestion: if you don’t have a partner handy, use a friend, or maybe just ask your pharmacist, if it’s someone you know and trust. If you were creative enough to be a successful addict, then this is not going to be so difficult.

But why? Why should this attraction, this conflict, come back and haunt me now — so many  years later? The answer, of course, is to be found in the brain. When I teach about addiction, whether to my university classes or on lecture tours, I repeatedly pound in the critical fact that physical addiction and psychological addiction are two different animals. And yet psychological addiction is obviously physical, in the sense that it stems from changes in bodily structures — namely, synapses — the connections between neurons. Synapses in the amygdala, the striatum (nucleus accumbens), and the cortex blossom in new places or just get stronger — more easily passing electrochemical energy from one set of neurons to another — as we become increasingly drawn to a drug (e.g., oxycodone, crack, booze), an activity (e.g., gambling, football, playing the guitar), or a person. So what happens to synapses that are left “unused” for 20 or 30 years? There are two answers to that question.

1. They are not left unused. You know those dreams you wake up from in a sweat, all those years after giving up smack or Andrea or whatever/whoever it was? Or the images in your mind when you read that article about the scourge of methamphetamine use in Kansas? You just gave those synapses a very thorough workout. And that’s what helps them grow stronger.

OR

2. Just as with PTSD, there are synapses that “contain information” that is just too emotionally loaded to ever disappear completely. Strong emotion builds strong synapses. By sending floods of dopamine, norepinephrine and other neuromodulators to brain regions at the crossroads of emotion and imagery, the initial experience (especially when repeated) provides a sort of super-fertilizer for synapse growth. Like the patch of weeds that sprang out of that spot where you accidentally spilled fertilizer last season, those synapses may be essentially indestructible.

There are other variants to these answers. But you get the general idea. Development is not a two-way street. You can’t ever go in reverse. Which is why “recovery” is not about deleting addictive impulses or images. It’s about saying “No.” And saying it often enough. And then building new synaptic pathways from that point onward — and maybe connecting those up to other pathways that went dormant for a while — pathways that are also supercharged by emotions, but, in this case, emotions about nurturing yourself and others, loving and forgiving yourself (and others), and keeping yourself out of harm’s way. That’s how you change the meaning of the addictive impulse, you change its context, you change the value that getting some has for you. But as with other developmental landmarks, you can’t just erase it.

You know, there’s this little device invented to help organize people’s pill popping. It’s a plastic oblong container divided into seven units, one labelled for each day of the week. A certain number of each kind of pill goes in each compartment, according to a preordained plan, of course. It looks like this. At least it does in the Netherlands, where we go Mondag, Diensdag, Woensdag, and so forth.

All I need right now is painkillers, i.e., opiates (which I like) and muscle relaxants, i.e., benzos (which I hate). My neck still hurts about three times more since the surgery than before. It’s a Christian country, the Netherlands, so maybe they perform surgery in order to maximize pain now, in order to minimize the bill you’re going to be presented with when you die. I think that’s called penance. But probably it’s not that complicated. Bodies don’t like being sliced and diced and they register their dissatisfaction in the clearest possible terms.

So painkillers it is. And what’s to prevent me from taking an extra one or two today, and ending up a couple shy later in the week? The answer is self-programming. And that’s what the little box helps me to do.

I wrote a post on self-programming a few months ago. Here it is. The reason I bring it back up now is because I think it’s such a brilliant idea. Our brains are built in such a way that we are highly attracted to immediate rewards — pleasures, relief of various sorts, winning an argument at the expense of someone else’s self-esteem, or at the expense of the guilt you’re going to feel when you think about what a shitty, selfish thing that was to say. In general, present wants, needs, urges thoroughly trump wants and needs that can’t be cashed in till later. But the kicker is that we think we’re in the driver’s seat. We think our present actions are actually generated by the conscious intentions that preceded them. Psychological and neuroscientific research is pretty clear: they’re not. They’re mostly generated by habit, context (including cues), and biased thinking. So we keep up this mythology about deliberate intentions while coming in for a landing based on factors beyond our control. This common human dilemma is nowhere as clearly demonstrated as in addiction.

The solution: self-programming. The prefrontal cortex and it’s good buddy, the anterior cingulate, are beautifully designed for self-programming. That’s why these brain parts evolved over the last few hundred million years. So that we don’t just act on impulse; we create plans in advance that will filter, constrain, and otherwise improve our behaviour so that it isn’t just driven by impulse. Long-range planning works pretty well. Short-range planning is usually a sham, a rationale, for what you’re in the process of doing anyway.

So here’s this dandy little device that not only facilitates long-rage planning but actually helps us learn it — a critical skill for those prone to addiction. Simply a box containing compartments that tell you what you may do (take) and what you may not do (take) based on long-range reasoning. I love it! And do you remember the post in which I reported on research showing that regions of the anterior cingulate cortex increase in grey matter volume (synaptic density — probably a good thing in these regions, especially since it got eroded during all those years of using) after you quit? In fact, GM volume rises in a pretty straight line over months of abstinence, crossing the baseline estimate at about 9-10 months. Here’s the source article.  The authors conclude “that recovery involves distinct neurobiological processes rather than being a reversal of disease-related changes. Specifically, the results suggest that regions critical to behavioral control may be important to prolonged, successful, abstinence.” I’d be willing to bet that the regions showing increased grey matter volume are where the neural basis of self-programming is strengthened — through practice!

Of course, for many of us ex-addicts, many of those compartments, maybe all of those compartments, contain a big fat zero. (I mean for people on a full-abstinence program). But it’s not really a zero, because you fill up the compartments with other stuff. Is Friday night going to be a difficult time, being at a party with a glass of iced tea in your hand? Well then you fill that compartment with two hours of your currently favorite mini-series, or a visit to a dear friend, or a chapter from a book you love. And you leave early to get your dose. It’s your reward, decided on in advance. So you don’t have to think about what you will or won’t do on that particular evening. It’s already programmed. You programmed it three weeks ago when you got the invitation. And now you’re free to enjoy or at least endure the party. You have a nicely evolved cortex and you’ve learned to use it well. Keep learning.

Here are a couple of Buddhistic-type figures smiling down on my new self-programming aid. They recognize that good planning is the route to nirvana.

Hi all. The reason you haven’t heard from me for a few weeks is because I finally had that surgery I’ve been waiting for. Cervical spine surgery, bone growing where it’s not supposed to, I’ll spare you the details.

But what I’ll tell you about is my revisiting the land of addiction. This happened to me a little over three years ago too. Then it was lumbar spine surgery. Jeesh. I hope they’ve covered the whole thing by now. At that time, I published a piece about getting into, then out of, opiates, in a popular magazine called Toronto Life.

Here’s the sequel.

The story line is pretty straightforward: pain — painkillers — surgery — more pain — more painkillers — struggle with self because opiates still feel like opiates to me: and do I or don’t I need them for one / two / three more weeks? — and then quitting. I’ve gotten very good at quitting. But haven’t we all?

Here are a few lines I wrote the other day when I was still pretty spacey and feeling the pseudomagical draw of the pills:

The old cravings come shooting up through cracks in the sidewalk like weeds growing too quickly via time-lapse photography, pulling you, your attention, your focus, the thing that you want to be moving toward, that picture frame waiting for its picture, the pull, the pull that hasn’t really been absent all morning, you just forgot to remember it for a few minutes, that pull toward….toward what? Toward nothing. That’s the irony, the stupidity of it. Especially on this dose, enough to soften the pain quite nicely, but you’d think there wouldn’t be enough rope to hang myself. I mean, would there? With the tolerance I’ve built up in the last few weeks, I’d have to take a lot more than the prescribed amount — and I have cheated some, scoping out the territory — to….to….get to….where was it I wanted to get to again? In which case, I wouldn’t have enough left to override the pain for a couple more days, until it was time for the refill. But it would be worth it because everything is worth getting that feeling again, now, this afternoon. You know: that feeling that…that you both can’t forget about and can’t think about. That, once you’ve got it in you, you have to keep telling yourself is special and different, even though the fact that you have to keep reminding yourself implies that maybe it’s not so special. And after a few days of this stuff, let’s face it, it’s not different at all. It’s boring.

These are the strange meanderings of an ex-addict touring the past in the present. What’s valuable about it is that I can see, with vivid clarity, that the addictive urge is a pull toward nothing. Just the same tired replay of an illusion I know so well. It feels now like it did then, but with the addition of perspective, a life, a whole different set of habits of thought and feeling, a meditative warmth that allows me to exist wherever I am. And all that really puts a different slant on things. But there’s still the urge, there’s still enough of a memory of something beyond just okay. There’s still this synaptic freeway, this massive roll-out of holiday traffic, lining up, frantically checking the time, in order to get to a playland that’s been closed for years. And then realizing that it was already closed when I used to go there,  regularly, way back then, because even then, the brief fizzle of fun was like some sprinkler they forgot to disconnect at the entrance. There just wasn’t anything to do once you got through the gates.

Whether you want to call addiction a disease, a brain aneurism, a satanic possession, or whatever, the way things feel to me now, the same as before and yet so different, is the bedrock experiential proof that it’s a developmental process. Addiction and recovery that is. I’ve actually ceased seeing any value in talking about them as separate processes. It’s all development. Because, as with everything else that develops, you lay down habits — synaptic configurations — that don’t ever go away completely. Yet they change with time, the nature of  “the reward” changes with time and so does the way you deal with it. The configuration continues to transform itself. As the Muppets so sagely captured it: That’s good enough for me.

I’m okay now. The cravings came, they’re still there sometimes, other times not. I’ll be off the drugs in another couple of weeks, after some pretty conscientious tapering. (Thanks, Doc) And the pain is going down day by day. I can sit. I can type. The sun is shining. There’s a lot to do.