Category: Connect

A new act to control the prescription of narcotics (we assume they mean opioids) just went into law in Ontario on November 1. (Similar acts are not unlikely in the rest of Canada.) This act will presumably make it harder for people to forge prescriptions, use alternate names, borrow prescriptions, and so forth. One of the hallmarks of the act seems to be better enforcement of the recording of information never previously required, including the registration number for the prescriber (doctor) and an identification number for the drug itself. It’s hard to get specific, based on the wording of the act, but the upshot is that pharmaceutical opiates will be more difficult to obtain. What does that mean for those of you who treat or study addiction? What does it mean for those of you who use opiates?

Let’s start with the last question first. If users use less, if the problem really diminishes, then those who treat users will have less work to do. But if users get more desperate, or more clever, if they have to pay more, steal more, lie more, etc, then those who treat users may have more work to do. So all we need to do is figure out the consequences for users.

But it’s complicated. Like the age-0ld competition between cops and robbers, or rulers and rebels, there has been an ever-escalating stalemate between attempts to banish drugs and attempts to procure them. The dopamine-pumped addict, like the starved animal he resembles neurobiologically, has one goal and one goal only. All that dopamine crashing around in the nervous system…. When it doesn’t lead you directly to the goal, it supports the most effective, efficient, creative thinking on how to get around the obstacles and get you there regardless. Dopamine is good for thinking, planning, strategizing, and conniving. People with ADHD, and who can’t keep enough dopamine in their synapses, suffer from the dissolution of focused attention. They can’t keep their goals in mind. Dopamine-stoked addicts have the opposite problem. The goal is all they have in mind.

Also, dopamine makes you desperate, just like the starving animal. Contrary to the out-of-date view that dopamine is part of a pleasure circuit, dopamine is about doing when the goal is available and craving or striving when the goal is out of reach. That has pretty stark consequences for the law of supply and demand. When the supply of opiates is diminished (but not eradicated), the demand goes up. Way up. That’s why addicts of various stripes resort to poor quality drugs, hugely expensive drugs, and drugs mixed with all kinds of nonsense. It’s also why alcoholics on a low budget traditionally drink after-shave, cooking wine, or even rubbing alcohol (which is poison).

So picture the addict, with all that dopamine and no place to go, frothing wavelets rising higher and higher in the tank of the self. That dopamine has got to be good for something, and that something is success, regardless of the obstacles. Natural selection didn’t preserve dopamine because it helps you spit out watermelon seeds. Dopamine means business. Dopamine circuitry evolved to help achieve goals, difficult goals, despite the barriers of competition, scarcity, and natural enemies. Well, I suppose drug enforcement policy is a natural enemy for drug users.

Now if opiate drugs could be made completely unavailable, that would certainly diminish the problem of opiate addiction. But is that possible? If not, we’ll see what new tactics users adopt, with this latest plugged leak in the dopamine bucket.

In the last 24 hours, a video clip of a Texas judge beating his teenage daughter (for the crime of downloading music) has gone viral on the internet and news media. It’s a horrendous video, involving not only brutal violence but also vicious humiliation of a child by a parent. What makes the story more provocative still is that the daughter, 16 years old at the time, has cerebral palsy, the father is a judge who presides over child welfare issues, and, oh yeah, he was apparently addicted to opiates.

There’s little doubt that, as the story spins out in various directions, the issue of opiate addiction will hit the spotlight. While thousands clamour for the judge’s dismissal or worse, even his daughter, the victim of the abuse, says he needs rehabilitation instead. Could opiate addiction possibly explain this kind of behaviour? Could it excuse it?

There are drug families that change the personality in fundamental ways, as a direct result of brain damage. But it’s pretty clear what those drugs are: methamphetamine and crack are the most infamous culprits, and inhalants such as gasoline and various solvents also destroy cells up and down the nervous system. But opiates don’t damage the brain, in and of themselves, unless you OD, in which case you can lose a little, a lot, or all of your brain.

Yet some of the byproducts of opiate addiction can lead to behaviour problems so severe that the question of brain damage becomes a matter of definition. The first byproduct is craving itself. In a recent post, I compared the addict’s craving brain to that of an animal in a state of starvation. That’s not an analogy. The parallels are concrete. Drug craving laces the brain with dopamine, replacing the role of other neuromodulators. Thanks to massive gouts of dopamine in the ventral striatum, there is only one goal to pursue, and all the animal’s attention and behaviour is focused on that goal. But that doesn’t sound like the judge’s problem. Craving takes attention away from other people. The good judge was overly attentive to his daughter.

Withdrawal is another byproduct of opiate addiction. As junkies and drug counsellors know all too well, the physical discomfort of withdrawal symptoms produces a high level of irritability. Neurochemicals that have an arousing impact on brain and body (e.g., corticotropin-releasing factor, an ingredient of the stress response) are suppressed by opiates. When the opiates begin to leave the system, these neurochemicals rebound with a vengeance, yielding a state of agitation and hyperarousal. And with many common painkillers, that can happen within 6-24 hours following the last dose. So, was the judge going through withdrawal at the time of the beating? Probably not. The video clip, posted on Youtube (not fun to watch!) shows anger and methodical aggression, but there is no sign of the twitchy irritability that characterizes withdrawal.

I think the judge suffered from a more common ailment caused, not only by addiction, but by almost any kind of personal failure; and that’s shame. Shame is a powerful emotion, and it’s one of the few emotions that literally hurts. That cringing, crumpling feeling deep inside, the wish to fall through the cracks in the floor, to disappear from the world, because one’s own self is just so despicable — that hurts! Addiction to anything is shameful. It feels like, and perhaps is, a personal failure. But abusing a helpless child, over whom one holds both power and responsibility, is at least as shameful, and maybe a whole lot more. Being an addict and an abuser…well you see where I’m going. So the judge, like many violent people, was probably responding to and at the same time inducing intense feelings of shame. In himself.

Does that excuse his behaviour? Not at all. Shame doesn’t make you harm others. Shame is painful, and it elicits all kinds of defences. Violence is one of those defences, but to roll up your sleeves and indulge in it, to watch yourself doing it and not stop, is unjustifiable — especially for a justice of the peace. It’s one thing to abuse yourself: not nice, not logical, but you’re the one who suffers. It’s quite another thing to abuse someone else as a way to make yourself feel better.

In a recent reply to a reader’s comment, I waxed eloquent about whether addiction was an impulsive drive or a compulsive drive. Let’s consider the matter more closely. According to neuroscientist Trevor Robbins, impulses can be defined as urges or acts that arise from an input that you can’t inhibit. In other words, the problem is in the input stream—thoughts, perceptions, and stimuli that are just too attractive to turn off. Compulsion, says Robbins, is an urge to act that is too powerful to turn off, so you keep doing the thing again and again. Now the problem is in the output stream, and the classic case is OCD—obsessive-compulsive disorder.

Present scientific wisdom on addiction would classify it as an impulsive disorder. Because, according to neuroscientist Kent Berridge, addictive cravings are always cue-related. You don’t just crave. First, there has to be a stimulus, a cue, to make you think about the thing you want. That cue can be of any sort. It can be the runny nose of opiate withdrawal, the name of a dope connection suddenly showing up on the screen of your mind. It can be just the sight of last week’s leftovers – a few paltry grains of powder, a leftover pill, whatever. Then, suddenly, wham! you want it now. The ventral striatum, the seat of craving, is highly sensitized to drug cues through repeated exposure: based on a buildup of synaptic networks that provide a potent meaning for the drug, plus the surge of dopamine directly triggered by previous associations.

But compulsion can play a huge role in addiction as well. We feel “compelled” (not “impelled”) when we reach for the drug (or the drink or food or link to our favourite gambling site) again and again and again. Even after you’ve taken a dose of whatever it is in the last half hour, you just feel that it’s not enough, and the urge is to take more, no matter what the consequences. The consequences can be pretty severe. Coke and its cousin crack are the best examples. A coke high can last for an hour or two, but cokeheads snort more and more, sometimes minutes apart, just in case there’s not enough already inside them, and that can lead to a stroke or heart attack. With opiates, compulsive consumption can obviously lead to an OD. The source of compulsion is some kind of deep anxiety, but more on that another time.

The striatum has a component that focuses attention on the goal. That’s the ventral striatum, and it’s a key player in drug craving. But the striatum also has a motor component that generates action. The “dorsal striatum” releases actions, something like bullets from a gun. It puts the actions into effect. And there you are doing it – again! – before you’ve even thought about it. The dorsal striatum is the culprit when it comes to compulsive (repetitive) behaviour. But the close linkage between these two parts of the striatum – attention to the goal (ventral) and execution of the goal (dorsal) – is what moves us from impulse to compulsion.

That’s not good news for addicts of many stripes. But what can I say? Be careful! We have to live with the hardware in our heads, so we’d better get to know it and learn how to use it properly.

A reader recently brought up the fascinating connections between Buddhist meditation and neuroscience. There has been a lot of work in the last two decades, trying to develop a scientific foundation for meditation and also teaching science a thing or two, like how meditation changes the brain. In this post I want to suggest how meditation can reduce craving, thus potentially aiding recovery, and I want to briefly describe how this might work in the brain.

Last post, I suggested that “free will” or at least deliberate choice could be facilitated by slowing, down, relaxing, seeing the bigger perspective, and…even meditating. I was following Nico Frijda’s ideas about the importance of reflectivity in overcoming impulsive action. But how on earth do you slow down, relax, and reflect (let alone meditate) when craving is erupting throughout your consciousness. The craving for drugs (or booze, or other substances and activities) can be enormously powerful. As noted recently in a response by Mike Johnson, the dACC (dorsal anterior cingulate cortex), which is the seat of deliberate self-control, can be a leaf tossed around by a cyclone when the impulse to take drugs gets too strong.

Indeed, addicts are often caught in the cross-fire between two warring brain systems. The dACC, and its connections to the (probably left) dorsolateral prefrontal cortex, try to set up a long-range forecast, a bigger picture, a more reasoned perspective, and then use that perspective to inhibit behaviours that surely lead to failure and misery. Meanwhile, connections between the ventral striatum, which is the seat of goal-seeking, and the orbitofrontal cortex, another ventral system that anticipates the pleasure and relief of taking the drug or drinking the drink, get increasingly activated by dopamine, as the possibility, no, likelihood, no, GIVE IT TO ME NOW! gets closer and closer. The craving builds on itself in a self-reinforcing feedback loop in the ventral (lower) regions of the prefrontal cortex. While efforts to control the craving activate the dorsal (upper) regions of the prefrontal cortex, trying their best to hold the feedback in check. What’s a poor brain to do?! Or in human terms, how do you slow down enough to choose tomorrow, and the day after tomorrow, instead of the few hours’ relief promised by the drug?

Research into the neuroscience of meditation often uses practiced meditators, or else they compare people following a course of meditation against those who’ve taken some other form of instruction (the control group). These people are placed in an fMRI scanner or other brain-imaging system, and their brain activity is recorded, either while they are meditating or while they are engaged in other activities (such as looking at pictures designed to induce empathy). It’s difficult to sum up this entire branch of research in a few sentences, and results are not always consistent. But one finding from several studies (here’s an example) is that meditation causes increased activation in the dACC and/or in the (left) dorsolateral prefrontal cortex—the exact regions that support insight, reflection, and long-range perspective.

So it looks like meditation builds muscle, so to speak, in brain regions that can win against impulsive (e.g., addictive) thoughts and actions. How can addicts, recovering or not, use this information to their advantage? I’m no expert on treatment and recovery. But maybe we can think of these insight-generating brain regions as muscles, that are weakened by excessive use (trying, trying, trying not to give in) and strengthened by meditation. Then meditate whenever you can! And do it even if you’re still using. In fact, do it especially if you’re still using, or if you’ve recently stopped. Try it for 5 or 10 minutes, if that’s as long as you can last, even if you’re still thinking about getting high later in the day. But do it the next day as well. And the day after that. You can learn how in twenty minutes. Or check out this link to a talk by Jon Kabat-Zinn. As I said, I’m no expert, but meditation really helped me in the weeks and months following my last relapse. A little bit of meditation, spread over days and weeks, can gradually shift the balance between brain systems that dance to the music of craving and those that turn down the volume.

In my last post I talked about the debate between the disease model and the choice model of addiction. I argued that you need to understand a bit about the brain in order to make sense of choice in the first place, and I reviewed some of the changes in the brain brought about by addiction — changes that make it more and more difficult to choose NOT to go after the thing (drugs, booze, Facebook, whatever) that you are addicted to. But now I want to go deeper into the issue of how we make choices. This seems so important to the topic of addiction, in general, and to the immediate question: how do you tell yourself NO?

A current article in NatureNews (a science publication for the general public) reviews some recent neuroscience experiments into the nature of free will. What is free will anyway? We generally assume that we make choices out of…well out of choice. We decide, we are the decider, we are the ones who choose what we do and what we don’t do. (In which case, addicts must be real idiots!) Yet neuroscience tells a different story. There are activation patterns in the brain that foreshadow what we are about to choose, seconds before we actually decide. In a new version of a classic experiment, Bode and colleagues (2011) asked participants to lie in an extremely powerful (fMRI, 7 Tesla) brain scanner. They were told to push a button on a joystick either on the left or the right, whenever they felt like it. Meanwhile, a stream of letters went by on a screen, changing every half-second. As soon as they pressed the button, recently displayed letters appeared in a new window. Now they were asked to select the letter they saw precisely when they had DECIDED whether to press the left or right button. The results? Activity in the left “frontopolar cortex” (at the very front of the prefrontal cortex) predicted what decision they were about to make, several seconds before they were aware of making the decision!

These results suggest that the moment of choice is not free at all. It is already determined by events in the brain. The debate between free will and “determinism” has gone on for years (in fact it started way back in the 18th century, with philosopher David Hume). But the science that shows us the nature of determinism has become more and more sophisticated. Now it is hard to refute the idea that choice is a moment in a stream of biological events. It is never entirely “free”.

Maybe this should not be surprising. After all, if our brains didn’t fall into a specific pattern before choosing whether to turn right or left, whether to have a cookie or an apple, whether to buy heroin or turn on the TV, then where would the decision come from? It has to come from our brain — from our very own brain, with all its cravings and preferences — or else where would it come from? It wouldn’t be ours if it didn’t come from our brain. And brains take time to do things. So it may not be so weird to think that changes in brain activity precede the moment when we are aware of making a choice.

If you follow that argument, then the difference between deliberate choice and addictive (compulsive) choice isn’t easy to pinpoint. In which case, what should we do about our tendency to make addictive choices? Just sit back, give up responsibility, and take the consequences? No, there’s a better answer! The closest thing to free choice, says emotion theorist Nico Frijda, is to insert moments of reflection into the stream of impulses going on behind the scenes. Our brains include the machinery to reflect, as well as the machinery to act impulsively, and brain changes preceding moments of choice can call upon both. If you relax, sit back for a moment, even meditate a bit, the short-term gains of addictive behaviour start to pale next to the long-term gains of getting and staying abstinent. Yes, it’s all happening in your brain before “you” make the choice, but you can guide your brain into activation patterns that are not ruled by habit and compulsion. And the more often you do it, the easier it gets.

There may not be such a thing as pure free will. But I like to think that choices are moments in a river of brain activity that can be altered by reflection and foresight. Or as William James said, “My first act of free will shall be to believe in free will.”