Understanding Addiction

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for addicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

The judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

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I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

Any individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.

If you read my blog you know that I try to post smooth, polished pieces. I try to produce something coherent, even conclusive. This one’s different: a bunch of notes that I recently found in a forgotten file from five years ago. The notes pose questions that intrigue and trouble me as much now as they did back then. I don’t even remember writing this stuff. Probably much of it landed in previous posts and articles. But anyway, here are the questions. Still without clear answers.

I’ve annotated the text and filled in a few spots that would be completely incomprehensible otherwise. I’ve also added tips to more recent work and inserted several links. But the text I started with remains relevant, at least to me. Things don’t change very fast, and I think these are hard questions.

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My drug use began with psychedelics. Then came heroin. They’ve always seemed like diametrical opposites. This is where I get my intuitive feel for whether drugs are good or bad. Psychedelics open you up, heroin shuts you down. But I dropped acid roughly 300 times in my late teens and early twenties. I shot heroin about 30-40 times. Why do l assume that heroin is addictive and LSD is pure sunshine?

The one wedge nearly everyone agrees on is whether a drug is addictive or not. If only it were that simple. Is addictiveness really a feature of the drug? Or a feature of the person and the social surround (Rat Park)? When you take the addict as the unit of analysis, you place him in a cage, and then analyze his interaction with this or that drug. How stupid. How is it that scientists and doctors have become the priests of such stark distinctions?

The boiled-down argument re drugs and addiction: think about Percy Menzies [see his guest-post here] and the idea of chemical hooks (in Percy’s view, the only real cure for heroin addiction is OST, opiate substitution therapy, and he especially likes naltrexone: kill the good feeling and they’ll stop). [The idea of opiates as chemical hooks is also pitched in Dreamland, by Sam Quinones.] Then along comes Carl Hart (High Price) who says “addiction” is just a label used to badmouth drugs, and our only responsibility is to educate drug users. [In his new book, Drug Use for Grown-ups, Hart argues that all drugs, including heroin, can be taken recreationally, and  it’s repressive for governments to ban any drug for personal use by normal, sane adults.] And along comes Johann Hari (Chasing the Scream), who says that the opposite of addiction isn’t sobriety, it’s human connection. All very liberating. But what about addiction?

Addictive drugs: are they neurochemically distinct? Do addictive drugs mimic natural neuromodulation (opioids, dopamine, etc)….vs nonaddictive drugs (like LSD, psilocybin?) that effect perspective change? [But let me add this: last year I went to a neuroscience conference and learned that baby zebrafish will swim toward water laced with Vicodan, an opiate painkiller. I doubt they’d swim toward an LSD solution.] Mind-altering vs. mood-enhancing. Is that what decides? (Though SSRIs are mood-enhancing…and guess what, they’re addictive…sort of.) But behavioural addictions are just as serious, aren’t they? (Gambling addicts can destroy their lives as effectively as any crack-head) Can behaviour also be divided into mood-enhancing vs mind-altering? Probably not. Maybe there are just good and bad addictions…in life, love, and drugs. Oh, and in products. Where do we stop?

Why do we value control so much? Is control the wedge? Or is harm the crucial marker? Control vs harm and the history of antipsychotics…that increase control and kill the soul. Drugs that harm: don’t they require harm reduction? Or is it happiness, well-being, that’s key? Then why prescribe SSRIs when you could prescribe opiates for emotional pain? If you value control, then get this: drugs are a way to control our thoughts and feelings. Yet self-medication often leads to self-harm. How do we weigh the goodness of drugs when control, well-being, creativity, awareness and harm are all simultaneously changing variables?

Drugs and therapeutics…. Psilocybin vs. depression and anxiety. If that’s okay, why not prescribe opiates for those who crave them? The duplicity built into psychiatry: we want what’s best for you. Oh really?

Patches to move us from moralism to relativism:

Individual differences  — genetics are the simplest exemplar, but different life experiences matter hugely. Trauma leads to drug-use, not the reverse. Yet, the research shows that kids who never try drugs do worse than kids who do. How do we explain that?

Developmental differences  — the wrong drug at the wrong age might become the right drug at the right age.

Societal differences  — my undergrads at Nijmegen [a rural region of the Netherlands] still see addicts as a different species; in Amsterdam students don’t see it like that. Let’s send Mr Hazelden to an ayahuasca ceremony and see how/whether he evolves.

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A sort of summary:

Why would anyone put ayahuasca in the same category as heroin…isn’t there something intrinsically valuable about perspective change, for its own sake? And what’s the difference between methadone and SSRIs when it comes to allaying depression (yet one is for disgusting addicts and the other is for normal healthy people, like Aunt Mary). But I so disagree with Carl Hart when he says that when your teenage kid wants to try meth your only duty (and your only right) is to educate him/her about safety issues. Are the distinctions between good and bad drugs in the drugs themselves (as we often think reflexively) or in the relation between the drug and the user? We have to really get individual differences. And developmental differences. Binge drinking at 16, not so good…social drinking at age 28 can really help people connect. And what I learned from [my good friend and courageous colleague] Shaun Shelly: Isabel and I often reflect on his description of the unemployable/sidelined teens in Capetown smoking (not shooting) heroin…for social cohesion and a little pleasure. So, put it all together: look at the relationship between the person (of a certain age) and the drug, in the context of the social group and the society at large.

Coda: What makes drugs bad? Is there something simple and primitive like the idea of being too attracted?

Conclusion: I don’t know.

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A number of you posted very helpful comments about what you’d like to see in future posts. We’re working on it. Next, Eric Nada, a past contributor to the blog, will post a piece on psychedelic therapy for addiction. Given the above, I’m aware of possible ironies.

Hi everyone. I haven’t been writing on the blog much lately. My book was released in the UK on July 14th, and that meant shooting off articles for various publications and giving talks and interviews. So I went to London two weeks ago. It’s still there, as colourful and overwhelming as ever. Despite Englands’ majority vote to leave the European union, London is the most multiethnic city imaginable. On ever street you hear a bubbling cauldron of accents and see faces of every colour and shape. What a city!

My trip was fabulous. The first day I was interviewed by The Times, and that night I gave a talk with Johann Hari as my host and interviewer. An interesting man…complex, smart, fun, and a bit darker than expected. The next day, an interview with BBC and another with The Guardian podcast. That night I talked to nearly 400 people — the most positive audience I’ve ever had. Waves of applause and even cheers. Felt like a rock star.

But the most interesting event of my trip was meeting a man named Colin Brewer. If you google him you’ll see that he’s a wild child in British psychiatry circles. Most recently he was villainized by the media for providing supportive assessments for people seeking assisted suicide in a Swiss clinic. The trouble was that they didn’t have terminal diseases, and that’s a no-no. Was this man a monster? He’d gotten in touch with me by email and came to one of my talks. When he showed up at the foot of the stage, I recognized his face from the internet, and he certainly looked…unusual.

That night at my hotel I googled him more thoroughly and found that the people he’d helped obtain assisted suicide were actually in big trouble. One was 90 years old and in severe, untreatable pain. Another was in his seventies, going blind, another had motor neuron disease, and yet another had Alzheimer’s. It turned out that Colin was motivated by empathy and a firm belief in people’s right to die with dignity. He was no monster.

So I accepted his invitation to come for a visit and arrived at his home a few days later. He lives in a beautiful house in the heart of London. He showed me around the antique-laden interior with evident pride, swelling a bit when I complimented the taste and beauty of his home. And then, equipped with home-made elderberry cordials, we sat and talked.

Colin’s trouble started when he used his own instincts and methods to treat addicts, beginning in the 80s. He prescribed methadone, as did other doctors — no problem. But he would also provide a couple of months’ supply of methadone to people who travelled a great deal and could not renew their prescription daily or weekly. He also prescribed heroin for those who needed it (while this was still legal in Britain) as well as generous supplies of benzos and other drugs for those withdrawing from opiates or alcohol. He even supplied do-it-yourself detox kits to people who could not afford residential care. Another well-intentioned though dissident policy. The press branded his practice a drug supermarket and he was struck off the medical register in 2006.

Colin was indeed a renegade who made up his own rules for dealing with addicts. In fact, like Percy Menzies, who wrote a guest post for this blog several months ago, Colin enthusiastically prescribed naltrexone for opiate addicts as well as disulfiram (Antabuse) for alcoholics. He firmly believed in giving addicts a time-out, a substance-free period for resetting their circuitry — and he brought their families into the act, so that they could help encourage their addicted loved one to stick with the program until they were in safer waters. Far from someone who took his patients’ plights too lightly, he seems to have functioned as a deeply concerned caregiver, who wanted above all to give addicts the freedom to transform their own lives.

We wasted no time discussing whether addiction was a disease or not. We both saw the classic disease model as a dead-end. Rather, we talked about the power of placebos, the extent to which addiction includes placebo-like effects — namely the belief that taking something has particular benefits, when the belief creates the benefits. Colin introduced me to a study showing that even physical withdrawal symptoms can follow sudden termination of a placebo believed to be an addictive drug. Fascinating!

But the most important idea I left with was Colin’s belief that overcoming addiction is like learning a second language: reframing, retraining, and thus rewiring synaptic networks. I guess I already knew that, but here’s the new punchline. The best way to learn a second language is through total immersion: avoiding going back to your native tongue for some period of time. The reason my Dutch is still so shitty is because I speak English most of the time. That’s sometimes called “controlled use” in addiction parlance.

I’ll end with a quote from an article written by Colin and a colleague. It makes it pretty clear why total abstinence — at least for a time — is so very helpful.

Relapse-prevention is an educational process. Learning to abstain from alcohol or opiates after years of dependence involves selectively suppressing old, maladaptive habits of thought and behaviour and establishing new, adaptive ones. This process resembles foreign language learning…. ‘Immersion’, the most effective foreign language teaching method, discourages students from using their first language…requiring them to use the foreign language instead, however inexpertly.

Colin Brewer & Emmanuel Streel. Substance Abuse, 2003, 24(3) 157-173.

My blogging days may be winding down. But if they do, as they do, I want to put more energy into methods for helping beat addiction than ideas for explaining it. It’s critical to understand addiction in depth, and I still believe that linking neuroscience with lived experience provides a potent frame of reference. But lately I’ve been moving on, thinking almost exclusively about treatment. Is there a connection from brain parts to mind parts to effective methods for helping people? Let’s see.

I started this blog with an emphasis on addiction neuroscience. I can sum up most of that brain stuff in a few simple conclusions, but I’m going to add some points of clarification:

-even though brains change with addiction, addiction is not a brain disease, as often claimed. The brain changes with any and all learning, and the more emotional and repetitive the learning events, the greater and more enduring the resulting brain changes.

-habits are inscribed in synaptic networks (networks of connections among neurons). Those networks become the hardware for processing new information: “What fires together wires together.” Thus, novelty gets sidelined by habitual patterns of thought, feeling, and behaviour. That’s the case with love, politics, religion, and yes, addiction.

-the “narrowing” of synaptic networks is mirrored by a narrowing of the social world. Friends, family, finances, legal circumstances all become more limited, more “narrow,” for the person who finds fewer neural avenues for pursuing rewards. You’ve heard that life imitates art? It’s also the case that social change imitates brain change. (See my review article here.)

-the “narrowing” metaphor suggests that the connections between different brain parts become more entrenched, less open to change. But that doesn’t mean that diverse neural regions become fused in some way. The brain retains its functional components (e.g., frontal regions underlying conscious attention versus limbic structures in charge of automatic behaviour) and those components are designed to compete.

So now what? With all we know about the science and psychology of addiction, how do we put it all together? How do we help?

The neuropsychology of addiction is important! It exposes us to many critical concepts, like the biological embedding of habit formation. Yet we don’t generally treat addiction, either in ourselves or others, by altering the brain. At least not directly. We don’t perform lobotomies or lobectomies, nor is it common to use deep-brain stimulation or transcranial magnetic stimulation to help people recover. No, when it’s time to turn from thinking to helping, we turn to talk, often in the form of psychotherapy.

Talk is social behaviour. So the goal is to free up addicted people by expanding their social world, especially the social world they carry around in their minds — the way they talk to themselves, the way they interpret messages from others. At that point the neuropsychology of addiction takes a back seat, as an aid to our clinical intuitions and our capacity to listen. Once again, lived experience, both that of the client and of the therapist, becomes the needed partner for our scientific theories.

Now if both the brain and the social world “shrink” in tandem, then we should be able to “grow” the brain (the realm of synaptic possibilities) by “growing” social-psychological flexibility. How can this be achieved?

(There is one method of acting on the brain directly, bypassing all that messy talk stuff. We can give the addicted person drugs that directly affect their neurophysiology and/or how they think and feel. Antidepressants and antianxiety drugs to target underlying mood states, methadone or naltrexone to nudge drug-soaked synapses out of their ruts. But in my view, psychotherapy — if it works — goes deeper, induces changes that last longer, and provides a sense of well-being that no drug can mimic.)

I find Internal Family Systems (IFS) therapy to be the most effective form of talk therapy available. You’ve heard me rave about it over the last few posts. I’ll end today by pointing out that IFS brings to the table a fundamental experience that most addicts find exhaustingly familiar. For them (and of course I include myself) the internal social world, the voices in our heads, are most conspicuous because they are at war with each other. The internal critic tells you that your wishes and goals are reprehensible. But the childish wishes don’t go away. In fact, they get stronger, fueled by defiance against the internal critic and desperation to meet needs that are hunted down and locked away.

By recognizing this internal duality, this multiplicity of conflicting part-selves, IFS brings empathy and clinical intuition to bear on what neuroscientists already know but never think about. Brains are composed of components that are designed (by evolution) to compete with each other. Frontal inhibition (lateral prefrontal cortex) versus learned habits (striatum), future oriented action tendencies (dorsal cortical circuits) versus preoccupation with threats (ventral cortex and amygdala). These tendencies are supposed to compete. That’s what gives humans their incredible capacity for choice and intelligent action.

How did we psychologists forget that when going about devising treatment strategies?

So, here’s the breath of fresh air provided by IFS. Conventional methods of treating addiction involve training people to “just say No.” That doesn’t work. Mounds of disappointing outcome stats make that clear. Why doesn’t it work? Because it ignores the lived experience of people in addiction and it ignores the way brains actually work. In contrast, IFS trains people to listen to the voices or “parts” that occupy their minds and accept them, welcome them, soothe them, without trying to shut them down. In that sense, it respects the idea that the mind — as well as the brain — is multiple, and it is composed of competing functions.

But that’s enough for today. In my next post I want to be very explicit about the IFS alternative to “Just say No.”