Brain, Mind, Body and the Disease of Addiction
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What if someone uses amphetamines daily and really doesn't want to give them up. Are they addicted? What if they later learn they have ADHD and they've just been self-medicating? What if they don't have ADHD but the drug just improves their life? What if their name happens to be Paul Erdős?
If someone suffers depression from opiate withdrawal, we call them an addict. If someone suffers depression from going through a breakup, it's just par for the course. And yet both scenarios are withdrawal from a pleasurable stimulus. Why is one acceptable and the other not?
Addiction is by definition not something that is indulged in voluntarily by carefully weighing the consequences. I recommend you familiarize yourself with the Jellinek Curve, which accurately describes the guilt and shame that results from addiction.
> What if the only adverse consequence is a slight decrease in life expectancy?
Addiction itself not only has much worse consequences than that, but you're omitting the fact that addiction is present for a reason. Addiction is self-medication of excessive pain, and that excessive pain has deep, significant adverse effects. There is a reason that addiction is often comorbid with family dysfunction; addiction is a response to pain, not just a cause of pain. "Curing" an addiction involves reducing this pain to remove the need for self-medication.
> The line we draw here seems rooted in personal values, not an objective standard. We need to recognize that subjectivity when we discuss addiction.
The line is very clear. If you compulsively use, in a way that harms you, to relieve inner pain, it's addiction. Treating addiction as a "subjective" thing just ignores the pain-dimension which drives people to addiction in the first place, to run away from their pain.
Society's focus should be on becoming more nurturing and cohesive, which'll hopefully result in fewer people being in so much pain that they'll destroy their lives and relationships just to feel remotely human.
Well if you're going through excessive pain, self-medication sounds like a pretty reasonable response. What are you going to do, just suffer it? Therapy is nice but it doesn't solve everything.
Would it be better if you took the "self" out of the equation and were supervised by a professional?
> If you compulsively use, in a way that harms you, to relieve inner pain, it's addiction.
So this requires all 3 parts though, right? If you compulsively use to relieve inner pain but without harm, that's okay, right? How much harm is allowed before it's addiction?
No, it's a survival mechanism. It only reduces the pain superficially and temporarily. It's like giving an adrenaline shot to Atlas instead of getting the Globe off his back.
>So this requires all 3 parts though, right? If you compulsively use to relieve inner pain but without harm, that's okay, right? How much harm is allowed before it's addiction?
It's all motivation. Addictions are a way to deal with deep-seated and excessive shame, guilt, fears, hopelessness, despair, and loneliness. If that's why you take a drug, you're only hurting yourself by not seeking help for the aforementioned problems. If you're taking a drug just for fun, that's fine.
Note that many addicts will lie to themselves and pretend the latter applies to them.
What if these emotional issues are caused by a chemical imbalance that the drug alleviates?
These deep emotional issues are not random brain malfunctions, but often caused by childhood trauma, or other forms of trauma. Addiction is a pathological response to pathology.
If, on the other hand, the drug alleviates the emotional issues by distracting from or reducing the pain, that's pretty much the definition of addiction.
The real question is why not assume it's all of the things & approach accordingly? Most of my breakthroughs in addiction were the result of things I'd learned on my own & not through therapy. Yes, some of those things were suggested to me by therapists, but I did the work.
IMO, the biggest key to recovery (from addiction & anything else) is the patient becoming an active participant, rather than being someone who needs to be treated by others.
Has this link been established? I haven't got the impression that these things have such a causative link. People can be perfectly normal but have addictive tendencies where they can't touch things like alcohol or gambling, and then some people may be fairly miserable but not get addicted to things.
Addictiveness always seemed like its own trait, and the claim that people who get addicted to things must be miserable better have some solid evidence behind it. Really not a fan of the whole trend of trying to tell people they have "deep seated problems".
Then I came out of denial about being sexually traumatized numerous times by someone close to as a kid in March. The changes I've undergone since have been dramatic as hell & I became a completely different person within a week. I started learning to: speak my fears, say what's on my mind, abandon seeking the approval of others, let go of my anxieties, allow myself to feel my feelings, identify emotions I hadn't felt before or at least not since I was a kid, and more.
I now think we need to tell people the most thorough approach to dealing with addiction starts with assuming there's a deep seated problem until another cause has been proven because that mindset helps break through any denial the addict may not be aware of. I was certain my experiences hadn't traumatized me & it was only after I developed the habit of questioning everything I thought about myself that I challenged the assumption it wasn't traumatic.
The problem I foresee is people taking a less-than-compassionate approach or not educating the addict on the reasons for THE ADDICT to adopt that line of thinking. Once an addict is willing to admit they have a problem & to work on it, then we can ask the questions of how thorough they want to be with their recovery & whether or not they're willing to take a scientific approach for the sake of being thorough.
Addictions are often associated with substances or activities that are pleasant. It is not at all surprising that people who are in pain want to engage with pleasant substances or activities. So it is, again, not surprising, that some of those people may get addicted.
Yet, many people don't. Many people successfully "self-medicate" with such substances in the worst of times and don't become hopelessly addicted to them, easily dropping them once the aggravating factor goes away, and sometimes the substance even helps. And then there are people on the other side, where their life is completely normal and can instantly go off the rails if they have even one beer. People for whom addiction isn't a solution for a problem, but the cause.
Here's a reframing of my argument. I think:
- two sources of addiction that are the most difficult to identify are undiagnosed/unknown physical causes and undiagnosed/unknown psychological causes.
- belief impacts the brain's ability to recognize or ignore patterns
- medical professionals usually better able to diagnose/discover physical causes than patients because they've received a lot of training & have access to good tools for examining the patients
- medical professionals need to practice assuming (ie. TEMPORARILY choosing to believe) something's physically wrong with the patient (especially since addictions has physical effects on the brain!) in order to reduce the incidents where a patient's issues are easily dismissed as psychosomatic
- mental health professionals lack good tools for diagnosing/discovering mental issues & can't directly inspect a patient's psyche
- patients can help mental health professionals diagnose/discover mental issues, as well as confirm the absence of any, by assuming (again...temporarily & only during the time when with the professional) they do have deep seated issues & they simply aren't aware of them
Once someone's willing to explore their own psyche with curiosity and if they're willing to share w/the professional whatever comes to mind, they can start making a list of things in their past that seem questionable, including the things they normally wouldn't consider.
If there's anything I'd like to convince people of, it's the benefits of learning how to temporarily challenge one's own standard patterns of thought, ie. having an open mind.
Many soldiers, while deployed to Vietnam, ended up addicted to cocaine. Yet when they returned home, the vast majority kicked the habit. Why? War is about a billion times more stressful than being home. They needed a coping mechanism, and they found one, albeit an unhealthy one. Removal of the environmental stressor removed the need for a drug addiction.
http://www.npr.org/sections/health-shots/2015/01/05/37189491...
In addition, addiction is often the result of sheer psychological immaturity: www.substance.com/most-people-with-addiction-simply-grow-out-of-it-why-is-this-widely-denied/13017/
Certainly, there are genetic factors that play into addiction. It is a complex phenomenon. But to say that someone developed an addiction because they have addictive traits is far too reductive.
This doesn't seem a deep seated problem with the person, but a problem with their environment, like you said. That seems very different from what concinds is talking about.
War is also a bad example in general because it tends to rearrange priorities. Can we even say that they were addicted? If I was in a war, I'd probably do a lot of unhealthy things, too, because a war is far more unhealthy than most of them. This doesn't really imply I would be addicted.
War is traumatizing. I think self-medicating in the face of trauma is a natural response when other resources aren't available & it's not possible to escape the source of trauma. It's a survival mechanism that's no longer needed when the trauma's removed, or as you said, the person's no longer in the traumatic environment. While the drugs allow for survival, though, I don't think they prevent the sufferer from being traumatized. The drugs numb the pain, but not the effects, so PTSD could've still occurred, which can essentially bring the environment (and sometimes addiction) back home.
I'm not certain "addicted" is accurate to describe we the soldiers who kicked the drugs because addiction has physical changes in the brain that come along with it.
The rat park experiment is a good read: http://www.stuartmcmillen.com/comics_en/rat-park/
There are 4 aspects to dependence.
1) Tolerance
2) Pre-occupation
3) Craving
4) Continuing when you know it's harmful
Here you'd have people who'd continue the activity beyond the slight decrease in life expectancy because, as you quote, there's an element of compulsivity.
All addiction is harmful misuse. Not all harmful misuse is addiction.
I think that's kind of what the article's looking to address is we need to broaden the definition of addiction.
I don't think what he's saying is meant to be applicable to people who suffer from chronic pain from irreparable/incurable afflictions & so are physically dependent on drugs to alleviate their pain.
I do think there's harm in prescribing drugs to alleviate chronic pain in sufferers whose pain was triggered by something long since treated & now persists as a learned pattern in their mind. Treating that condition with drugs instead of mental techniques to unlearn the pattern is like putting Neosporin on an open wound that won't heal shut without stitches.
The subjective "high" caused by a drug is determined by how fast the concentration of dopamine increases¹ in the brain. Each individual drug has a distinct mechanism of action, so they all increase dopamine concentration at different rates. The high is also linked to the route of administration of the drug; the fastest routes are intravenous administration and inhalation, followed by intranasal administration.
Prescription stimulants are designed¹ to modulate neuronal circuits in a healthy manner. Recreational drugs do the opposite. They aim for a massive release of dopamine in the brain's mesolimbic reward system. All drugs that can lead to addiction have this effect.
High concentrations of dopamine results in neuroadaptation² in those circuits. Their receptors are down-regulated so as to better tolerate the drug. Less receptors for the same concentration of neurotransmitter translates to a diminished response. This is why the first use of the drug provides the strongest stimulation. It also explains why addicts may continuously escalate the dose; they're attempting to get that same level of stimulation again.
Neuroadaptation is also associated with withdrawal effects. After down-regulation occurs, the new amount of receptors is appropriate for higher concentrations of the neurotransmitter. After the drug wears off, concentrations are back to physiologic levels which are no longer adequate. The resulting neurotransmission deficiency results in withdrawal effects. The flow of information within the affected circuits has become dependent on the higher neurotransmitter levels³ caused by the drug.
>How bad do the consequences have to be before a behavior becomes pathological?
In the development of addiction, a dramatic change in behavior can be observed: addicts gradually shift from impulsive use of the drug for pleasure and reward to compulsive use in order to avoid the adverse effects associated with withdrawal.
These impulsive-compulsive disorders are proposed¹ as the common neurobiological substrate of many disorders, not just addiction. They're also linked to OCD, gambling, obesity and others.
¹ Stahl's Essential Psychopharmacology. Chapter 12 and 14. http://imgur.com/a/LcgkT
Chemicals are chemicals, and have exactly the same effect (at equivalent dosages, etc.) whether they are produced by a large pharmaceutical company, or a bunch of guys in rural Afghanistan. The heroin one buys on the street is exactly the same chemical with exactly the same effect as the heroin that might be given to you in a hospital. Generally, street adulterants are simply there to dilute the product, and have no real pharmacological effect. It's also perfectly possible to abuse medication directly - oxycodone or morphine pills, for example, and they do not suddenly behave differently because they were not prescribed by a doctor.
If someone doesn't get food or water and is deprived of sleep for a few days they will develop the symptoms of depression.
Humans need food, water, sleep, and social connections to thrive. When one of those is temporarily thwarted, mental and physical pain is a signal to take action. It's not always pleasant, but it will keep you alive and your genes in the game. This is unavoidable and often useful pain.
Recreational opiate use on the other hand is an extremely dangerous short circuit of the brains pleasure centers that very often results in physical dependance, legal problems, and death.
Part of maturing is understanding that you don't always have to mask pain and chase pleasure. It's ok and even healthy to feel like shit sometimes.
So much of these debates seem like there's a confusion of causes and symptoms. Childhood trauma is as predictive of addiction in adulthood as obesity is of heart disease. Loneliess and personal trauma are just enormously corrosive to a person's mental well-being, but it seems like the mental health frame rarely attempts to deal with problems like that.
I think viewing mental health as similar to physical health is useful (since, in mental as in physical health, lack of symptoms does not indicate good health). It's that we have no clue how to bring people from low psychological health to solid psychological health.
For physical health, you need a good diet, exercise, and sleep. What do you need for mental health? Meditation? Even then, doctors have never told patients to "meditate more", whereas they do tell obese patients to eat less and exercise more. I know meditation isn't effective at solving pathologies, but it's telling that we as a culture have no clue what causes and promotes pathology in the first place.
I've been able to dramatically reduce my daily anxiety without medication in a matter of minutes. I'm finding the model directly implies things we already know, such as why first impressions are important & how to overcome bad ones, as well as aspects of how bad first impressions are related to trauma in some ways. Using the model, I came up with a technique to drastically improve the rigid action in my left pinky for 30 mins to the point that it moved almost as smoothly as my right pinky. 10 years of playing piano and/or sax when growing up didn't help it at all, but 2-3 mins of a simple exercise practically cured the issue.
I'm currently looking for experts to help me flesh out what I believe to be a new approach to mental health that's more effective & can more easily be specifically tuned for individual problems. What I need are category/type theorists to help w/the mathematical model, neuroscientists for the brain stuff, and anyone else willing to explore/play with the ideas. I could also use help figuring out a way to develop an open source science experiment that anyone can participate in & that produces scientifically legit data.
[0]: https://www.selfleadership.org/outline-of-the-Internal-famil...
Would you be willing to call me at 206-432-7671? I'm not great w/email right now, but if you'd rather that, it's crawford.comeaux@gmail.com.
For reference, he's the NPR article on the SG's report on addiction[0]. All the Surgeon General is trying to do it to shift addiction from an issue of personal blame that's widespread in the culture ("he's just an alcoholic!") and make people view it as a complex pathology that we need to address. The SG also proposes school programs to teach about substance misuse, and stress-management, as stress obviously contributes to addiction. What's unreasonable about any of this? The article in OP seems impossibly nitpicky.
[0]: http://www.npr.org/sections/health-shots/2016/11/17/50240240...
And he doesn't even demonstrate that we even feel a "need" to do this to feel compassion. That's why it feels like a non-sequitur. The article is more quip than demonstration.
By "need" I just meant that it was a matter of course that the surgeon general said it.
But as we know (or at least currently believe), the separation of disorders into "hardware" (non-moral/impersonal) and "software" (moral/personal) is ultimately an illusion: The material substrate for our personality is precisely our neurobiology.
For example, ΔFosB overexpression in the Nucleus Accumbens following repeated reward stimulus is "the most significant biomolecular mechanism in addiction since its viral or genetic overexpression (through chronic addictive drug use) in D1-type medium spiny neurons in the nucleus accumbens is necessary and sufficient for many of the neural adaptations and behavioral effects (e.g., expression-dependent increases in self-administration and reward sensitization) seen in drug addiction" (https://en.wikipedia.org/wiki/FOSB#Role_in_addiction)
If we reach a point where we also find sufficiently convincing neural correlates for the more "high-level" aspects of addictive psychology and personality, wouldn't that eventually lead to us treating the whole complex in non-moral terms?
My feeling is that we intuitively choose the conceptual structure that we feel is most functional, given our state of knowledge. Morality is just another model for predicting and interacting with the behaviour in question, albeit less formal and more heuristic-based.
That once addiction has set in, it is every bit as much a disease that requires external intervention and treatment to correct the imbalance as the other conditions.
The author further argues that people make this reduction because they think it prevents addicts from being blamed for their addiction, and that doesn't make sense because when you talk about what is going on in someone's brain, you are talking about most of what you consider to be the person, including that person's personality, beliefs, thoughts, feelings, etc.
So, it's not an attempt to blame anyone. It's an argument that the mechanisms people use to deflect blame don't make sense.
In other words, people who blame addicts for their addiction have no reason to stop blaming them if addiction is reduced to a neurological pathology, and people who don't blame addicts have no reason to start blaming them if addiction is reduced to a neurological pathology. The neurological pathology thing doesn't make a difference.
Is diabetes really that straightforward? Diabetes and heart disease are linked to obesity which is linked to diet and exercise. Most people who are pre-diabetic or hypertensive can reverse their condition through lifestyle changes, yet most fail to do so.
And I would disagree that addiction lacks a physiological component in its later stages. Withdrawals are absolutely a physiological phenomenon and a big reason why people continue to use.
A broken leg isn't a disease, it's an injury. You treat the injury - avoid the situations which lead to it - and things are fine.
Moralizing is destructive, but so is saying "now it's not your fault that you went skiing without knowing how."
I think the best way of looking at lots of mental health issues is through the lens of _injury_, not illness.
More on this: https://markpneyer.wordpress.com/2015/06/01/broken-leg-disor...
> Now, I agree that addicts should be treated with love and compassion instead of judgment and punishment. But what does it say about us if the only way we can muster compassion and love for those among us with substance abuse problems is by suggesting that they are solely bystanders unjustly afflicted by mechanisms in their brains?
This is a recurring problem that I think is only going to get worse once we get more knowledgeable about many things. Genetics, mental processes, ethics.
I believe it's tightly coupled to the idea of total free will, and as long as that idea is the dominant philosophy of a society, it cannot have compassion for these people as it perceives them as acting freely. This leads to the just world hypothesis. We feel compassionate about injustice; negative outcomes coming from free will are, by definition, not unjust. Among those whose desire to have compassion is great enough, they have to say that the people in question are dealing with a physical problem, as physical causes are the only things that are perceived as capable of encroaching on total free will.
In reality, there is no problem. A person may have a mental model that leads them to addiction. That mental model, most likely, makes sense to them and in their circumstance. Note that mental problems are not fully logical - we're not solving the framing problem. Genetics and environment are pieces here. Given this model, they choose addiction, because in their model, it makes sense. It turns out (we think, md224 has some interesting comments on that part of the equation) that their model is somewhat faulty, and now in addition to having a faulty model and knowing that it's faulty somewhere, they have the expected effects of physical addiction to deal with. Just reading this paragraph shouldn't lead anyone to believe that it will be straightforward for them to suddenly develop a perfect mental model to deal with the addiction from this situation, even if such a thing is possible. The person has made a choice, but it doesn't really matter that they did, and the choices they continue to make, may, again, not matter. There's nothing magical about choices, they're still limited by one's mental model and therefore will never be truly free. They may find a way through to a good model. Or maybe some good people will help them make their way there. Or perhaps a physical intervention will accomplish the same even faster.
Feeling compassion towards someone trying to navigate this complex world? Easy. Just get rid of the idea that we're all sitting in front of two nicely presented plates where one clearly has good choices on it and the other clearly has bad choices on it. That's not how it works.
But we can't think like this. The philosophy of total free will does not allow it. A person either has free will or they don't. Therefore the plates must clearly be there, and any good person will choose things from the right plate. Therefore, any person choosing addiction is fully aware of the outcome and expects exactly the same thing that we expect, so if it happens to them, we get to blame them and put the full weight of the responsibility that free will implies upon them. And from there comes pain.
The terms we use when we talk about agency: attitude, personal responsibility, consequences. These terms became steeped in guilt and shame and authority. Because that is the price we put on agency: if you want to have it, you must feel constant guilt and shame, over any decision you make that we didn't want you to make that has a negative outcome. These are not light emotions, and especially those raised to be good and conscientious will be rather vulnerable to them. These inform of one's status and worthiness and acceptance in the tribe. To feel constant guilt is to not just make mistakes, but to also be wrong fundamentally, as we know one must not feel it constantly. What is one to think when they are convinced by others that they, completely freely, constantly make bad choices? That's a hell of a cross to bear.
Little surprise is it, then, that many people decide that they don't want any of that agency if it comes at the price of constant pain and living life at the lead of someone else. We want to avoid pain, not experience it. They either deny the choices themselves, or deny that they made them, or deny that the choices existed. Anything else leads to pain. They are not allowed to merely banish guilt and shame and reclaim their agency due to the philosophy of total free will, so they just banish all of their agency all together.