(If she’s not saying, “Here’s how it is, bitches,” then I just dunno…)
BTW, that’s not what I’m saying. Bitches.
If addiction is not truly a “chronic, progressive, recurrent brain disease,” WTF is it?
Addiction is a complex set of behaviors that revolve around drug use. *
It is usually characterized by:
1) repeated, compulsive use despite self-destructive consequences.
2) use is directed at modifying your mood.
3) its importance disproportionately occupies your thoughts.
4) tolerance, dependence, and/or withdrawal symptoms are often evident.
*I am focusing all of this on substance use disorders, by which I mean drugs and alcohol. “Behavioral addictions” (gambling, etc.) may have similarities, but I haven’t taken the time to read that literature and incorporate informed comments on the topic.
“Our long-term goal is to change the conversation about addiction, replacing “beyond a reasonable doubt… addiction is a disease of the brain” (NIDA, 2010), with “addicts retain the capacity to quit drugs.” – Heyman & Mims in Addiction and Choice (Heather & Segal, 2016)
Key Points
✔Drugs don’t “cause” addiction.
-Food does not “cause” obesity.
-Horse racing does not “cause” gambling addiction.
✔Addiction results from behaviors. Our behaviors are influenced by reasons. If we have free will (see below), it isn’t helpful to talk about our behaviors being “caused” by things, as though cause equates to forced or involuntary action.
✔Drugs are not inherently good or bad.
✔Drugs can be useful or harmful medically.
*For those of you who are philosophically inclined, we could have a long and enertaining but ultimately indeterminant discussion about Free Will. Many very intelligent people, particularly physicists who study quantum mechanics and cosmology, believe Free Will is impossible; an illusion. But other equally intelligent people disagree. Interestingly, those who do not believe we have Free Will usually argue that we must nevertheless ACT as though we have it! Therefore, I am going to operate under the assumption that for all intents and purposes, I have Free Will, and can choose my actions, sculpt my beliefs and desires, and am not a pre-programmed automaton.
The “disease model” does tend to mitigate guilt and shame for those experiencing SUDs, and it helps their family, friends, and society in general understand, accept and forgive their actions. This is a major aspect of addiction that shouldn’t be ignored. Let me state clearly: addiction is not simply a moral failing. Drugs of abuse cause neurologic changes that explain why control is compromised, judgment is poor, and values get displaced. These brain changes reflect normal neuroplasticity associated with learning and repetitive behavior.
“Is being addicted really something else than not wanting to change behavior? Resisting change in spite of negative consequences is such a basic element of everyday life… [it] is not often read as loss of control, but in the case of addiction it is.” (Peter Cohen, 2009)
What else?
Tom Horvath, PhD (Practical Recovery founder; former national director of SMART Recovery) states that severe addiction appears to cause confusion between our learned desires related to “satisfaction” (pleasure, contentment, etc.) and our innate desires related to “survival” (hunger, thirst, mating, etc.). I find that to be insightful. It speaks to the feeling of “need” and lack of easy control in moderating drug use.
Stanton Peele, PhD, advocates that addiction be addressed as a dysfunctional coping mechanism from which one must “learn their way out”. Peele describes a model for recovery, The Life Process Program:
✔Addiction is a dysfunctional way of coping with problems and feelings.
✔The solution is self-awareness, learning and using coping skills & endeavoring to change one’s behavior.
✔You must work to identify your specific underlying problems and their solutions.
✔The best models for this are other people who are coping successfully.
Marc Lewis, PhD, (The Biology of Desire, 2015) is a neuroscientist and former SUD patient.
✔The medical community operates by defining problems as “diseases”, so it’s not surprising that addiction has been labeled as such.
✔The intention of labeling addiction a medical disease is good in several aspects- to shine the light of science on the problem. To lessen the stigma and guilt associated with addiction by designating it a disease that is not chosen and cannot be controlled. And to open it up to insurance coverage/treatment options that may not otherwise be available.
➤But, he points out:
*Most problem drug use is resolved naturally, without formal treatment.
*Teaching the disease model may undermine self-image, self-esteem, self-efficacy.
*Most former SUD patients view themselves as free/cured, not “in recovery.”
*50% of former problem drinkers become moderate drinkers.
➤Addiction is unique; a very bad habit, indeed. Why is it so different from other habits?
*Addiction involves thoughts, feelings & behaviors, a complex array of factors that makes change very difficult. All three of those things need to be addressed when working on recovery.
*Drug use activates dopaminergic pathways that can cause intense pleasure and then intense desire for repetition.
*Intense stimulation of desire and pleasure results in habits that are particularly strong. These behaviors are self-reinforcing in an artificial and magnified way, and other habits end up relatively neglected, less desired, and subsequently weakened.
➤Therefore, our usual ways of behaving (which are mediated by these dopaminergic pathways) become disordered. Choice becomes disordered. Prefrontal cortical-striatal connections involved in cognitive control, decision making & judgment are compromised.
➤This is all normal when it comes to brain function, and represents changes due to learning, associations, and repetitive behaviors.
➤Therefore, addiction is a learned dysfunctional behavior. Recovery occurs by adopting new beliefs and behaviors that are associated with sobriety. Changing the behaviors will result in another round of neural remodeling that will strengthen behaviors associated with sobriety. Because desire and pleasure are such strong factors, successful resolution of addiction depends on transforming your desires and goals into things that are incompatible with substance use. Only the individual can do this work. This work is cognitive and behavioral, not “medical treatment” (drugs or surgery).
And once more to put a nail in it:
Is Addiction a Brain Disease? Grifell & Hart, American Scientist, 2008.
NIH/NIDA advocate a neurobiological approach to addiction. Let us consider Parkinson’s disease – a chronic, progressive neurological disease where loss of >30% of dopaminergic neurons in the substantia nigra results in motor symptoms. Without dopamine replacement therapy, advanced-stage Parkinson’s patients lose their ability to move.
“Viewing this illness from a neurobiological perspective provides clear, indisputable evidence of the superiority of this approach compared with a psychological or behavioral perspective. Such a theory might, for example, emphasize an environmental or behavioral modification to lessen Parkinsonian symptoms. This approach, of course, would be inappropriate and less effective than neuropharmacological manipulation.”
“In the case of addiction, however, the diseased-brain theory does not have such clear explanatory power, especially when informing guidelines to treat the disorder. Behavioral and psychosocial therapies, such as CBT, contingency management, or motivational interviewing, remain the predominant treatments for substance use disorders.”
“Simply knowing that a drug causes, for instance, an increase in dopamine transmission does not necessarily provide any information about addiction to that drug.”
____________
I hope you agree that all of this makes a compelling argument to approach addiction as a problem that you can manage. Permanently.
I know, respect and love people who believe addiction is their life-long disease. People who have managed to control it with 12-step group support, “working the steps.” I want nothing but happiness and success for them.
My experience is that I developed a substance use disorder for a variety of reasons. I definitely went through times where I felt out of control and helpless. But the day came that I felt ready and indeed desperate to change. And after a long period of feeling trapped, I got help and made changes. Very rapid and profound changes. When I walked into PSI in Chicago, I knew that it was up to me to stop using opioids. And to like it! Once I made the decision, it really wasn’t very hard. I flipped a switch in my head. I can honestly say that I have not experienced cravings or serious thoughts of seeking opioids since I quit. It’s not “one day at a time.” It’s just over. And I’m thankful to feel this way.
I knew nothing about 12 step programs until I went to PSI, so I had no biases or expectations. Suffice it to say I was completely shocked to learn that AA and NA are Christian faith-based programs.* Although I was emerging from a period of feeling out of control at some level, it felt wrong and profoundly unhealthy to say that I was “powerless” and that I (even on day one) was “an addict.” I was an addict yesterday! But I decided to quit; I am done. I am no longer an addict! I introduced myself only one time as “Hi, I’m Andy; I’m an addict.” If I repeatedly used that phrase, I felt I would have been planting a flag into “addiction” and claiming it as my whole identity. From then on, it was, “Hi, I’m Andy; I’m in recovery from addiction.” That felt right. Healthy. Affirming. And at the same time, it acknowledged that I had a problem (“had” being the operative word).
(*Those who don’t see the fundamental fusion of Christianity and AA, and suggest that it’s adaptable to anyone’s beliefs are perhaps well-intentioned, but are profoundly, umm, misunderestimating the program’s central message regarding belief in God. I direct you to the Big Book, Chapter 4, We Agnostics, where it is argued strenuously that any disbelief is a prideful “perverse streak”, and that ”…we were fooling ourselves, for deep down in every man, woman, and child, is the fundamental idea of God.” And later, on page 181 (Pioneers of AA): ”If you think you are an atheist, an agnostic, a skeptic, or have any other form of intellectual pride which keeps you from accepting what is in this book, I feel sorry for you. …Your Heavenly Father will never let you down!”)
I bet we can agree it would be easier to say that when I was actively addicted to opioids, I was powerless; had lost control. As I have mentioned, a feature of the disease model is that it helps take responsibility off the individual, and thereby eases guilt and shame. But I believe that if I’m honest, each time I chose to use opioids – it was exactly that: a choice. At times it was a choice to take a medication that relieved my back pain. Other times I believe it was a bad judgment made in the moment skewed by the desire and pleasure opioids are known for. It was: “I just want it;” “I need it;” “I deserve it;” “fuck it.” Being dependent on opioids and going through withdrawal definitely fueled that flame. Still, every time it was me doing something that I felt was my “best” move.
(That was – metaphorically – a disease, indeed! It was disordered thinking enhanced by the brain’s innate ability to rewire itself.)
I now believe I was a textbook example of the PDP (Positive Drive Principle) in action. I learned this from The Freedom Model by Slate, Scheeren & Dunbar (2017):
“The PDP states that everyone is motivated by the pursuit of happiness to make the choices that, at the time of the decision, appear to provide them with the most happiness. Happiness doesn’t only mean joy and positive rewards, but also includes choices that provide temporary relief or gratification, reduce stress, and may even have little reward compared to the consequences resulting from making that choice.”
I’ve now introduced the foundation of what my recovery is built on. A belief that I had a bad drug problem that had become deeply ingrained; that was interfering with my decision-making, judgment, and values. A problem that I was responsible to correct, and would be able to resolve.
In the 3rd & final section, I will introduce you to SMART Recovery, The Freedom Model, and my amalgamation of the two programs (with a good measure of The Biology of Desire, and The Life Process Program): “How I Beat Addiction.”