Addiction

The underlying causes of an escalating crisis

As a society we want to pathologize addiction without understanding why it happens
Photo: d26b73
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Ted, 62, had been a regular patron of a high-end hotel bar in Vancouver, but lately complaints were piling in over his conduct. The former business mogul was a resident of the hotel and known to staff as a generous family man; he was empathetically described as “terrific when sober.” Ted loved his rye and couldn’t seem to keep his drinking under control, even though it was taking a private, and now public, toll on him. The father of four had become more belligerent in social settings and, on the day I had come to meet him at the restaurant below his condo, had already been given a warning by hotel staff about his behaviour with women guests and employees.

When discussing his struggle with alcohol, Ted told me a story that matched the dozens I’ve heard in my interviews with others about their addictions: seemingly together, then falling apart. The question buzzing through the hotel was not a new one: How could this happen to such a reputably great man?

Curiosity about addiction lives everywhere. On a separate occasion, I was discussing the root causes of the affliction with an inquiring sommelier at another establishment — namely, how the underlying causes of addiction have long been ignored by both drug war policies and much of the medical establishment.

“Sorry to interrupt,” a man reading his newspaper chimed in. “But everything you’re saying sounds like what my friend Dooley is always going on about. I think you should meet him.”

Dooley, otherwise known as Dr. Alexander Goumeniouk, by trade is a neuropharmacologist, and by profession a consulting psychiatrist at The Orchard Recovery’s addiction treatment centre on Bowen Island. He is also a clinical professor emeritus of anesthesiology, pharmacology, and therapeutics at the University of British Columbia, as well as former chair of the Scientific Advisory Committee at Aequus Pharmaceuticals.

The burgeoning consensus among nearly every professional who has taken a serious look at addiction is that it is not a moral failing or weakness of will

I reached out to Dr. Goumeniouk via email. When we met, it was shortly before he was set to deliver a speech to a room full of pharmaceutical company directors at Gotham restaurant, a hot spot for high-class steak lovers, so I arranged our meeting at a more modest lounge down the street. Knowing his industry’s reputation, I was skeptical about the nature of the dialogue to come — I was not there to talk about pharmacological solutions to addiction.

To my surprise he got right to the point, almost as though we had already discussed what we were both there to say.

“While the data says that 80 per cent of people who end up in rehab centres have some trauma, childhood or otherwise, my experience is 100 per cent…. Charlie Nemeroff, who’s the head of the University of Miami’s behavioural science and psychiatry [department], has done a lot of work on looking at the input of adverse early childhood events on outcome, and it’s clearly there,” he noted. “I have to say that I probably have taken away more psychiatric diagnoses than I've handed out.”

The burgeoning consensus among nearly every professional who has taken a serious look at addiction is that it is not a moral failing or weakness of will, and it is not determined solely by genetics. Yet these misunderstandings show up in public policy, as seen in our criminal justice system, and in medicine, as seen in the overwhelmingly autocratic, pharmaceutical-based response to addiction.

To solve the issue of addiction, we should be tackling it at the roots, not focusing on the symptoms.

The three tiers of addiction

Addiction is defined as a state in which an individual compulsively engages in rewarding stimuli, despite adverse consequences. This can result in an addiction to substances such as opioids or to rewarding behaviours such as overeating. But what causes this incessant drive toward something?

In both the research on addiction and personal stories on addiction, three main factors continue to surface:

  1. The power of conditioning. Repetition reinforces behaviour. The “cue, routine, reward” circuitry of conditioned activity becomes more intractable with each recurrence.
  2. Childhood trauma. Neglect and abuse in the developing years affect the functioning of the nervous system, which amplifies the stress response across a lifetime.
  3. Social and economic exclusion. Rejection and isolation degrade the conditions required for healthy — and happy — neurotransmitter activity.

Addiction is typically caused by one or a combination of these three elements.

How the brain works

Before getting into the tiers of addiction, let’s take a quick look at how the brain works.

The human brain’s ability to execute actions largely stems from two types of control centres. The first is the more primal limbic system, which is impulsive, reward-driven, and often subconscious. The second is the more evolved grey matter of the brain, known as the prefrontal cortex, which is where we plan goals, predict outcomes, and weigh consequences. In addiction, the impulsive limbic system vetoes the careful decisions of the prefrontal cortex. (A children’s text once simplified this as the “feeling brain” overriding the “thinking brain.”)

The basic physiology of how something addictive works goes like this: after consumption, soothing feel-good hormones known as endorphins are released in the reward centre of the brain. Endorphins are the brain’s natural opioids — they deliver that “ahhh” feeling of ease and comfort.

Sending you on your quest to obtain that endorphin reward is dopamine, the brain’s motivator chemical. Dopamine is responsible for feelings of excitement and anticipation. It narrows your focus and intensifies your drive. Dopamine is released by external cues (which can be sights, smells, sounds , even emotions) that surround the rewarding endorphin-releasing act.

Once cued, dopamine can hold such tremendous power over your focus and drive that you’ll swat away thoughts coming from the prefrontal cortex trying to tell you, "Don’t do it!"

The power of conditioning

“I can’t help it, I just love desserts. I have a serious sweet tooth,” Sara, 32, told me over dinner while ordering her second dessert. “I have to try them both.”

The more we repeat something, the more difficult it becomes to stop ourselves from doing it.

She had confessed that it baffled her that anyone could eat dinner and then not look at the dessert menu. I told her I had a hunch that something other than her sweet tooth was at play: a little psychological tic that renowned Russian psychologist Ivan Pavlov first coined as classic conditioning in 1901 and oft-cited Harvard behaviourist B.F. Skinner expanded into the concept of operant conditioning in 1938.

Through conditioning, the more often we repeat a behaviour, the more that behaviour engages the brain’s reward system. Our associations of pleasure with those external cues become more robust, and the more anticipatory dopamine is released. The more we repeat something, the more difficult it becomes to stop ourselves from doing it.

Author Charles Duhigg points to this habit-forming repetition, or conditioning, in his bestseller The Power of Habit. In part due to researchers at MIT who first dubbed it the Habit Loop, Duhigg helped popularize the more explanatory name for this powerful phenomenon: the cue-routine-reward circuitry. Telling the story of everyone from a compulsive gambler, to an NFL player, to a new CEO, Duhigg explains how the more a person repeats a behaviour, the more tenacious the reward-seeking action becomes. This Habit Loop engages both classical conditioning and operant conditioning.

The effects of conditioning are easier to understand than those of the other tiers of addiction. Conditioning is also the easiest to overcome. Dr. Marc Lewis, a retired professor of developmental psychology at both the University of Toronto and Radboud University in the Netherlands, is another champion of the addiction-as-habituation model. His most recent book, The Biology of Desire: Why Addiction Is Not a Disease, examines how repetition can lead a habit to spiral out of control.

“Addiction is about habit formation, brought on through recurring, self-reinforcing feedback loops. And although choice is not obliterated by addiction, it is much harder to break deep habits than shallow ones,” he wrote in aeon magazine.

“From a neural perspective, habits are patterns of synaptic activation that repeat, when connections among rapidly firing neurons fall into the same pattern over different occasions repeatedly,” he said. In other words, neurons that fire together wire together.

Getting away from cues and routines long enough to break the spell is one reason why treatment centres can be effective, Dr. Goumeniouk told me. The more time spent away from things that trigger your Habit Loop (he says 60 days), the weaker the cues and synaptic firings become. When I asked why so many fall back into addiction after rehab, he talked about the effects of unresolved trauma on the nervous system.

Trauma from childhood adversity — like neglect, abuse, and isolation — are all underlying aspects of addiction that Dr. Lewis doesn’t dispute either. “As a neuroscientist, I recognise that the brain changes with addiction, but I see those changes as an expression of ongoing plasticity in an organ designed to change with strong emotions and repeated experiences,” he wrote in the Guardian. “Similar changes have been recorded when people fall in love, become obese, gamble compulsively, or overindulge on the internet.”

“Addiction isn’t about rationality or choice; it’s not about character defects,” he pointed out in aeon. “Childhood adversity is clearly a risk factor.”

So why would something that happened so long ago impair a person’s ability to override highly consequential urges today?

Trauma in the developing years

Living in Vancouver, it’s hard to come by anyone who isn’t familiar with the name Dr. Gabor Maté. In addiction circles, he’s known around the world. A physician who started out in palliative care and family practice, Maté eventually resettled in the city’s Downtown Eastside. He worked at Onsite, a detox and transitional housing centre, later noting it was “a place where a lot of people live, who otherwise would be living on the street.”

Dr. Maté has a cautious disposition. One might be quick to attribute it to the many years he’s worked with the country’s most marginalized and disenfranchised, but hearing his personal history it becomes clear there’s a deeper reason. His famous statement, “It’s not ‘why the addiction?’ It’s ‘why the pain?’”, can be applied to him as well.

Born in 1944 to Jewish parents in Budapest, Hungary, shortly before the Nazi occupation began, Maté was given up by his mother in order to save his life. His father endured the forced labour camps under Nazi rule. Maté was reunited with his mother five or six weeks later, but he was traumatized by these events.

“I wouldn’t look my mother in the eyes, which is [a] clear sign of trauma,” Maté explained during a 2009 talk filmed by Heartspeak Productions.

In the Realm of Hungry Ghosts, Maté’s most recent book, details his own period of addiction and points to these early experiences as the cause of his adult suffering. Maté knows that the cause-and-effect relationship between childhood trauma and addiction is undeniable; it affects every person experiencing addiction that he’s ever worked with.

“I don’t have a single female patient in the Downtown Eastside who was not sexually abused as a child,” he told the audience in 2009. “Not one. Not even by accident. I’ve talked to hundreds. Many of the men were abused, many sexually. If not sexually, then physically in other ways or emotionally abandoned, neglected, and hurt.”

Humans are most vulnerable to trauma during childhood, when adversity can affect physiology in the most irreversible ways. Violence, instability, and neglect can alter the development of the brain and its chemical activity by heightening an individual’s stress response.

“These patients of mine die young,” said Maté in the 2009 talk. “And the question is, ‘Why?’ Why do people keep doing these terribly damaging things to themselves, which have such negative consequences in [their] lives?”

Maté was the first professional I heard so publicly call out the “willpower” and “morals” dogma concerning addiction. “It’s not possible to answer these questions if we see [addiction] as weakness of will, or if we see it as moral failure or some kind of bad decision that people make. It’s much deeper than that,” he said.

“The question we really have to ask is, ‘If people are using drugs despite the negative consequences, what do the drugs do for them?’ It must do something very essential, otherwise, they wouldn’t do it.”

Most coverage of addiction today focuses on the opioid crisis, which the Public Health Agency of Canada says was linked to nearly 4,000 deaths last year. Opioids include drugs derived from the opium poppy such as heroin and morphine and synthetics including fentanyl, which are used in medicine as painkillers. According to Maté, “they don’t only kill physical pain, they also kill emotional pain.”

“If you look at brain scans of human beings when they’re feeling emotional pain, the same part of the brain lights up as when they’re feeling physical pain.”Maté explained that emotional pain is essential to the story of addiction, particularly because addictive drugs and behaviours activate the reward centre of the brain, which soothes the stress that trauma leaves behind. “[Opiates] work in the human brain because we have receptors for them,” he said. “Our brains have their own natural opiates, and those are called endorphins. Endorphins are a body’s naturally occurring morphine-like substances.”

“Opiates and endorphins, while acting primarily as painkillers, are also necessary for feelings of joy, elation, and reward,” he said. “This should tell you something about the nature of addiction because it’s not just about drugs; you can get addicted to all kinds of things.”

Endorphins kill pain and give us elation. Maté explained that endorphins also connect infant to parent. “When a little baby is looking into your eyes ... endorphins are being released in their brain and yours, so endorphins are necessary for that loving connection.”

Maté asked the audience what would happen to infant rodents in the wild who had endorphin receptors bred out of them, as he’s seen in research labs. “They’d die. The mother’s loving, nurturing presence is required to protect the child and to bring up the child. Without that, the child is not looking to the mom because there’s no connection, no life.”

“Opiate addiction arises in the most essential brain circuit human beings have, which is responsible for pain relief, reward, love, and connection: the essential dynamics of human life,” Dr. Maté confirms.

The most disturbing and heartbreaking stories Maté has chronicled in Hungry Ghosts are sure to anger. His accounts range from a three-year-old boy who was left in a dryer with a heavy object on top while the mother drank at a bar, to women who were repeatedly raped and tortured by assumed caretakers. Without early nurturing affection to develop the endorphin-reward system in the brain, it’s no wonder these individuals get hooked after discovering an anxiety-easing feeling for the first time.

For the person who has never experienced addiction, understanding trauma is made easier by looking at physical pain. Painful events alert the stress response of the nervous system the same way that touching a red-hot stove iron does. The painful burn from the iron teaches you not to touch it again: you’ll be on high alert every time you’re around the stove.

"What if it’s actually what happens in people’s lives that makes them addicted? That’s a different story because then you have to look at the whole society. How are we treating each other? What kind of system do we live in?"

Now imagine the same physiological response to other people as you grow into adulthood. If you were constantly hit as a child, your nervous system learns to keep you on high alert around others (whom the senses equate with abuse). Unfortunately that can mean the stress system is always engaged, which can make interaction so exhausting that self-isolation is likely to follow.

Maté explains further. “Certain circuits don’t work [properly] in addiction. One of them has to do with stress: the adrenaline circuitry. Adrenaline is a stress hormone… If I was to attack you, your body would create a lot of adrenaline [to] help you either escape or fight back.”

Adrenaline is a fight-or-flight hormone. So is cortisol. “When you talk to [people with addiction] and you ask them, ‘Why do you do drugs? What is it that they do for you?’, one of the things they’ll say is, ‘It helps me to not be so stressed.’”

“The person who’s addicted gets stressed very easily. Or the person who gets stressed very easily is more likely to [get addicted]. They’re more likely to use drugs to soothe their stress because drugs are stress relievers .”

But drugs don’t have the capacity to regulate stress or relieve chronic stress, so the person with addiction has to constantly retreat to those substances.

If trauma sets off the stress response repeatedly, and endorphins relieve pain and stress, then to decrease dependency on having drugs do the relief work, might we need to give individuals a bit more compassion to soothe their pain instead?

“Here’s why we have to look at life experience,” Dr. Maté says. “What if it’s actually what happens in people’s lives that makes them addicted? That’s a different story because then you have to look at the whole society. How are we treating each other? What kind of system do we live in? How do we look after our children? These questions, of course, are much more painful to answer than simply saying it’s a matter of genetics or drugs themselves.”

Indeed, putting a microscope up to our own society is much harder than just prescribing pills or jailing people for drug use.

Social and economic exclusion

“Their childhoods were spent dealing with problems that would break most adults,” photojournalist Chris Arnade once wrote in The Guardian. This sentence was one of the reasons I was keen to meet up with him while in New York.

“One thing that people don’t like to admit is how the act of using a drug is a very social process,” he said. “People’s first experience using a drug is very often because someone else showed them how to do it, or told them what it was like to do it. When a person goes into a ‘crack house’ or a ‘heroin den,’ not only do they get to use drugs to provide a moment of relief from that trauma, but they also meet people who’ve had equally traumatic experiences they can relate to. It’s like, ‘Wow, you too.’ Finally, they have someone who doesn’t look at them like they’re disturbed.”

Educated as a physicist, Arnade took his PhD to Wall Street, where he worked as a high-flying financial trader. Soon he grew sickened both by the culture and by his own life, picked up a camera, and rode the train to Hunts Point, N.Y. Now an esteemed photographer and reporter, Arnade focuses the entirety of his journalism on poverty, addiction, and marginalized communities in the United States. “I’ve put almost 200,000 miles on my car over the last five years just driving and visiting places that — for lack of a better way to put it — very few people visit.”

He told me his story in the city’s West Village, where I naively asked him to meet me. Glancing out the window at the fancy cobblestone walkways, tree-lined streets, and multi-million dollar townhouses tightly wedged into one of the world’s most expensive postal codes, he asked how anyone with the background and experiences of a person with addiction could ever be expected to suit up and fit in around here.

Arnade landed back on disconnection and how drugs all too commonly provide a coping mechanism for social rejection. “[Drug culture is] a very accepting community that equips them with a sense of belonging, which we all need. They’ve finally found inclusion and relief through using drugs,” he said.

“There’s a very universal human desire to be included, to be social. And a lot of [people living on the street with addiction] are people who haven’t been included by broader society. They’re outcasts because ‘civil society’ is too uncomfortable sitting with what’s happened to them and how they act because of it.”

Thinking back to my conversation with Ted from the bar in Vancouver, I reminded the ex-Wall Street trader that wealth can’t protect people against abuse, neglect, and the isolating effects that inevitably come from it. His rebuttal was that the solution for the affluent is an expensive rehab centre, adding that they can afford to take those multiple weeks off. The solution to the addicted person in Hunts Point has chronically been the notoriously ill-fated Rikers Island Correctional Facility.

“You could define addiction as falling in love with a drug rather than a person, and that is really what goes on in the brain”

Not only has Arnade spent over a decade reporting on the stories of the most heavily afflicted, but the people he’s met over the years have become some of his closest friends. He has spent many afternoons at court hearings, penitentiary visitation rooms, “drug dens,” and even small-town McDonald’s restaurants, just humanizing and listening to these individuals.

“In general, the people I know who are street addicts have been removed from their families or social circles because all too often they’ve suffered a trauma. When you think about the kinds of traumas that the people I know suffered, they’re unimaginable things like having been raped by an uncle, beaten by their own parents, or witnessed killings at a young age. All these things immediately make it very hard to interact socially with other people. They’ve been ejected by those experiences that they didn’t ask for, or do anything to deserve,” Arnade told me. “Their experiences set them up to behave very differently because they’re traumatized.”

The resulting loneliness is the catch-22: their addiction and other users are all they have left to soothe them. If endorphins are the love and affection chemicals as Dr. Maté described, it’s understandable that people reach for them at such great cost.

“You could define addiction as falling in love with a drug rather than a person, and that is really what goes on in the brain,” addiction journalist Maia Szalavitz told me when we met for coffee in midtown Manhattan. Szalavitz is a millennial favourite. She has appeared on Democracy Now! and writes for VICE and The Atlantic in her frank and brazen style, often calling out drug war policies. But she’s also a Guardian and New York Times regular, giving her the clout many other prohibition critics don’t have. She also happens to have credibility from knowing the system: a former heroin user herself, she’s familiar with the courts, and because of who she’s seen harmed by drug criminalization — mostly minorities — she advocates firmly against prohibition.

“The same kinds of brain systems and chemicals are involved in both love and addiction,” she told me, echoing Maté and Arnade. “We can understand addiction once we understand love because it requires the same neuro pathways. The biological drive that mammals have for love, which is critical to reproductive success, gets transferred to this drug. When you don’t have that drive for love towards other humans, you often have it for a drug or substance that gets abused.”

“The biological drive that should exist within us to take care of a child or maintain a relationship,” said Szalavitz, “well, that gets misdirected towards a drug. It changes their priorities and it can make them do things that they wouldn’t necessarily do [otherwise].”

A society that doesn’t provide secure social connections, and depends on individualism and competition for economic progress, breeds individuals who suppress their biological need for connection.

The late University of Chicago social neuroscientist John T. Cacioppo, who studied social connection for over 20 years, penned a scathing account of the health consequences of isolation in his last book, appropriately titled Human Nature and the Need for Social Connection. In it, he described how excessive individualism and rejection heighten the human stress response, which can lead to all sorts of physical ailments. Too much disconnection can even decrease your lifespan, just as loneliness can kill. It propels an individual to grasp at anything to escape that lull in neurotransmitter activity.

A society that doesn’t provide secure social connections, and depends on individualism and competition for economic progress, breeds individuals who suppress their biological need for connection. Addiction, many say, unfolds from the resulting lack of natural attachment.

The exuberant Dr. Goumeniouk, during our discussion on the roots of addiction back in B.C., explained a concept he called ‘learned helplessness’ by describing an experiment with a rodent left in a glass tube. He held up a cup from the table that was about three inches wide to demonstrate. “It was of insufficient diametre for the rat to turn around and had a screen at both ends so it could get fed at the mouth end and get its poop cleaned out at the rear end,” he said. “It tries to go forward, hits the screen, tries to back up, hits the other screen. Eventually, it does nothing because there’s no point.” It’s stuck and alone, and it can’t do anything to change that.

“If you then measure the cerebral spinal fluid for the neurotransmitters dopamine and serotonin, you’ll find they’re depressed. In our field, there are four things you can do to restore that brain chemistry: drugs, shock therapy, and transcranial magnetic stimulation, which is high-intensity magnetic pulses over the prefrontal cortex. Or you can take the rat and reintroduce it to a social environment where it can develop nurturing relationships. This will restore the neurotransmitters; it’s as antidepressant as shock therapy, drugs, or transcranial magnetic stimulation.”

Ted, the former executive who struggled with his drinking, had recently divorced, and his children had all graduated and left home. He said he was once publicly threatened with extortion, so he now kept quiet about his wealth and profile, but this left him living high above the city, alone and disconnected from all the friends he felt he could no longer trust. He had sold his business, so he rarely spoke with clients, secretaries, or partners anymore.

Making matters harder for him, the very entrance to Ted’s home was a hotel bar; he had to pass glowing shelves of back-lit liquor bottles on his way to the elevator every day. Through repetition (stopping by the bar for a nightly cocktail), the first tier to addiction — conditioning — had snagged him. The additional lull in dopamine and endorphins, caused in part by his environment of sudden loneliness, created a formidable challenge.

By looking at how the environment changes what’s happening in the mind, we can have a real discussion about better health care and policy solutions for people like Ted, Sara, Arnade’s Hunts Point friends, and Dr. Maté’s and Dr. Goumeniouk’s patients.

Addiction is one of the most widely misunderstood crises, but it can be halted . We need to move away from the outdated but commonly held belief that the onus of addiction lands on the individual. Both the theory that addiction is solely determined by genetics and the assertion that addiction results from poor morals or willpower are flawed. Neither address conditioning, trauma, and isolation. It’s time the research that moves beyond these two belief systems is accepted more broadly in policy and society.

The names of some individuals facing addiction have been changed.

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