Rob was at a place where he no longer cared about anything. The Ontario-based accountant had been pulled over, taken from his vehicle, and placed in handcuffs. It was his third encounter with the police while driving after consuming alcohol and, as he described it many years after the incident, one of the lowest points in his life.
He had two prior charges for impaired driving and a charge for driving while suspended. On that fateful evening, he had collided with a truck that suddenly pulled out in front of him. Luckily, no one was hurt. But Rob — who agreed to speak under the condition of anonymity — was convicted for driving while impaired and sentenced to time behind bars.
“I did three months, and everybody who knew me thought I was in rehab,” he disclosed in a phone call years later. Since he travelled often for work, he was further able to hide his jail time from clients. “For me to spend time incarcerated like that, not only is it embarrassing, but it would be disastrous for my career.”
After his release, Rob went back to heavy drinking. “Oh, I can have a few beers,” he thought at the time. But he now understands how mighty a force addiction can be. The disorder overpowered his will to limit his drinks. “The next thing I knew, I was right back,” he remembers.
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In a small, suburban town just north of Toronto, Rob grew up like many other Canadians. His family was middle class, fairly religious, and spent a lot of time outdoors. He practised martial arts and played hockey in the winter. It was a normal childhood until he started to experience severe sleep issues.
“I developed insomnia when I was in grade nine,” he explained. “That’s when I started seeking alcohol to see if I could get some sleep. I never really addressed it from a medical perspective.” As is common in those who experience addiction, alcohol began as a perceived solution to a problem.
After graduating from university and becoming a chartered professional accountant, he worked for numerous clients, often travelling to meet them. He soon realized his flexible schedule made room to drink during work hours and, like many who have faced addiction before him, he told himself it was okay because he still managed to perform at work.
Rob eventually moved back up north, away from city life in Toronto. “I had some real estate and construction experience, so I went up to manage a large resort. … It had four restaurants and everything was free,” he reflected. “That’s when the booze started to really flow.” Drinking became part of every meal, and sometimes part of every hour. It led to a divorce, conflict with his children, and difficulties with his career. Ultimately, it sent him to jail.
For so much of his life, Rob’s neck was under the boot of addiction — and he didn’t know how to get it out.
A learning mechanism gone wrong
Addiction is known to be a brain disorder characterized by compulsive engagement with rewarding stimuli despite adverse consequences. While no single factor can predict with 100 per cent accuracy whether an individual will develop problems with substance use, the main risk factors found in research range from trauma in the developing years, to adult dislocation (economic exclusion, social isolation, or both), to basic neuroplasticity — the more we repeat a behaviour, the more we strengthen corresponding connections in the brain and prune other neural pathways. In Rob’s case, the latter two risk factors were apparent. He had constant access to alcohol and engaged with it on a daily basis while he travelled alone for work.
When we routinely do something that initially gives us pleasure — especially in response to elevated stress or loneliness — that behaviour increasingly engages the reward circuits of the brain. The term “reward” is meant to explain what happens internally: the release of endorphins, which soothe the body and relax the mind. Endorphins are the body’s natural opioids, inhibiting the communication of pain signals and producing a euphoric sensation. But that reward is only temporary.
So we are prompted to seek the sensation again and again. The more present the pain (which can include physical sensations from stress), the more focused our drive on reducing that pain through an endorphin release. Alcohol, cigarettes, gambling, heroin, and even high-fat, high-sugar junk foods can lead the body to release endorphins.
Neuroscientists often explain addiction as learning mechanisms gone wrong. We’re supposed to learn and develop a healthy drive toward rewarding stimuli to keep us alive: social intimacy releases endorphins, exercise releases endorphins, and compassionate love releases endorphins (which, evolutionarily speaking, is required to raise children). When this wiring gets derailed or veers off track toward a non-beneficial substance, severe problems can begin.
While endorphins soothe the body, dopamine narrows our focus and intensifies our drive toward something in order to obtain that endorphin reward. Dopamine is a powerful motivating chemical. Its propensity to be released in response to environmental stimuli (an ad showing people drinking beer at a hockey game or the sound of ice falling into a glass) increases the more we engage with an act, such as drinking alcohol. Simply put, thanks to dopamine, the more we drink, the more we’re focused on obtaining that next drink. Even at great cost.
Returning to the same environment can be triggering
After his divorce, Rob tried treatment at the behest of his children, who were now away in college. But nothing worked. The next decade had him in various treatments — “both voluntarily and involuntarily,” as he mentioned when we first spoke. Outpatient programs like Alcoholics Anonymous as well as inpatient programs at rehab centres all failed.
The science shows why. While an individual with substance use disorder may detox and abstain during a period of time, as soon as they’re back in their home environment with the same stimuli, dopamine is again released, sending the person on a powerful course to obtain the endorphin reward again. This is especially true if the home environment was one of high stress or loneliness, since endorphins reduce the experience of stress and pain in the body — a feeling often described as a warm hug.
When Rob was at work, he knew that the office fridge had beers and his desk drawer held a bottle of spirits. In his line of work, meetings almost always involve having a drink or two. A deal is often met with a clink of ice cubes in a glass. Showing any weakness is frowned upon, especially if you’re to make gains with your clients. This would be highly stressful for any individual. It was a formidable mix: the sight of the whisky glass paired with the stress of business, the disconnection from his family, and the repetition of a daily habit, increasingly slipping out of control.
New medications may help break old habits
The COVID-19 pandemic has led to an increase of the risk factors for addiction: most people are isolated in their homes, avoiding contact with others, while economic stress is rising in response to a fragmenting economy, and many people are drinking daily. The good news is that both social and scientific advancements in substance use disorder treatment are on the rise — and many are offering online access.
In 2017, months after his jail sentence, Robert was scrolling through Facebook and saw an ad for a medication-assisted treatment (MAT) program in Vancouver called Alavida. The ad said it was possible to still drink while also receiving treatment. That wasn’t something rehab programs or the treatment industry usually promote. In an initial email, Rob wrote to me that he was willing to speak about this program, because, as he wrote, “it has changed my life.”
The medication used in this program is a prescription pill called naltrexone, which is an opioid antagonist. It causes receptors for the endorphins released by drinking to be partially blocked. The drinker, therefore, doesn’t experience as much pleasure from a drink. Eventually, it mixes up the messaging that the external stimuli send, so the sound of a cocktail shaker no longer cues the incessant drive toward obtaining that martini.
MAT also incorporates traditional therapies like motivational interviewing and cognitive behavioural therapy. Rob found it helpful to have someone to discuss his addiction with in an honest way at the same time the naltrexone helped reduce his desire to drink. “Nobody looked at me like I was an idiot,” Rob explained. “Nobody looked at me like there was something broken in me.”
Now in full recovery, Rob told me that he doesn’t have to abstain from alcohol entirely, “but I choose not to drink liquor anymore. I’ll have a beer now and then but every day I get up and I remind myself that this is the new me. It’s not having a drink and sneaking a bottle into my desk at work,” he said proudly. “It’s like night and day.”
I got in touch with the MAT program’s director, Elliot Stone, to ask how the program works. Stone sat down with me some time ago to discuss this new way of thinking about treatment. Since many of us can drink without developing problems, the notion of recovery is finally expanding past the fear-based, abstinence-only approach that most rehab programs push.
Stone credits the program’s success rate to the many mentors who helped him design the program, like Finland’s Dr. Hannu Alho and his in-office colleagues who run the therapy side of treatment. “Everyone is a master’s-level therapist, either an RCC, registered clinical counsellor, or MSW, master’s-level social worker. They’re all trained in addiction work.”
I asked him about the use of medication, and Stone explained why he chose to incorporate it along with other more traditional treatment elements like therapy.
“We use them as a tool for helping to retrain the brain and to make the process of paring down your drinking easier from a biological sense,” he said. “If you don’t get that neurochemical reward, then you aren’t as inclined to [seek the substance that delivers it]. If you’re able to block that reward for a period of time in specific circumstances, it can pull someone out of that compulsive cycle and give them a bit of space to make decisions. And that space is where we really double down on the therapy.”
Much of the therapy takes place through video conferencing and an app developed for the treatment program. This makes treatment accessible in an era of physical distancing — and takes the sting out of social isolation.
Rob, who now lives in Toronto but can access the therapy portion of the program online, explained how he used that space afforded by the program to reflect on his life absent the all-consuming focus on his next drink. “I just looked at what my life was, my habits, and what I did.” He would get up and have a drink, then drink until he went to bed.
“So I started small. I didn’t drink when I got up in the morning. That was the first thing that I stopped,” he said. “I still drank at work, but I didn’t drink when I got up in the morning.” This was a major accomplishment.
“Then I cut the drinking out at work and then I cut the drinking out before I got home from work. [Eventually] I cut out the alcohol and just had a few beers. Then I went to zero.” Rob said that his line of work is still shrouded in boozy meetings, but he’s not scared of spiralling if he has a beer with a client. “People who know me [say] I look 15 years younger. It’s a new me.”
The mixed history of medications
In 1979 a new combination drug aimed at altering motivational activity in the brain’s reward pathways was being studied at the University of Rochester. Fenfluramine/phentermine, released under the name Fen-Phen, was used moderately throughout the ’80s, with use spiking in the ’90s for compulsive overeating disorders. This polypill was shown to be effective in halting the tremendously powerful dopamine drive that propelled patients towards compulsive eating despite not being hungry.
In 1997, Fen-Phen was pulled from the market by the U.S. Food and Drug Administration. The regulators cited serious side effects that affected the heart valves due to serotonin toxicity. It also had the potential to lead to anhedonia, an inability to feel pleasure.
While Fen-Phen primarily acts on serotonin and dopamine activity (as an agonist), most MAT programs — including Stone’s — use the medication naltrexone, which is an opioid antagonist, acting on endorphin receptors. I reached out to Dr. Keir Peterson at the program to ask how naltrexone hinders the reward experienced through alcohol but not other things that also cause a release of endorphins such as highly palatable food, exercise, and pain medications.
“Naltrexone is not 100 per cent selective in blocking the reward associated with alcohol use. It can, in some cases, affect other pleasures,” he noted. The dose and timing of naltrexone use is adjusted for each patient “to maximize its effect on the reward from alcohol and minimize the potential impact on other areas,” Dr. Peterson explained.
In the case of opiate-containing pain medications, because naltrexone blocks opiate receptors, “we would therefore not prescribe naltrexone for patients who are taking these medications, and would instead emphasize the counselling component of our program, as well as consider the possible use of alternate medications.”
As for other rewards, the science is still a work in progress, Dr. Peterson admitted. “Looking at pleasures from food, for instance, there are some studies exploring the treatment of overeating and obesity with naltrexone. So, at least for some people, there is an effect of naltrexone on the pathways that affect reward from food,” he said. His experience in assessing the effect of naltrexone on patients’ lives, in areas like exercise and food, is that the medication, with careful attention to doses and timing, is unlikely to negatively affect other pleasures.
“This is, however, something we watch for during treatment and tailor our use of naltrexone to each individual patient,” he added. “As drinking reduces with naltrexone, both overall mood and non-alcohol-related pleasures increase. Patients are happier with their relationships and have more time and energy to appreciate the people and experiences” in their lives.
Unfortunately, as Rob, the recovering accountant, disclosed during our interview, the MAT program that he believes saved his life did cost a fee. He had an income that allowed him to access treatment, but others can’t because of their financial circumstances. If MAT programs were covered under our single-payer healthcare system, we might see substance use disorder wane. The political will, though, must be there — especially with so many suffering through the social and economic effects of the COVID-19 pandemic.
If we understand addiction by its definition — continued use despite adverse consequences — we can see why punitive approaches in drug policy and drug treatment haven’t been working. The punishment of people with jail sentences or outdated rehab programs requiring abstinence from all drugs — even research-based addiction medications — have been shown to be ineffective for the majority of people experiencing addiction. The science behind MAT and opioid agonist treatments offers a proven way out. Access and coverage are the next critical steps.