#4 The difference that makes a difference: Craving

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What really makes the difference between the addict and the non-addict is the suffering involved with addiction. For the addict, the most immediately conscious aspect of addiction is craving. This isn’t just a matter of really wanting something. Craving is the most powerful motivational force the brain can marshal. How strong is it? When an addict reports craving, the same neural processes are active in her brain that are active in a person with obsessive-compulsive disorder who is experiencing a compulsion (Koob & Le Moal, 2001). This is the primary source of an addict’s suffering.

In order to understand how craving works, we need to look at how it’s produced. Today, I’ll explore the neurochemistry behind stress, and how stress is related to craving. You know that an addictive substance or behavior (which I’ll just call “drug” from now on) makes the midbrain mark it as highly salient to survival, and rewards its use. It’s easy to see how reward-seeking motivates drug use, but how does that transition to dependence?

Enough with the carrot; time for the stick:  Continue reading

#3: Reward and Learning

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The most important part of addiction for the addict is the phenomenon widely known as craving. It’s the hardest part about recovery, so it’s what we need to pay the most attention to when we’re thinking about treatment. What I’m about to describe is what occurs in the brain before the phenomenon of craving is ever consciously experienced. I hope that it will shed light on the addict’s situation, and help us rethink some assumptions about the moral status of addiction.

In the last post, we saw that genes explain some vulnerability to addiction. However, genetic vulnerability doesn’t fully explain why some people become addicts and others don’t. I’ll explain here how addiction begins in the reward system of the brain, and how the brain learns to be addicted.

Me, myself, my amygdala:

There are two major aspects of the brain: the Frontal Cortico-Striatial Circuit (frontal cortex) and the Amygdalar-Cortical Circuit (midbrain). The frontal cortex does all the executive functioning. It cares about the consequences of your actions. It cares about being socially appropriate. It can pay attention, make goals, solve problems, and say no when it ought to. It remembers how badly things turned out last time you did that stupid thing, and plans to avoid such behavior in the future. Notes to self are posted in the frontal cortex (note to self: don’t use actual thumbtacks for this). It is in charge of all moral reasoning.

The midbrain, however, does not give even one fuck about your future. It is entirely socially inappropriate (not wearing white shoes after Labor Day egad! inappropriate, but sniffing people’s crotches inappropriate). It’s impulsive and does not do stuff like “think.” It is in charge of survival activities (food, fight, flight, sex), and only for the next 15 seconds. Continue reading

#2: The Disease Model, Genetic Vulnerability, and the Complex Tyranny of your Grandmother’s Taste in Men.

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The disease model, in modern medicine, has served us pretty well. Saved a lot of lives, helped us find a bunch of cures, made us pay strangers to poke us… What’s not to like?! In terms of pathophysiology, the model goes like this:

Organ –> Defect –> Symptom. Find the defect, and you’ll have your cause. That’s basically all it takes for something to count as a disease/disorder in medical terms.

Example: The pancreas –> doesn’t produce insulin –> coma. Cause = whatever makes insulin is sleeping on the job, those little islets or whatever. Disease detected! We call it diabetes. Example: Leg –> broke –> femur sticking out through skin, blood and yelling. Disease detected!

But how is this supposed to work with psychiatric disorders, or with addiction? Brain –> ummmm… stupid? –> pouring endless drinks into facehole promptly at 5 pm every day until you’re divorced. Cause = criminally delicious $2 margaritas? Cause = really bad job? Cause = deep, unacknowledged hatred of spouse? Cause = fundamental incontinent failure to reconcile professed moral commitments with actual behavior? Continue reading

On Addiction Part 1 of 4

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Well, hi there! Welcome back! I’m finally able to write a little, so I want to tell you about what I’ve learned while I’ve been gone. Y’all, I don’t exaggerate when I say that what I’ve learned in my time off the air has entirely changed my understanding of identity and embodiment. When people say something like that, I find it usually means one of three things:

  1. they Got Religion,
  2. they got some really good hallucinogens, or
  3. they met someone who knows where the G-spot is.

However, I already got religion like 3 times, and while the other two are entirely worthwhile endeavors, I assure you, none of these are the case this time around. Rather, I want to introduce you to the chemistry of addiction.

This may sound iffy and boring and self-indulgent to you. Maybe you’re not an addict, or you don’t know an addict, or you’re disgusted by anything that might make lame excuses for the repugnant behavior of addicts, or maybe you’re afraid I’ll tell True Confessions about my life (I won’t; not here). Give it a minute, though. I offer you a reason for taking up an interest in this issue:

The problem of addiction, given careful thought, will force you to confront your bad metaphysics, your terrible moral reasoning, and your stupid ideas about social norms. Well, that’s what it did for me, anyway. You’re probably thinking your ideas about these things aren’t as bad as mine, as evidenced by the fact that you haven’t been in rehab… YET. But challenging my assumptions about addiction has given me a completely different perspective on the nature of the self generally, not just in terms of addiction.

What kind of person becomes an addict? I always thought of addiction as some sort of moral weakness on a par with a weak constitution, like not being a good runner, or being sickly. Something you’re physically susceptible to, but with sufficient willpower, could be counteracted. I noted that it runs in families, and therefore it came to be, in my mind, a sort of hybrid genetic/moral curse, something with mystical undertones of sins of the fathers and an Amanda Palmer soundtrack.

“They” say addiction is a disease. I’ve seen people do horrible things and seem to get away with it, ostensibly because it’s a disease. I hate this. Mainly because it seems like the part of addiction wherein a person shoves a bunch of Substance into his or her Substance-Hole(s), seemingly freely, is pretty hard to ignore.

The ceaseless pouring of All the Drinks into one’s facehole in the first place, I agree, certainly has something to do with alcoholism. Oh, yes. But not in the way you think it does. This is what I’d like to challenge you to reconsider. I will show you the best arguments I know for concluding that addiction is, in fact a disease.  I’ll describe at least five levels of physical disorder involved with addiction: genes, reward/pleasure mechanisms, memory/learning systems, stress responses, and then, much later, at the level of actual choice. And I’ll explain why I think looking at addiction this way could make us better off overall.

So, over the next few posts, what we’ll be looking into is this: Is addiction a disease, and does it matter? If it’s not a disease, then we have to tackle it in terms of education, restriction of access, and general moral browbeating. If it is a disease, that changes everything about how we tackle it.

Go here for Part 2.

[By way of citation, the guiding text and the basis of research I’ve done about addiction since is Pleasure Unwoven, by Kevin McCauley; book and film both.]