Shame on me – Stigma and addiction in treatment

I keep hearing that back in the old days of addiction treatment, shame was the main motivating factor used by rehab counselors. Everyone admits that it proved to be a horrible motivator. It simply didn’t work! With all the advances in research into addiction, that must have changed, right?

I don’t think so. I see shame and stigma every time I hear an addict talk about their drug use. The shame is there in their eyes as they tell the stories of their trouble and the struggles of their recovery. Given the low rates of success in addiction treatment, the shame rests firmly in the inability to quit as well. A relapse is often seen as the ultimately shameful experience for an addict. The stigma of addicts as hopeless is rampant.

Still, we have evidence of genetic predisposition to drug abuse and addiction, we know of environmental factors that make it more likely that people will get hooked. The effect of many drugs on the brain make unsuspecting lab animals as likely to become addicted as any one of us and I’m pretty sure that shame doesn’t play a role in their process.

With all this evidence, why is the stigma of drug addicts still around? Why are they the only ones being blamed for their condition?

The evidence I cited isn’t that different from that known for cancer, yet we scarcely blame cancer patients for their disease. Even in the case of smokers who become ill, their is still sympathy for their suffering. So why are addicts different?

There are good addiction treatment options out there, as long as we don’t give up on the person and simply view their addiction as evidence of their weak character. Given the changes that long term drug use produces in the brain, it’s a miracle anyone recovers at all. We should be grateful for that.

Understanding addiction research will require us to argue our corner but be flexible to change corners.

Hello everyone,

My name is Christopher Russell, I am a doctoral student in psychology at the University of Strathclyde in Glasgow, UK. My addiction research interests are wide and varied, but my core interests are in addiction theory (“why people do what they do”), the issue of freedom to control when using drugs, interpretations of addiction research evidence, and the use of licit and illicit drugs in the law.

Respect and rational debate of addiction research

Dr Adi Jaffe has very generously asked me to become a contributor to A3 and after reading about what A3 stood for (the mission and the abbreviation) and what Dr Jaffe is trying to achieve through A3, I am delighted to be a part of A3. Adi noted in a previous post that we do hold some different opinions about the nature and course of addiction. Above our differences, however, I respect that Dr Jaffe and I are able to debate addiction research rationally, respectfully, and vigorously without either of us resorting to ideological proclamations, disrespect for the alternative view, claiming a moral high ground or attacking each other’s moral character, or worst of all, name calling! Such people are hard to find in the academic world! The truth is that I, like Dr Jaffe, am still learning about addiction, and I’m not foolish enough to believe that my way is the way! If addiction research over the past 100 years has shown anything it is that a researcher would be foolish to hang his hat on any interpretation and proclaim it as fact – for example, for the past 200 years, masturbation was considered the most prevalent psychiatric disorder until it was replaced by drug use, and up until 1973, homosexuality was still diagnosed and treated as a form of mental illness! We must be willing to bend with the wind, to accept when addiction research evidence invalidates our beliefs, and to respond to falsifications by constructing models which stand up to our efforts to falsify them.

A3 and the fluid landscape of addiction research

The landscape of addiction research changes by about 50% each decade, as do many scientific ideas, so it is important that we all hold our beliefs about addiction lightly and be willing to consider that some dearly held addiction “truths” may not be as truthful as we had thought, perhaps hoped. Scientists are constantly revising what they thought they knew, changing their approach to measuring and conceptualising the problem, disseminating the latest findings to the public; like any good scientist, those who are involved with addiction, either personally or professionally, should always try to update their model, and sometimes, evidence can arise which causes us to question everything we thought we knew about the nature of a problem. Such evidence may require us to not merely adapt our exisitng models of the problem, but if called for, to abandon them in favour of more potent models which need not necessarily be liked or fully understood.

Hearing what addiction research is telling us, not what we want to hear

However, despite our pledges to be good scientists, our basic ways of thinking tend to get in the way of building better models of a problem. For example, a classic contribution of psychology research has been the finding that people prefer to try to discredit a new piece of evidence about a concept which doesn’t fit with their existing understanding of that concept rather than assimilate the new evidence into our understanding because it is cognitively easier to leave our belief structure as it is. This phenomenon is quite common in the addiction research community; some people just refuse to believe that addiction could be something other than what they had long thought it to be, and no amount of validated, replicable evidence to the contrary will move them to revise their beliefs. It is regrettably common that, for some, beliefs about addiction are based on an unwavering ideology rather than a science-grounded conclusion. Addiction researchers cannot afford to be this pompous, lazy, or inflexible; too many people are counting us to get the right answers to them, no matter who they come from or what form they come in. I know that my contributions to A3 are only useful to the extent to which they help get people from where they are to where they want to be. To achieve this, I must argue my corner but be willing to bend when the wind blows. We all must.

In the hope that I can be both teacher and student of A3, I believe that the value of my arguments will be measured by how well they hold up in the face of your most passionate, insightful criticism. Therefore, I invite all those who read my contributions to criticize, refute or support any of my arguments when you feel it is warranted. I will always try to give an intelligent answer and I swear to never resort to clichéd answers, bumper sticker answers, or the “it just is because it is” answer, which is in effect, no answer. And I will never resort to name calling (except when you really deserve it!).

I look forward to providing you with thought pieces, philosophical contributions, reviews of evidence, and most of all, interacting with you the readers, the lifeblood of A3.

Christopher

Why the addiction-brain connection has to be part of the addiction treatment picture

Dr. Dodes recent article, apparently trying to blow up the myth of addiction as a neurophysiological disorder, sounded persuasive, although its underpinning was oversimplified and it’s understanding of the brain-science involved in addiction, and other associated mental health disorders, was lacking. Hopefully, by presenting a more complete picture of the evidence for a brain-aspect to addiction, I can un-bias the discussion somewhat. I, for one, don’t believe that neuroscience will ever be the only factor important in addiction – an individual’s environment, social influences, and other factors will always end up playing important parts as well – still, I think that to dismiss all of the evidence for biological factors at play in the development of addiction is foolhardy. Especially when there’s so much of it that was glossed over in Dr. Dodes’ introduction.

Pleasure center activation is only part of the picture in addiction

Firstly, supporters of the notion that addiction is, at least partly, an outcome of specific brain function point not only to pleasure center activation, but also to a whole host of findings showing genetic variability that is either protective from, or a risk factor for, dependence on drugs and likely also behavioral addiction like eating disorders, compulsive gambling, and maybe sex addiction as well (you can start out looking up ALDH2-2 variability and alcoholism and cocaine addiction, DRD4 and stimulant addiction, and many more).

While it is true that all those who consume addictive substance activate the brain similarly, there are considerable differences in the specific of that activation in reaction to drugs. Some release more dopamine while others have more “active” versions of specific important receptors; neurotransmitter recycling is quick in some, but not all, and drug metabolism is different in different individuals in ways that have been shown to be important not just for addiction risk, but also for the probability of treatment success. Just look at the nicotine and CPY26 literature for an example. It’s right there.

Additionally an entire body of literature exists that shows differential activation, as well as structural differences, between addicts and non-addicts in regions as varied as the OFC, PFC, Insula, and more. This is not to mention a slew of evidence that shows different behavioral test performance on risk-taking, impulsivity, and delay-discounting, all personality variables highly associated with addiction. If one simply ignore all of this evidence, it may be easy to believe that there is no biological explanation for these phenomena, but that’s just wrong.

To say that mesolimbic activation (what the good doctor called “pleasure centers”) is the only evidence for physiological factors in addiction is dismissive at best.

Drug addiction develops in only some drug users

The notion that not everyone who takes drugs becomes addicted is nothing close to evidence against a brain explanation for addiction. Everyone’s motor–cortex, striatum, and substantia nigra (the areas of the brain responsible for movement) activate in the same way during movement, but only a small group ends up suffering from Parkinson’s or Huntington’s disorders. One fact does not preclude the other but instead may specifically point to the fact the group which develops the disorder has somewhat different neurological functioning. Researchers aren’t concerned with explaining why all individuals can become addicted to drugs, but rather why that small subgroup develops compulsive behavior. A short reading of the literature makes that fact pretty clear. Additionally, while Dr. Dodes’ claims otherwise, imaging technology HAS produced evidence explaining this “mystery”, including differences in the ways addicted smokers respond to smoking-related triggers, and an increased dopamine response in cocaine addicts to cues, and well as to cocaine.

As mentioned in the motor disorder section above, ingestion of chemicals is not at all necessary for brain disorders to occur or indeed develop later in life. Dr. Dodes example of shifting addiction could be used as evidence for an underlying neurological difference just as well as it would serve to make his point… Or even better. If there’s a faulty basic mechanism attached to rewarding behaviors, it doesn’t really matter what the behavior is, does it? Sex addiction, gambling, and more can all be explained using a similar mechanism, though drugs of abuse may just have a more direct impact. I know, I’ve written about them all.

The Vietnam vet heroin story used by Dr. Dodes as evidence that emotional, rather than physiological, factors are responsible for addiction actually fits right in line with the notion of predisposition and underlying differences, and I’m surprised to hear a physician point to group differences as an indicator of no neurobiological basis. Indeed, when it comes to the emotional reactivity associated with drug associated cues, normal learning literature, as well as drug-specific learning research, has revealed over and over that drug-related stimuli activate brain regions associated with drug reward in the same way that natural-reward predictors do for things like food and sex. Once again, these facts are part of the basic understanding of the neuroscience of learning, with or without drug abuse involvement.

My own dissertation work shows that it is very likely that only a subsection of those exposed to nicotine will develop abnormal learning patterns associated with that drug. However, among those, learning about drug-related stimuli (as in “triggers”) continues in an exaggerated manner long after the other “normal” animals have stopped learning. That sort of difference can lead to a seriously problematic behavioral-selection problem whereby drug-related stimuli are attended to, and pursued, more so than other,  non-drug-related ones. If that sounds familiar, it should, since drug users continuously pursue drug-associated activities and exposures in a way that seems irrational to the rest of the world. It just might be due to such a mechanism and others like it.

Some important points about science in Dr. Dodes’ article

One very true fact about mental health pointed out by Dr. Dodes is that diseases like schizophrenia, which used to be explained simply as demon possession and evidence of witchcraft can now be, to a large extent, explained by the study of behavioral neuroscience and cognition. The same is true for bipolar disorder, depression, ADHD, and a host of other such conditions. In fact, the study of psychology has only been able to rely on technological advances that allow us to “see” brain function for a few short decades, leading to incredible advances in the field that I think will continue. The thinking that no such advances have, or will continue to be, made in the study of addiction is, in my opinion short sighted.

As I mentioned above, I don’t for a second think that the entire explanation for drug abuse and addiction will come from neurophysiological evidence. The doctor points out that “If we could take a more accurate image of addiction in the brain, it would encompass much of the history and many of the events that make us who we are.” I agree that we need to advance our technology as well as expand our understanding, but I think that to discount neuroscientific explanations completely is a big mistake.