At one point or another, you’ve probably met someone who identifies as “a social drinker” — you may even identify as one yourself. People drink casually for a host of reasons: to help them unwind, because they enjoy the taste, and even as a “social lubricant” to help feel less awkward and make socializing a little easier. While there’s nothing wrong with responsibly sipping some wine or beer at a party, alcohol also has the potential to be misused, particularly when it comes to dealing with social anxiety. A new study found that social anxiety disorder may be linked to substance use disorder, and specifically alcohol use, that weren’t reflected in other types of anxiety disorders.
Lots of people feel nervous when meeting someone new or entering new social situations, but social anxiety disorder is distinguished by a constant fear towards a variety of social situations where the person “is exposed to unfamiliar people or to possible scrutiny by others,” the National Institute of Mental Health (NIMH) writes. A person with the disorder may be anxious about embarrassing themselves to the point where it interferes with their ability to live their life, and NIMH estimates that roughly 12 percent of American adults experience social anxiety disorder in their lifetime. The new research, published in the journal Depression and Anxiety, focused on understanding how the disorder might affect an individual’s relationship with alcohol and their drinking patterns.
Researchers interviewed roughly 2,800 adult twins, assessing level of alcohol consumption and mental health factors including panic disorder, specific phobias and agoraphobia, generalized anxiety disorder, and social anxiety disorder. People with the disorder were associated with a higher risk for potentially developing alcoholism later in life, while the other studied anxiety disorders didn’t appear to be risk factors. Alcohol abuse also had the most significant link with social anxiety disorder.
This link is significant because of how it could affect treatment for both disorders. “Many individuals with social anxiety are not in treatment. This means that we have an underutilized potential, not only for reducing the burden of social anxiety, but also for preventing alcohol problems,” study author Dr. Fartein Ask Torvik said in a statement. “Cognitive behavioral therapy with controlled exposure to the feared situations has shown good results.”
Cognitive behavioral therapy, otherwise known as CBT, is a type of psychotherapy that helps patients by altering patterns of harmful and unhelpful thoughts, behaviors, and emotions. The therapy largely focuses on solutions that help patients question and confront “distorted cognitions and change destructive patterns of behavior,” according to Psychology Today, as well as to develop coping skills. It’s been proven effective as a treatment for a several mental health issues, including anxiety disorders, depression, and eating disorders.
Based on the study results, treating social anxiety and helping prevent it with therapies like CBT could potentially have the benefit of limiting alcohol abuse in patients. The relationship the study pinpointed between excessive drinking and social anxiety suggest further research on the topic is necessary, especially if people are drinking to deal with their mental health instead of seeking mental health treatment.
If you or someone you know is seeking help for substance use, call the SAMHSA National Helpline at 1-800-662-HELP(4357).
Ed Diener and Martin Seligman screened over 200 undergraduates for levels of happiness, and compared the upper 10% (the “extremely happy”) with the middle and bottom 10%. Extremely happy students experienced no greater number of objectively positive life events, like doing well on exams or hot dates, than did the other two groups (Diener & Seligman, 2002).
So it’s not really what happens. It’s what you pay attention to and the perspective you take on things. “Look on the bright side” is a cliche, but it’s also scientifically valid.
Paul Dolan teaches at the London School of Economics and was a visiting scholar at Princeton where he worked with Nobel-Prize winner Daniel Kahneman.
Your happiness is determined by how you allocate your attention. What you attend to drives your behavior and it determines your happiness. Attention is the glue that holds your life together… The scarcity of attentional resources means that you must consider how you can make and facilitate better decisions about what to pay attention to and in what ways. If you are not as happy as you could be, then you must be misallocating your attention… So changing behavior and enhancing happiness is as much about withdrawing attention from the negative as it is about attending to the positive.
Make sense, right? So how can you and I put this to use?
Here are 5 questions to ask yourself about attention that can have a profound affect on your happiness.
Are you actually paying attention?
“Savoring” is a powerful method for boosting happiness. It’s also ridiculously simple:
Next time something good happens, stop whatever you are doing, give it a second and appreciate that moment. Pay attention to it.
Savoring is all about attention. Focus on the bad, you’ll feel bad. Focus on the good and… guess what happens?
In one set of studies, depressed participants were invited to take a few minutes once a day to relish something that they usually hurry through (e.g., eating a meal, taking a shower, finishing the workday, or walking to the subway). When it was over, they were instructed to write down in what ways they had experienced the event differently as well as how that felt compared with the times when they rushed through it. In another study, healthy students and community members were instructed to savor two pleasurable experiences per day, by reflecting on each for two or three minutes and trying to make the pleasure last as long and as intensely as possible. In all these studies those participants prompted to practice savoring regularly showed significant increases in happiness and reductions in depression.
Do one thing at a time. Pay attention. Enjoy it. You’ll feel less busy and you’ll be happier.
(For more on how to savor those precious good moments in life, click here.)
Okay, you’re going to pay more attention. But maybe that’s not your problem. You might be paying attention to the wrong things.
What are you paying attention to?
Why are lawyers 3.6 times more likely to suffer from depression and more likely to end up divorced?
Training your mind to look for errors and problems (as happens in careers like accounting and law) makes you miserable.
I discovered the tax auditors who are the most successful sometimes are the ones that for eight to 14 hours a day were looking at tax forms, looking for mistakes and errors. This makes them very good at their job, but when they started leading their teams or they went home to their spouse at night, they would be seeing all the lists of mistakes and errors that were around them. Two of them told me they came home with a list of the errors and mistakes that their wife was making.
Don’t pay so much attention to the bad. Pay more attention to the good. Stop looking for problems. Enjoy what you have.
Gratitude is arguably the king of happiness. What’s the research say? Can’t be more clear than this:
…the more a person is inclined to gratitude, the less likely he or she is to be depressed, anxious, lonely, envious, or neurotic.
You must teach your brain to seek out the good things in life. Research shows merely listing three things you are thankful for each day can make a big difference.
Every night for the next week, set aside ten minutes before you go to sleep. Write down three things that went well today and why they went well. You may use a journal or your computer to write about the events, but it is important that you have a physical record of what you wrote. The three things need not be earthshaking in importance (“My husband picked up my favorite ice cream for dessert on the way home from work today”), but they can be important (“My sister just gave birth to a healthy baby boy”). Next to each positive event, answer the question “Why did this happen?”
…we found that gratitude, controlling for materialism, uniquely predicts all outcomes considered: higher grade point average, life satisfaction, social integration, and absorption, as well as lower envy and depression.
(For more on how to use gratitude to improve your life, click here.)
Now I know what many of you may be thinking: I agree, but my attention span is terrible.
Well, we can do something about that too.
Can you pay attention?
You spend up to 8 minutes of every hour daydreaming. Your mind will probably wander for 13% of the time it takes you to read this post. Some of us spend 30-40% of our time daydreaming.
Do you remember what the previous paragraph was about? It’s OK, I’m not offended. Chances are that your mind will wander for up to eight minutes for every hour that you spend reading this book. About 13 percent of the time that people spend reading is spent not reading, but daydreaming or mind-wandering. But reading, by comparison to other things we do, isn’t so badly affected by daydreaming. Some estimates put the average amount of time spent daydreaming at 30 to 40 percent.
People spend 46.9 percent of their waking hours thinking about something other than what they’re doing, and this mind-wandering typically makes them unhappy. So says a study that used an iPhone Web app to gather 250,000 data points on subjects’ thoughts, feelings, and actions as they went about their lives.
This is why you keep hearing so much about mindfulness these days. Meditation can help you train your attention. A 2011 Yale study showed:
Experienced meditators seem to switch off areas of the brain associated with wandering thoughts, anxiety and some psychiatric disorders such as schizophrenia. Researchers used fMRI scans to determine how meditators’ brains differed from subjects who were not meditating. The areas shaded in blue highlight areas of decreased activity in the brains of meditators.
(For more on the easiest way to learn how to meditate, click here.)
Another issue may be that you’re not really noticing what truly makes you happy and unhappy. It’s a common mistake. But one we can fix.
Are you paying attention to what makes you happy and what doesn’t?
When something makes you really happy, jot it down. Then do that thing more often. Daniel Nettle jokingly refers to this as “Pleasant Activity Training.”
This staggeringly complex technique consists of determining which activities are pleasant, and doing them more often.
Yeah, it’s stupidly simple. But as Stanford professor Jennifer Aaker explained in my interview with her, you probably don’t do it:
…people who spend more time on projects that energize them and with people who energize them tend to be happier. However, what is interesting is that there is often a gap between where people say they want to spend their time and how they actually spend their time. For example, if you ask people to list the projects that energize (vs. deplete) them, and what people energize (vs. deplete) them, and then monitor how they actually spend their time, you find a large percentage know what projects and people energize them, but do not in fact spend much time on those projects and with those people.
(For more of the things research has proven will make you happier, click here.)
Okay, time to bring out the big guns. This is something you can do at any moment to make yourself happier. And all it takes is asking yourself one question.
Are you paying attention to what’s going on right now?
You probably spend a fair amount of time worrying about the future, regretting the past or reliving an argument that ended long ago.
And that means you’re not paying attention to what’s happening right now. None of those negative things are actually occurring here in front of you. If you were focused on right now, bang, you’d be happier.
They savor life’s pleasures and try to live in the present moment.
That thing you’re making yourself miserable about: is it here, right now, in front of you? Or are you projecting into the future or the past? Pay attention to the present and you’ll probably feel much better.
(For more on what makes the happiest people in the world so happy, click here.)
Still paying attention? Let’s wrap this up.
Most people don’t do anything to make themselves happier.
In our culture, we don’t tend to talk about being “a little bit” addicted to something. It’s not like there are AA meetings for people who are “kind of” alcohol dependent, or a treatment plan for someone who is “a little” obsessed with working out.
But a new book, titled The Addiction Spectrum, is rethinking the idea that addiction is so cut and dry. Author Paul Thomas, MD, an addiction medicine specialist and integrative practitioner, argues that addiction is more of a sliding scale that factors in the severity of the addiction as well as life events, genetic predispositions, and other contributing factors. And, he says, this addiction spectrum is just as applicable to things like food or social media as it is to drugs or alcohol.
Experts have been thinking about addiction as a disease for a long time. But in his book, Dr. Thomas argues that by classifying addiction as a disease, you’re not getting the full picture of how addiction works—and thus you’re missing out on opportunities to turn around a problematic habit before it gets out of control.
But if addiction is more of a spectrum than a you-are-or-you-aren’t kind of thing, how do you know if you actually have a problem? And what does all this gray area mean for treating substance use disorders? Here, leading addiction experts give all the intel, explaining what you really need to know about addiction—and why you don’t have to hit rock bottom to turn a potentially destructive habit around.
Understanding the spectrum
Sometimes addiction is obvious—like when it starts affecting your relationships and career—and sometimes it’s more hidden, making it harder to identify. “I use [noise] volume as a metaphor to explain it to people,” says Neeraj Gandotra, MD, the chief medical officer at Delphi Behavioral Health, a national addiction treatment network. “Sometimes it’s a disorder that’s very loud and disruptive, and sometimes it’s more quiet.”
That’s where the addiction spectrum comes in. “The way someone can figure out where they fall on the spectrum is based on the number of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria you meet,” says Samantha Arsenault, the director of national treatment quality initiatives for Shatterproof, a non-profit dedicated to ending the destruction addiction causes. There are 11 different factors that specialists use to determine someone’s place on the addiction spectrum, including how much of the substance a person is taking and how long they’ve been taking it, whether they feel cravings for that substance, and whether it’s causing problems in their relationships.
“Technically, a mild substance abuse disorder means they have two or three different factors,” Arsenault says. Someone in the middle of the spectrum would have four of five of these factors, she says, while a person with a much more severe addiction would have six or more of symptoms. While the DSM-5 is currently used for substances like alcohol, stimulants, cannabis, and opioids, Dr. Thomas says the concept of the addiction spectrum could apply to anything that could potentially turn problematic (like exercise and sugarconsumption).
“The reason why it’s so important to view addiction as a spectrum is because it means you don’t have to hit rock bottom to turn it around.” —Samantha Arsenault, Shatterproof
Interestingly, this fits in well with the ASAM’s viewpoint on unhealthy substance use. While they do define addiction as a disease, the group also says that there is a whole range of behaviors, from low-risk use (where you’re consuming alcohol or drugs below harmful levels) to hazardous use (where you’re consuming these substances in a way that increases the risk of health consequences) and ultimately addiction. Addiction is less about how much of a substance a person uses or how often they use it, and rather the way in which they respond to those substances, the ASAM says.
To put this thinking in context: “I had a client who was a high-powered executive and he would drink a bottle-and-a-half of wine every night after work to de-stress,” says clinical psychologist Kevin Gilliland, PsyD. “But even though he drank a lot, he would always make it to a 6 a.m. workout. Was he on the severe end of the spectrum? Well, not fully, because he’s holding down a good job and to the outside world he’s not destroying his life in any obvious ways. But he was still putting his health at risk and it actually was greatly harming his relationship with his wife, so it was problematic in those ways.”
A generally non-problematic habit, like a daily glass of wine, can potentially get pushed into more dicey territory. “There are factors that could cause someone to creep up on the addiction spectrum, such as genetic predisposition,” Dr. Thomas says—meaning that if someone in your family is an addict, it could make you more likely to develop an addiction, too. “Or if stressful events in your life occur and you’re turning to that glass to relax, it could increase to two, three, or more a night.” He also adds that it’s pretty common for tolerance to increase, so if you’re drinking a glass of wine to get a little buzz, it could morph into needing more to have the same feeling.
This is not at all to say that everyone who drinks a glass of wine a day will always develop an addiction. But something that seems harmless could potentially transform into a destructive pattern, depending on other factors in your life and your genetic makeup.
The varying degrees of addiction
This might seem overwhelming. But changing how we think about addiction—not as an “on-off” switch, but more as a gradient with levels of seriousness—could be helpful when it comes to prevention, at least according to the experts who tout this way of thinking. “The reason why it’s so important to view addiction as a spectrum is because it means you don’t have to hit rock bottom to turn it around,” Arsenault says. “If you’re on the low or medium end of the spectrum, you can look at that and think about the lifestyle changes you can make before it gets worse.”
Since addiction comes in varying degrees, treatment can vary, too. When Dr. Gandotra is working to treat a patient with an addiction, his first thoughts are on their most basic, primary needs. Do they have a place to live? Are they going to be going through withdrawal? Do they need to be enrolled in a rehab program? “Rehab isn’t always the best answer,” he says. “It really does depend on where they are on the spectrum and factors like if they’re able to hold down a job and have familial support.”
He adds that the substance in question matters, too. “There’s a hierarchy in terms of the consequences. Someone using an illicit substance is at risk of being arrested, or using cocaine puts you at risk for sudden death.” Definitely not the same as being addicted to your phone.
For a person on the lower end of the spectrum, the experts say treatment starts with meeting someone where they are, and what they’re willing to change. “Maybe someone isn’t ready to stop drinking alcohol completely, but they can make the step to limit it to every other night [rather than] every night,” Dr. Gandotra says. “It also allows for the chance to tweak the script a little bit and ask them, ‘Is there any aspect of your drinking you would like to change?’ That can help someone figure out where to start.”
However, in the case of someone with a severe addiction (or a person who is addicted to a life-threatening substance), quitting cold turkey is necessary. “If someone is on the severe end of the spectrum, the physical symptoms need to be addressed first. Then, the lifestyle changes can be addressed,” says Dr. Thomas.
“What I’m really hoping to get across by talking about addiction as a spectrum is, again, you don’t have to hit rock bottom to change,” adds Dr. Thomas. “Maybe your relationship with alcohol, food, screen-time—whatever it is—isn’t as healthy as you would want it to be. You don’t have to reach a tipping point to change it.”
While the exact number of adults with ADHD is unknown, it is estimated that 4% of the U.S. adult population is affected by ADHD. While most people can function very well and become successful despite their condition, ADHD is also associated with life-long impairments in several facets of life, including educational and professional achievements, self-image and interpersonal relationships. But one of the darkest sides of ADHD is its propensity for addiction.
Why ADHD can lead to substance abuse
Addiction is a global problem that affects people from all walks of life, irrespective of gender, financial status, skin color, sexual orientation, religion, or spiritual practice. According to the American Society of Addiction Medicine (ASAM), addiction is “a primary, chronic disease of brain reward, motivation, memory, and related circuitry,” which leads to dysfunctional behavior in order to provoke relief in spite of the negative consequences a person may attract.
“Addiction is an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death,” according to a characterization on the ASAM website.
It’s these changes in the brain that make addiction so dangerous, causing a person to lose control over his or her use of substances. This also leads to subsequent problems at work, in relationships, and with one’s sense of self-worth and esteem.
Some people are more vulnerable to addiction than others. One primary factor which specialists have identified are adverse childhood experiences, which create their own brain changes. Research has also identified neurological conditions that make people prone to addiction, ADHD being one of them.
Attention-deficit hyperactivity disorder (ADHD) is a syndrome characterized by persistent patterns of inattention and/or impulsivity and hyperactivity that is inappropriate for a given age or developmental stage. The exact causes of ADHD are still unknown but the evidence so far suggests that dopamine neurotransmission dysfunction is at least partially responsible for the disorder’s symptoms. This dopamine link may also explain why ADHD often co-occurs with substance use disorders.
The risk of drug and substance abuse is significantly increased in adults with persisting ADHD symptoms who have not been receiving medication.According to one study, ADHD is associated with a twofold increase in the risk of psychoactive substance use disorder. In addition, it is estimated that more than 25% of substance-abusing adolescents meet diagnostic criteria for ADHD. A 2004 survey found that 60% of the adults with ADHD have been addicted to tobacco while 52% have used drugs recreationally.
“One of the strongest predictors of substance use disorders in adulthood is the early use of substances, and children and teens with ADHD have an increased likelihood of using substances at an early age,” Dr. Jeff Temple, a licensed psychologist and director of behavioral health and research in the department of obstetrics and gynaecology at the University of Texas Medical Branch, told Health Line.
Bearing all of this in mind, clinicians working with patients that suffer from both ADHD and substance abuse may need to use a different approach than they would normally. While the treatment literature for ADHD in patients with substance use disorder is not well developed, the emerging trend is that medications effective for adult ADHD may be effective for adults with ADHD and co-occurring substance use disorder. Exercising regularly and having behavioral health checkups during treatment are also important.
The key seems to be starting ADHD treatment as early as possible, before a person has the chance to develop a substance use disorder during his or her teens. Although there is no “cure” for ADHD, there are accepted treatments that specifically target its symptoms. However, it is essential that ADHD treatment begins when the patient is sober, so some drug or alcohol detox may be required before treatment.
“A conservative approach for treating co-occurring ADHD and SUD would be to begin treatment with a non-stimulant pharmacotherapy, but if an adequate response is not obtained, consider stimulant pharmacotherapy. The decision regarding the use of stimulant medications for a patient with ADHD and a co-occurring substance use disorder should be made on the basis of a broad clinical assessment and an individual risk-benefit analysis. For many patients, psychostimulants can be used safely and effectively; however, careful monitoring during treatment is essential to ensure prescribed stimulants are being used in a therapeutic manner, and in the case of worsening substance use or when faced with evidence of the diversion of prescribed medication, treatment should be discontinued,” according to researchers at the New York State Psychiatric Institute.
Over the last decade, the prevalence of opioid addiction has increased to epidemic levels, but unfortunately therapeutic interventions for the treatment of addiction remain limited. We need to better understand the triggers for the development of addiction in order to develop more targeted prevention and treatments. One of the key questions that researchers in the field of neuropsychiatry are trying to answer is why some people are more vulnerable to addiction. As in most cases of psychiatric disorders, genetic and environmental factors interact to determine how vulnerable, or likely, you are to developing a substance use disorder.
Drugs of abuse, including opioids, act on the brain’s reward system, a system that transfers signals primarily via a molecule (neurotransmitter) called dopamine. The function of this system is affected by genetic and environmental factors. For example, a recent study published in the scientific journal PNAS revealed one of those genetic factors. Researchers demonstrated that a type of small infectious agent (a type of RNA virus called human endogenous retrovirus-K HML-2, or HK2) integrates within a gene that regulates activity of dopamine. This integration is more frequently found in people with substance use disorders, and is associated with drug addiction.
How does stress induce epigenetic changes?
Accumulating evidence suggests that environmental factors, such as stress, induce epigenetic changes that can trigger the development of psychiatric disorders and drug addiction. Epigenetic changes refer to regulations of gene expression that do not involve alterations in the sequence of the genetic material (DNA) itself. Practically, epigenetic changes are information that is added on to already existing genetic material, but can affect the expression of genes.
A stressful situation, such as the death of a significant other or the loss of a job, triggers the release of steroid hormones called glucocorticoids. Those stress hormones trigger alterations in many systems throughout the body, induce epigenetic changes, and regulate the expression of other genes in the brain. One of the systems that is affected by stress hormones is the brain’s reward circuitry. The interaction between stress hormones and the reward system can trigger the development of addiction, as well as a stress-induced relapse in drug or alcohol recovery.
Stress reduction can help reduce the risk of developing an addiction and prevent relapse
Fortunately, the negative effects of stress can be alleviated by other factors, such as physical activity or social support. These behaviors produce epigenetic changes that prevent the development of addiction and can have a beneficial role in treatment when used in combination with other interventions, such as cognitive behavioral therapy and, for some people, medications. One of the ways that physical activity could be effective is by reducing negative feelings, including stress and the accompanied stress-induced epigenetic changes. In the example of a stressful situation such as the death of a significant other or loss of a job, if a person engages in physical activity this can reduce their stress-induced epigenetic changes, which will decrease the risk of developing addiction or stress-induced relapse.
Hope for targeted addiction treatments
We now know that the function and dysfunction of the brain’s reward system is complicated, plastic (undergoes changes based on negative and positive factors), and involves complex interactions of genetic and environmental factors. Alterations in gene expression can lead to changes in the function of the brain’s reward system, so a person is more or less likely to self-administer drugs. Together this knowledge can ultimately lead to the development of multilevel and more efficient prevention and therapeutic approaches to address the ongoing opioid epidemic.
One morning in July, here’s the scene outside a neighborhood train station: While an ambulance winds its way through traffic nearby, people sit on the stairs with their heads buried in their arms. Others hustle for spare change or hawk “works” — street slang for a syringe. Several of the drug users stand stooped, their bodies droop then jerk back up again in the rhythm of a heroin nod.
At this spot, less than a week earlier, six people overdosed in the span of 15 minutes.
“It’s like watching TV,” said local resident Cano Gomez. “You stand here and it’s like watching a whole reality show, a one-hour reality show, to stand out here. I’m telling you man, it’s crazy.”
For people addicted on the streets, overdosing is just one worry on a long list of hardships. Many have lost their homes, jobs and families. They’ve seen friends die and get locked up. And when they try to explain how all of this happened, many say they are sick.
No matter who is talking about addiction these days, chances are they are using that term: “disease.”
From former President Barack Obama, to former New Jersey Governor Chris Christie, to President Donald Trump, politicians on both sides of the aisle now talk about addiction as a public health issue.
“This epidemic is a national health emergency,” Trump declared less than a year into his presidency.
There’s a growing consensus that addiction is a disease of the brain that requires medical treatment. Among consensus are people in recovery, their advocates, and police.
It feels like a far cry from the days when conventional wisdom viewed addiction as a moral failing that called for criminal punishment.
But calling addiction a brain disease, and not a bad life choice, is still a fairly new concept — one that has been built up over the past few decades by researchers toiling to understand how addiction affects the brain. As that view gains wider acceptance, some critics are challenging whether it’s really appropriate to call addiction a “brain disease.”
A rewired reward system
Charles O’Brien, a professor of psychiatry at the University of Pennsylvania, has been doing research on addiction since the 1960s. He says back then, psychiatrists tended to view drug addicts as, essentially, psychopaths.
“It was related to antisocial personality, and that’s not really true,” O’Brien said.
Researchers did know that the body could become dependent on a drug over time. And with new technologies, O’Brien and his colleagues were able to see the impact drugs had on the brain.
“Beginning in the 1980s, we started doing brain imaging, and we developed cues that were associated with drug use,” he said.
The cues were pictures of things like drug paraphernalia, or a syringe jabbed into a forearm. When O’Brien showed these pictures to people who had a history of addiction and scanned their brains, the effects were astounding.
“People thought that I was giving drugs to my patients in the laboratory, and I wasn’t,” O’Brien said.
The pictures were enough to activate parts of the brain that form what’s known as the “reward system.” They were the same areas that would light up if the person had, say, snorted a line of cocaine.
“Drugs like heroin or alcohol can take over that system,” O’Brien said. “People use the term ‘hijack.’ ”
The reward system is the brain circuitry that gives us a motivating hit of pleasure when we get the things that we need to survive, such as food, sex, and social connection. But drugs deliver a reward that’s much more powerful than those so-called “natural” rewards. When someone becomes addicted, the drug rewards begin to drown out the natural rewards, and the brain gets wired to seek the drug above anything else.
O’Brien’s brain imaging research revealed one very important way the brain gets rewired: people developed a conditioned response to things they associated with their drug use that mimicked the effects of getting high. So even just the sight of a needle or a bottle could trigger powerful cravings that could make it almost irresistible to start using again, even long after someone’s gotten clean.
“They relapse because it’s still in their brain,” O’Brien said.
His finding helped explain the hallmarks of addiction: how people almost always relapse, and keep using drugs despite the often devastating personal costs. The work provided a scientific basis for calling addiction a brain disease.
Scientists continue to build on this discovery to better understand the complicated — and sometimes unexpected — ways that addiction affects the brain.
What cute babies can tell us
In a basement laboratory at the University of Pennsylvania, psychiatrist Daniel Langleben uses a giant fMRI machine to see inside the brains of people recovering from addiction.
As a 25-year-old mother — who’s in treatment for opioid addiction — lies inside, researchers show her a series of baby photos while the machine scans the woman’s brain.
“The task involves you being asked to either rate how cute is the baby, or to what extent you would like to take care of it,” said Langleben, a research professor at the university.
As it turns out, these cute babies can activate the same part of the brain’s reward system that lights up when people use drugs.
“Specifically it’s called nucleus accumbens,” Langleben said. “It’s a very, very small area, deep inside the brain.”
He’s done other research showing that the nucleus accumbens responds to the unique features of an infant’s face, which are called “baby schema.”
“Big eyes relative to the face for example, large forehead, small chin — all these things that will tell you this is a baby,” Langleben said.
Research suggests that our brains are wired to get a motivating hit of pleasure just from seeing baby schema, he says.
“The hypothesis is that it is made to be rewarding exactly because nature needs us to take care of the young,” Langleben said.
But opioid addiction could make people less sensitive to baby schema. So he’s testing whether a participant’s response to those cute babies changes as they progress through addiction treatment, and whether that correlates with better parenting.
Brain research has helped to explain the cravings and relapse people experience in addiction, and this new frontier of research Langleben is involved in may shed light on some of the social consequences, such as neglecting childcare. Science has moved our understanding of addiction out of the realm of morality and into the medical world, as a disease that can be treated.
Nevertheless, the “brain disease” definition of addiction has attracted plenty of critics.
Sally Satel, a psychiatrist in Washington, D.C., and lecturer at Yale School of Medicine, doesn’t contest the science on how addiction affects the brain. But she still takes issue with calling it a “brain disease.”
Satel says addiction isn’t like catching an infection, or a defect that spontaneously appears in the brain. To make her point, she draws a comparison with Alzheimer’s disease. It would be “meaningless,” she said, to ask someone with a brain disease like Alzheimer’s why they have the condition.
“But if I were to ask you why do you drink too much, why are you using heroin everyday, that’s a meaningful question,” Satel said. “And it goes to the fact that people use drugs for reasons.”
That makes her skeptical that interventions such as medication are really enough to help people stay in recovery.
“A lot of people still want to alter their consciousness, they’re in a lot of psychic pain,” Satel said.
Another critic is trying to reconcile addiction’s roots in both biology and behavior. Maia Szalavitz, a journalist who’s been covering addiction for 30 years, was addicted to drugs herself when she was in college.
She’s also a self-described “deadhead,” a devotee of the legendary rock band The Grateful Dead.
In her book, “Unbroken Brain” — a play on the title of one of the band’s songs — she writes about her first time doing cocaine, at age 17, with Jerry Garcia, the front man of the group.
“I sort of had the kind of hippie attitude of like, ‘white powders are bad,’ but you know if Jerry offers you a line you’re gonna do it,” Szalavitz said.
A few years later, she got busted for cocaine possession. It was a wake-up call. Soon she entered treatment and began her recovery.
Szalavitz says you can’t blame Garcia for all of that, though. She’d already experimented with other substances at that point. The druggy music scene she was a part of in the 80s gave her a sense of identity, and the chemicals themselves relieved her social anxiety.
“Generally 90 percent of addictions happen in the teen and young adult [years],” Szalavitz said. “That’s a sensitive period of brain development.”
For Szalavitz, addiction is not a brain disease, exactly. In her book, she takes a deep dive into modern addiction science and makes a case that addiction is fundamentally about learning. She offers the example of what can happen when people are put on opioids in the hospital after surgery.
“There are people who become physically dependent on opioids in the hospital for pain, and they don’t know it,” she said. “And they go home, and they feel like they have the flu […] they never realized that they had a physical dependence on an opioid.”
Eventually, the opioid withdrawal symptoms pass and they go on with their lives, Szalavitz says.
“If you don’t learn that a drug fixes some kind of problem for you, you can’t be addicted to it because you wouldn’t know what to crave,” she said.
Szalavitz says the way that compulsive drug use is learned isn’t given enough weight when we label addiction a brain disease. She thinks it should take center stage. The gist of her argument goes back to those baby photos researcher Daniel Langleben was showing to former opioid users. Szalavitz says the connection between opioid addiction and the way we can become obsessed with a cute baby is key to the story of what addiction really is.
The same holds for other human relationships, she says. A lover’s touch, a friend’s reassuring presence, a happy baby cradled in your arms — all of these moments are rewarded by naturally occurring opioid neurotransmitters in the brain.
“What opioids do in the brain when they’re not relieving pain is they are there to create social bonds,” Szalavitz said.
When we don’t abandon an infant that throws up on us and cries through the night, or continue to chase a love interest after a crushing rejection, Szalavitz points out that these behaviors look a lot like addiction.
“People with addiction are persisting despite negative consequences in a way that’s necessary for human survival,” she said. “We evolved this thing for a reason, because it’s hard to deal with people, and babies are a pain in the butt, and they cry and you have to change them, and you have to persist if you are going to survive and reproduce successfully, right?”
Szalavitz says people have learned to love the wrong rewards.
Plus, she says, to understand why people want to alter their experience with chemicals in the first place, you have to look outside the brain.
“Trauma is one of the other big factors,” Szalavitz said. “About two thirds of people with addiction have at least one childhood trauma.”
There’s also socioeconomic factors that contribute.
“Unemployment, poverty, kind of being socially disconnected,” she said. “There are very few people with addiction who have none of those elements.”
Szalavitz says the way we talk about addiction now, as a brain disease, misses the mark. But she says it’s not so much the words that matter, but what exactly we mean when we say them.
“I just want people to understand that this is a learned behavior in which a system that is there for essential survival and reproduction stuff goes in the wrong direction,” Szalavitz said. “It’s not an inhuman behavior, it’s not about evil, manipulative, horrible, lying people.”
This story was made possible in part thanks to a grant from the Scattergood Behavioral Health Foundation.
It is a well known fact that those that suffer from PTSD are at a much higher risk for falling into substance abuse. Many people with PTSD often find themselves going for the bottle or something else harmful to help quickly find relief from their pain. But could early substance abuse actually lead to PTSD? […]
Detoxing off heroin or opioids without medication is sheer hell. I should know.
For many users, full-blown withdrawal is often foreshadowed by a yawn, or perhaps a runny nose, a sore back, sensitive skin or a restless leg. For me, the telltale sign that the heroin was wearing off was a slight tingling sensation when I urinated.
These telltale signals — minor annoyances in and of themselves — set off a desperate panic: I’d better get heroin or some sort of opioid into my body as soon as possible, or else I would experience a sickness so terrible I would do almost anything to prevent it: cold sweats, nausea, diarrhea and body aches, all mixed with depression and anxiety that make it impossible to do anything except dwell on how sick you are.
You crave opioids, not because you necessarily want the high, but because they’d bring instant relief.
Quitting heroin was my plan every night when I went to sleep. But when morning came, I’d rarely last an hour, let alone the day, before finding a way to get heroin. My first time in a detox facility, I made it an hour, if that. As I walked out, a staff member said something to the effect of “I didn’t think you’d last long.”
After my parents moved out of town, in part to get away from me, I would show up at their new home five hours away with big hopes of kicking the habit and starting a new life. But after a night of no sleep, rolling on the floor convulsing while vomiting into a steel mixing bowl, I’d beg them for gas money to drive the 300 miles back to where I lived and a little extra cash for heroin. I did this so often my mother once told me in frustration, “You show up, throw up and then leave.”
Going through “cold turkey” withdrawal is, not surprisingly, impossible for many. That’s why the medical community has largely embraced the use of methadone and buprenorphine — known medically as medication-assisted treatment, or MAT — combined with counseling, as the “gold standard” for treating opioid addiction. As opioids themselves, these drugs reduce craving and stop withdrawals without producing a significant high, and are dispensed in a controlled way.
“Detox alone often doesn’t work for someone with an opioid use disorder,” said Marlies Perez, chief of substance use disorder compliance at the California Department of Health Care Services, who estimated that it might be a realistic option for only 15 out of 100 people.
Studies have also shown that MAT reduces the risk of overdose death by 50 percent and increases a person’s time in treatment.
Yet even with strong evidence for MAT, there is debate over whether to offer MAT for people struggling with opioids. Some states, like California, have vastly expanded programs: The Department of Health Care Services has 50 MAT expansion programs, including in emergency rooms, hospitals, primary care settings, jails, courts, tribal lands and veterans’ services; the state has received $230 million in grants from the federal government to help with these efforts. But many states and communities hew to an abstinence or faith-based approach, refusing to offer MAT as an option. In 2017, only about 25 percent of treatment centers offered it.
Just as each person’s journey into addiction is unique, different approaches work for people trying to find their way out. Public health experts believe they should all be on the table.
Diane Woodruff, a writer from Arizona who became addicted to opioid medication prescribed for a bad back, described withdrawal like this: “If you’ve ever had the flu it’s like that but times 100.” Woodruff went through the sickness every month for five days until she could refill her prescription of OxyContin.
Other people described the sickness as if ants were crawling under their skin or acid was being injected into their bones. Woodruff was able to quit for good after she went cold turkey, sort of. She used kratom and marijuana to help with the detox.
Noah, a 30-year-old from San Francisco who asked that his last name not be used, said that MAT was a “miracle,” therapy adding, “It saved my life.” Noah spent five years on Suboxone, a brand-name formula of buprenorphine and naloxone, right around the time fentanyl began taking lives with impunity. Suboxone took away his craving for heroin, but he kept drinking alcohol and injecting cocaine and using other drugs for a while until joining a sobriety community. He finally weaned off MAT half a year ago.
“There’s no debate that MAT works — the evidence is clear,” said Dr. Kelly Clark, president of the American Society of Addiction Medicine. Opioid use changes the chemistry of the brain, sometimes permanently. Buprenorphine and methadone stop the withdrawals, diminish cravings and, when taken as prescribed, block the high from other opioids. These medications “tone down and reset the brain,” helping to “normalize” the individual, Clark added.
Within the nine years of my heroin use, I tried to get sober many times: detox, residential rehab, and with morphine and methadone under the guidance of a health care professional. For me, Suboxone didn’t prove the answer, although (to be fair) I never took it as prescribed under the supervision of a doctor. I was ambivalent and incapable of following directions, let alone a treatment plan. I didn’t want to be shackled to another opioid or have to check in with a health care professional every week or month or have to go to counseling — even if all that could have helped me to function better. (A common critique of methadone or buprenorphine is that it is just replacing one drug for another.)
But Suboxone ultimately kick-started me into sobriety. One day in December 2008, I tried one more time to detox successfully off heroin at my parents’ house. To make it easier, I had a couple of pills of Suboxone, illegally obtained. So, after the body aches and that weird feeling when I peed, the buzzing ball of anxiety began to grow in the pit of my stomach and, just when life began to seem unbearable, I crushed one of the Suboxone tablets up and snorted it off my dresser. Unbeknownst to me at the time, when Suboxone is crushed, it releases an anti-tampering chemical that sends the user into full-on withdrawal.
I spent the next three days shut up in a room as my body and mind began to unravel. I barely slept and there was plenty of diarrhea and vomiting. After the worst of it was over, I apathetically roamed my parents’ house, not sleeping for two weeks. Then, I joined a sobriety community and haven’t touched an opioid in 10 years.
MAT was not the escape route from addiction for me, personally, and I have mixed feelings about these medications. But with tens of thousands of opiate overdose deaths each year, it makes sense that people struggling with addiction and facing the terrifying specter of withdrawal have every option available.
A significant amount of data has been generated in recent years showing that cannabis access is associated with reduced levels of opioid use and abuse. But emerging data also indicates that many patients similarly substitute marijuana for a variety of other substances, including alcohol, tobacco and benzodiazepines.
Last month, a team of researchers from Canada and the United States surveyed over 2,000 federally registered medical cannabis patients with regard to their use of cannabis and other substances. (Medical cannabis access has been legal across Canada for nearly two decades).
Investigators reported that nearly 70 percent of respondents said that they substituted cannabis for prescription medications, primarily opioids. Forty-five percent of those surveyed acknowledged substituting cannabis for alcohol and 31 percent of respondents said that they used marijuana in place of tobacco.
Among those who reported replacing alcohol with cannabis, 31 percent said they stopped using booze altogether, while 37 percent reported reducing their intake by at least 75 percent. Fifty-one percent of those who reported substituting cannabis for tobacco said that they eventually ceased their tobacco use completely.
This documentation of cannabis substitution is not unique. A 2017 study of medical cannabis patients similarly reported that 25 percent of the cohort reported substituting cannabis for alcohol, while 12 percent substituted it for tobacco. A 2015 paper published in the journal, “Drug and Alcohol Review” also reported that over half of patients surveyed substituted marijuana in lieu of alcohol. A placebo-controlled clinical trialperformed by researchers at London’s University College reported that the inhalation of CBD — a primary component in cannabis — is associated with a 40 percent reduction in cigarette consumption.
Numerous studies also indicate that legal cannabis access is associated with reductions in overall prescription drug spending. While much of this reduction is the result of the reduced use of opioids, studies also report decreases in patients’ consumption of other prescription drugs, such as sleep aids, anti-depressants and anti-anxiety medications. A 2019 study by a team of Canadian researchers reported that the use of marijuana is associated with the discontinuation of benzodiazepines. (The popular anti-anxiety medication was responsible for over 11,500 overdose deathsin the United States in 2017, according to the US Centers for Disease Control). In their study of 146 subjects, the initiation of medical cannabis resulted in significant and sustained reductions in patients’ use of the drug.
By the trial’s conclusion, 45 percent of participants had ceased their use of benzodiazepines. In a separate study, also published this year, of over 1,300 US medical cannabis patients suffering from chronic pain conditions, 22 percent reported substituting marijuana for benzodiazepines.
These scientific findings run contrary to the so-called “gateway theory” – the long-alleged notion that marijuana exposure primes users to ultimately engage in the use of far more intoxicating and addictive substances. By contrast, for many people cannabis appears to act as an “exit drug” away from potentially deadly pharmaceuticals, booze, cigarettes and even other illicit substances such as cocaine.
As more jurisdictions move away from cannabis prohibition and toward a system of regulated access it will important to monitor the degree to which these trends continue and to assess their long-term impacts on public health and safety.
Paul Armentano is the deputy director of NORML — the National Organization for the Reform of Marijuana Laws. He is the co-author of the book, Marijuana Is Safer: So Why Are We Driving People to Drink? and the author of the book, The Citizen’s Guide to State-By-State Marijuana. Laws.
When we think of addiction, our thoughts tend to turn to drug and alcohol addiction but addiction can relate to numerous different things; drugs, alcohol, food, exercise, pornography, gaming, social media, tattoos, self-harm, gambling, shopping – anything that we feel as though we’re not in control of, and has an impact on our mood and behaviours. Addiction can be incredibly difficult to cope with, particularly when the things we’re addicted to are often readily available. Depression and addiction can go hand in hand. Addiction can help us to cope with depression, but equally, depression can be caused or worsened by the things we’re addicted to.
Depression: Coping With Addiction
In terms of addiction, triggers are any emotional or environmental factors that cause us to feel as though we need to use our addiction. It could be related to people, places, things, times of the year, or something else. Working out what our triggers are can take time, but once we know what they are, we can avoid them or learn ways to manage them.
High-risk situations are similar to triggers, but rather than being a specific ‘thing’, such as ‘seeing a person walking a dog’, they’re specific situations. This could be something like Christmas, seeing family, or getting a piece of negative feedback at work. Sometimes these situations can be difficult to spot until we’re in them, so it can be helpful to make a note when a situation causes us to feel like we need our addiction.
Once we identify these situations, we can make a plan for how to cope with them without turning to our addiction.
For example, if one of our high-risk situations is ‘seeing my auntie’, we might choose to see them less often, only see them in the company of other friends/family, and invite a friend to stay over for the night whenever we do see them, so that we’re not having to cope alone. We could also note down any alternative coping mechanisms we could use, so that we don’t have to think about them ‘in the moment’, and can just refer to our notes. It’s often helpful to write down a couple of different ideas because sometimes our first or second ideas aren’t possible or don’t work.
Depression: Coping With Addiction
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WORKING OUR HOW OUR ADDICTION HELPS US
If our addiction didn’t help us on some level, we wouldn’t keep using it. Something that can be really key when coping with addiction is working out how it helps us and then finding a healthy coping mechanism to replace it. It can sometimes be helpful to use the acronym ‘Hungry Angry Lonely Tired (HALT)‘ when thinking about the need that we’re filling, as these are common emotions associated with addiction.
ALTERNATIVE COPING MECHANISMS
Having a list of coping mechanisms that we can use when we want to turn to our addiction is helpful. We’re all different, and we all turn to our addictions for different reasons, so we will find that different coping mechanisms work for different people. As an alternative to our addiction, we could try things like watching TV, reading, walking, talking to a friend, drawing, writing, painting, listening to music, listening to podcasts, doing some breathing exercises, ripping up sheets of paper, drawing on ourselves, running, cleaning, self-soothing, doing some puzzles, singing, hugging a pet, dancing, playing with play-doh or contacting a helpline. Sometimes we’ll have to try a coping mechanism a few times before we can get it to work for us – practice makes perfect!
There are times when we don’t see the point in fighting our addiction. It feels too hard. We’re too tired. There’s no point because we can’t do it so why even bother trying?!
At times like these, we have no interest in reaching out for support, or in using healthy coping mechanisms.
These times are very ‘high risk’, in terms of falling back into our addiction. Having reminders of why we don’t want to go there can help us to keep going. This could be in the form of photos on our phone, on the wall, or in our purse or wallet. We might have lists of ‘reasons to keep going’, or ‘things we want to do once we’re up to it’. There might have been a time when we had a particularly amazing day, and we might have a momento from that day that we can hold. A specific smell or taste could take us back to happier times that we’re hoping to replicate at some point in the future. Keeping little reminders in our house, bag, or coat pocket, can help us to keep going at times when we want to return to our addiction.
There are times when things go really well, and we feel like we’re beating our addiction. At other times, things don’t go so well, and it can feel as though our addiction is beating us.
It’s important to remember that a lapse is not the same as a relapse. Recovery is not a straight line. Whether things go right, or wrong, it’s important to reflect and learn from them.
If we’ve managed a difficult situation without turning to our addiction, then that’s wonderful progress! How did we do it? What coping mechanisms did we use? Is there anything that could be helpful to note down so that we know to try it again in the future?
If we’ve struggled through a difficult situation and turned to out addiction, then we haven’t failed, we’ve just had a wobble. Recovery is a learning curve, and we can learn as much (if not more) from our mistakes as from our successes. What went wrong this time? Was there a trigger that we weren’t expecting, or a high-risk situation that we didn’t know would be high-risk? Did anything go right? Can we think of anything we could do differently in future? Sometimes we have to try a coping mechanism a few times before we can get it to work. At other times, we might have tried a coping mechanism that didn’t work for us at all, so it’s not one that we want to try again.
This reflection can be really important because it can help us to keep moving forward. Some of us might find it helpful to journal this sort of thing.
Depression: Coping With Addiction
HONESTY IS IMPORTANT
One of the most important things when it comes to addiction is honesty. Honesty to others, and honesty to ourselves. Lying to ourselves and others is likely to cause a lot of problems, so even when it’s really difficult, it’s important to try and tell the truth.
We don’t have to cope with addiction alone. Addiction can be incredibly strong, so we need to try and build up a strong support system to fight it with. Our support system doesn’t need to be massive, but it can be helpful to have a couple of friends or family members or organisations we can turn to when we’re struggling. Sometimes, it can be dangerous to stop an addiction ‘cold turkey’, so it’s often a good idea to reach out for some professional support on top of the support we get from our loved ones. We might also find that some medication, therapy or counselling from professionals is something that we need.
There are times when we struggle to let people help us. We might feel as though we don’t deserve it or we’re being a burden – but we do deserve support, and in the same way that if one of our friends were struggling, we’d want to support them, our friends will probably want to support us. There are times when it can be hard to reach out for support because we don’t have any hope, but there’s nothing wrong with letting other people hold our hope for a little while until we’re able to hope again.
On top of support from our friends, family, and professionals, we might find that support groups with others who have experienced similar addictions to us can be comforting and can help us to cope. Sometimes being around others who’ve experienced similar things to us can help us to feel less alone, and can give us some hope of things improving. There are different support groups for different addictions including alcoholics anonymous, narcotics anonymous, national self-harm network, sex addicts anonymous, overeaters anonymous, Beat support groups, on-line gamers anonymous, and gamblers anonymous.
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