Science is giving us new insights into our dangerous dance with addictive substances.
By then, her son’s addictive path from cannabis to alcohol to methamphetamine was heading one way. He was lonely, unemployed and sunken-eyed, with bruised track marks up his arms. He connected only with those who tolerated his behaviour: other addicts.
Like a forensic scientist, Whyte searched for clues in her son’s life to discover why a clever, sensitive boy and keen athlete started the downward slide into addiction. Rogue genes? Close relatives had a history of alcohol and cannabis abuse. Trauma? His parents separated when he was young; an undiagnosed learning disability led to a slow aggregation of academic and social failures. Environment? Whyte later discovered her son had started smoking cannabis at 13; his heavy drinking at 16 was not unusual at a time when getting wasted on the weekends was seen as par for the teenage course.
“Tell me one person who hasn’t tried alcohol or dope,” Whyte says from her Kāpiti home. “People go to hospital, have morphine, laugh about it. Let’s be honest, we’re a culture that likes getting out of it.”
The result is that “alcohol and other drugs are tearing families and communities apart”, according to the report of the Government’s Inquiry into Mental Health and Addiction, “He Ara Oranga”. Sixty per cent of community-based offenders and 87% of prisoners have or have had an alcohol or other drug problem, the report says, and more than half of youth suicides involve alcohol or illicit-drug exposure.
A 2017 Massey University Illicit Drug Monitoring System (IDMS) report corroborates these findings. It identifies sharp rises in the availability of methamphetamine and crystal methamphetamine (the imported type) and a growing street morphine market. Although cannabis, synthetic cannabinoid and ecstasy availability has fallen in recent years, there is evidence that all three have become stronger.
And then there are opioids, such as fentanyl, which are killing more Americans than road crashes. Opioids killed more than 43,000 Americans in 2017 compared to about 40,000 in car crashes, and the crisis is so severe it’s causing overall US life expectancy to fall. New Zealand anaesthetist and pain physician Mike Foss says we are heading in the same direction. “New Zealand needs urgent action to ensure we avert a similar disaster,” he says, describing opioid addiction as one of the greatest public health crises of our time. Misuse of fentanyl, a powerful painkiller, is one of the main culprits.
In the past, addicts were seen as morally flawed individuals deserving only of social isolation until they atoned for their “sins”. In the second half of last century, brain research advances gave new insight into the processes that underlie desire, learning, emotional regulation and habit formation. In the following decades, studies identified the effects of cocaine, amphetamine, morphine, cannabis and alcohol on the area of the brain responsible for reward-seeking, the striatum, as well as in the amygdala, which mediates emotional salience; the hippocampus, involved in memory; and several regions of the prefrontal cortex, responsible for various cognitive functions.
In the 30 years since US neuroscientist Judith Grisel ended her 10-year addiction to drugs and alcohol, she has been researching the science behind our centuries-old dance with addictive substances.
Alcohol, for example, is a tiny molecule that alters levels of certain neurotransmitters, the chemical messengers that control thought processes, behaviour and emotion. It suppresses glutamate, which controls energy levels and the brain activity critical for forming new memories, and increases the inhibitory neurotransmitter GABA, which reduces energy levels and calms everything down. In moderate doses, this reduces anxiety, but at higher levels, it has a sedative effect and eventually causes sleep – or blacking out. All in all, she says from her office at Bucknell University in Pennsylvania, alcohol is a blunt tool, working like a sledgehammer to disrupt cell functioning.
Cocaine, heroin and ecstasy have a more specific effect on the brain, working in a few discrete spots to block the recycling of dopamine and other neurotransmitters in a way that enhances pleasure, arousal and movement.
In contrast, the active ingredient in marijuana, delta-9-tetrahydrocannabinol (THC), acts throughout the brain, enhancing or exaggerating communication between cells. By flooding the entire brain, Grisel says, marijuana can make everything take on a “sparkling transcendence”. It’s great for boredom and, perhaps, creativity, but chronic exposure reins in the brain’s natural endocannabinoid system, instrumental in sorting out relevant items from the relentless stream of inputs. “Those [brain receptor] sites downregulate. The more you use and the more often you use, the fewer of those receptors there will be. So, when you take the drug away, things seem lifeless and grey.”
Opiate compounds such as heroin, fentanyl and oxycodone, or their less-potent analogues tramadol and codeine, are still the drug of choice for acute or chronic pain. Users feel content and comfortable, but again, the brain comes to rely on the external substances to produce the desired effect. “When we take them away, we feel full of suffering, more than we had to begin with.”
All these changes relate primarily to the transmission and reception of dopamine, a neurotransmitter that ferries the message of pleasure around the brain. In addiction, the user’s chosen substance or behaviour, or just the anticipation of that substance or behaviour, becomes the main instigator of that dopamine activity. For some, all it takes is the smell of tobacco, the pop of a champagne cork or a pokie machine’s flashing lights to send dopamine levels soaring, crowding out considerations of health, work, family or life itself.
Seductive trap of addiction
“Dopamine is a signal to the person that what they are doing is really important,” says Doug Sellman, professor of psychiatry and addiction medicine at the University of Otago. “People seek drugs, go to the casino, take alcohol as if their lives depended on it.”
And addiction does take practice. Sellman describes it as a kind of apprenticeship. Over time, the brain comes to rely on these external stimuli to trigger that dopamine signal. At first, you keep using a drug to feel good, but eventually you keep using it not to feel bad.
This is the seductive trap of addiction, leaving the user with an insatiable urge to re-experience that first rush while avoiding the increasing blandness of an unenhanced world.
“An addict doesn’t drink coffee because she is tired,” Grisel writes in her new book, Never Enough: The Neuroscience and Experience of Addiction. “She is tired because she drinks coffee. Regular drinkers don’t have cocktails to relax after a rough day; their day is filled with tension and anxiety because they drink so much. Heroin produces euphoria and blocks pain in a naive user, but addicts can’t kick a heroin habit, because without it they are in excruciating pain.”
In the US, in particular, these neurological findings have been used to reframe addiction as a disease of the brain. This is the definition adopted by the American Psychiatric Association, the American Society of Addiction Medicine and the National Institute on Drug Abuse.
Not a disease
US neuroscientist, developmental psychologist and former addict Marc Lewis disagrees. He argues that addiction is a form of self-medication that works against psychological suffering. Yes, brains do change with the regular use of certain substances, but the brain is meant to change with new learning experiences, and it changes more radically in response to repeated experiences that have a high feel-good effect. Over time, those changes stabilise and consolidate.
This difference is important, says Lewis, on the phone from the Netherlands, where he is teaching at Radboud University. The disease scenario makes it harder for addicts to believe they will ever kick their addiction or that they can recover as a result of their own efforts. Once you realise it is not a disease, “you recognise the lot of work people can do on their own. Suddenly, they can say, ‘I don’t want to live like this, I don’t need this any more, I can change this.’ And most of those who do stop, stop on their own without any formal treatment.”
Lewis tried a number of times to kick his addiction – to heroin, then LSD, then pharmaceutical opiates. Each time, he went back. “Until I didn’t. Until I got really sick of being an addict.”
He wrote the word “No” on a piece of paper and tacked it to the wall. He told himself repeatedly not only that he couldn’t do drugs any more but also that he didn’t want to do drugs any more. He meditated and took up tai chi. After a few weeks, he wrote, “The thought of going back to drugs was not only less and less appealing but also increasingly repellent. Over several months, thoughts about drugs became boring. In a year, I found it hard to remember exactly what the attraction had been.”
So, brain or behaviour? Disease or decision? Sellman says the arrows go both ways, that addiction is both a neurologically based brain disease and a behavioural disorder, part of an ongoing feedback loop between experience and brain change. “It is a spiritual condition, a behavioural condition, a learnt condition, a progressive brain disease – all these positions can be justified. It often starts with pleasure as a pursuit, then becomes driven, compulsive, dehumanised behaviour.”
Some people are genetically predisposed, and are better at it. Sellman says there is about 50% heritability in addiction. About half of that genetic vulnerability is a generalised factor, so if you have one addiction, you are more vulnerable to others, but the other half is more specific, be it for alcohol, cannabis, gambling, food or sex.
“But it is not one or two genes, it is 300 or 400 interacting with each other and with many environmental influences. So, it is not a genetically determined disorder, it is a genetically influenced disorder. We are all on a continuum for addiction: we are humans, we are pleasure-seeking animals, we move away from pain and we like things easy.”
Genetic influences are also contingent on early childhood experiences. The gene involved in the uptake of the neurotransmitter serotonin, for example, can affect our tendency to act impulsively, engage in pro-social behaviour and succumb to anxiety, but anxiety is also shaped by relationships with our primary caregivers. Those with high anxiety – whether from inherited liabilities, stressful experiences or both – are obviously more likely to enjoy the benefits of sedatives such as alcohol and benzodiazepines.
Lewis says addiction is frequently accompanied by depression, difficulties in negotiating the social world, family issues, feelings of inadequacy and an overwhelming sense of shame. “In these cases, the ache is deeper, so the drug high, whatever it is, becomes more attractive.”
In some instances, people do just stop – teenage gaming, for example, may simply peter out as other activities become more appealing. Sometimes it takes a major event – a health scare, bankruptcy, a foundering marriage – to prompt the slow crawl back to non-addiction.
Sellman says for some, addiction to alcohol, drugs, gambling or even recreational food gets worse and worse “until people die or suicide or get put into prison or mental health hospitals. It is not a matter of changing your mind, you have to change your brain, and the way you change your brain is by practising new behaviours.”
He recommends a range of individually tailored treatments and services to achieve those changes, including medication to help in the early days of withdrawal and to suppress craving, a kindly doctor, a psychiatrist or psychologist, self-help groups, peer support, residential programmes and detox services. For some, a 12-step programme, such as that offered by Alcoholics Anonymous, is the key. For others, cognitive behaviour therapy, acceptance and commitment therapies, meditation and/or mindfulness play an essential role. “It is a process of recovery,” says Sellman, “one that needs to be supported by a string of internal resources and people.”
Some addicts, says New Zealand Drug Foundation (NZDF) executive director Ross Bell, need support to reach their goals of sobriety or abstinence, whereas others have more modest goals. “It could be to cut down, to use sterile injecting equipment, to maintain a relationship with their kids, to hold down a job. We have to look at those goals, then ask, ‘What sort of support systems do we need to put in place?’”
Addiction and relapse
Recovery itself is a mutable term. Over time, thanks again to the brain’s innate plasticity, the old pathways begin to shrivel up and new behaviours start to trump old behaviours, but the memory of the past lingers. People who relapse don’t have to work as hard to fall into those old patterns as they did when they first became addicted; the old pathways, says Sellman, “get reignited worryingly quickly”.
Grisel has been clean for more than 30 years, but moderation is still not appealing. “Often, people ask whether I want a glass of wine or a hit off a joint, but I don’t want just one glass or a light buzz, I want the whole bottle, the bag and then some more of each.”
Addiction and relapse are all the more likely in an environment that accepts and promotes such behaviour, be it the consumption of junk food or alcohol, vaping, gambling or the touch-button psychological hit of online gaming or pornography. Sellman says the easy availability of cheap alcohol normalises this country’s heavy drinking culture.
“Worse, it is glamorising it. It is making people who don’t use [alcohol] feel they are not in the in-group. It is tobacco all over again. It is a huge issue in the courts, in hospitals, in GP surgeries, in people’s houses, but it is so prevalent, so much a part of our culture, that people don’t even recognise it as an issue. If we took heavy drinking out of the picture, the country would get so much gain and well-being and economic benefit.”
Hindering these efforts, Sellman says, are the immediacy of electronic forms of behavioural addiction, such as online pornography, gambling and gaming, and the commercial industries that benefit from the promotion and sale of addictive products.
“Look at vaping. ‘Big money’ is corrupting a potentially valuable intervention for tobacco smoking by commercialising it, glamorising it and attracting young people to vaping who never thought of smoking, as if it is a cool thing to do, then they realise cigarettes are even more compelling.” The potential legalisation of cannabis for personal use, which hinges on a referendum at the 2020 election, is buoying the same entities, which see another commercial opportunity.
Young people, in particular, are most at risk. Adolescence, up to the age of about 25, is a critical period for brain development, particularly the prefrontal cortex. This area, just above the eyes, is most responsible for “adult” abilities, such as abstract reasoning and impulse control. Unfortunately, it’s the last brain region to mature.
Grisel is convinced that because she started her drug use so young, it affected her development. “It’s likely that by pounding so hard on vulnerable neural circuits, I developed an insensitivity – the way listening to too loud music can make you hard of hearing. It’s not that I can’t feel pleasure, it just takes more volume to make an impression.”
Teaching young people how the brain adapts to chronic drug exposure, she says, will change this level of risk-taking behaviour. “When I was a kid, we didn’t use seat belts, but now everybody uses seat belts. We never used sunscreen, but now it’s part of being out in the sun. If we appreciated how great the brain is at adapting, and learn ways to mitigate that, we might have fewer people to treat.”
Sellman is calling for more taxes (beginning with a sugar tax), fewer sales outlets and higher age barriers. “If you can put off heavy gambling, heavy drinking, heavy drug-using and heavy sexual activity until a bit later, when brains are more developed, you will reduce that degree of addiction in society. But it needs a brave government.”
The Government has been warned. Its mental health and addiction inquiry report calls for stricter alcohol sale and supply rules, as recommended by the Law Commission in 2010, a shift in resources to more prevention, and a reframing of personal drug use as a health and social issue rather than a criminal issue.
Says the Drug Foundation’s Bell: “What we have tried to do for the past 40 years hasn’t worked. We need to do something better to address the underlying causes, to make sure help is available quickly and that families are supported. We need to shift from this idea that addiction is a moral failing to one that needs support.”
A system of safe havens
Mandy Whyte had little support in rescuing her son from addiction. Courts, prison, employment and housing programmes, drug rehabilitation and mental-health services had not been able to stop him injecting crystal meth. She tried tough love, anger and bribery with no success. When she tried to engage with the health system, she was told to back off.
But she knew her son wouldn’t get clean on his own.
“People say you should never force people [to quit drugs], that they have to come to it in their own good time, and I understand many people do come to it in their own good time. But there is another group who are not going to get out of that hole, ever. They will die there.”
As she describes in her recent book, Dancing on a Razor’s Edge: A Mother’s Mission to Rescue Her Meth-Addicted Son, she decided she couldn’t leave her son to that fate. “There was no need for him to die; it was a treatable condition, it was an illness.”
She returned to Australia and coerced him into going with her to Jambi, Indonesia, where she was living. It was homegrown rehab: no drugs, no alcohol, a regular gym workout. Months later, seeing his determination in a boxing ring in Jakarta, she knew he was going to be all right. “He was able to be the person he always wanted to be, something other than this invisible junkie. It was hugely empowering. He is not fighting now, and it doesn’t seem to matter. He has achieved that, he has climbed that Everest.”
But to get there, Whyte had to climb her own summit. “I got a lot of grief about being interfering, about sabotaging his recovery. What these rehabs don’t acknowledge is that from being a hard-out addict to getting to rehab is a very long process, and it is the parents or partners who fill that gap. But we are marginalised in the process.”
When she spoke to the Listener, it was her son’s 34th birthday and he is doing okay. He has a job, a driver licence, a new baby. “So, it’s a double joyous occasion for me: one, that it is his birthday, and two, that he is alive for it.”
To keep other addicts alive, she is calling for a system of safe havens (places where people can sleep, eat and be treated with kindness free from the pressure of drugs and suppliers), more peer support and accessible rehab facilities. But the long-term goal of any treatment programme, she says, is maturity.
“I don’t see anyone I consider mature abusing drugs. We are dealing with children, sometimes 45-year-old children, sometimes older. It’s a Jekyll and Hyde thing. There’s the dark face of the junkie and there’s the face of the damaged child. The junkie wants to mask and protect the child, but the child doesn’t want to be using drugs and going through this hell. But the first time they use this drug, they get this wonderful high, then the next time it is less and less, and then the addiction takes over and you are just placating this junkie all the time.”
DANCING ON A RAZOR’S EDGE: A Mother’s Mission to Rescue Her Meth-Addicted Son, by Mandy Whyte (Cuba Press, $38)
NEVER ENOUGH: The Neuroscience and Experience of Addiction, by Judith Grisel (available in June from Scribe, $37)
This article was first published in the April 13, 2019 issue of the New Zealand Listener.