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Antabuse/Disulfiram and Willpower 97

This is an effective deterrent for those who wake up in the morning determined not to drink, but by the evening have lost their resolve. It turns out that willpower is not an infinite human resource. It's more like exercising a muscle, and it can get tired the more we use it.

Depression and Addiction 78

Schuckit, a professor of experimental psychology, did a study of depressed men. They went into hospital for 4 weeks, during which time they received no treatment for depression, other than stopping alcohol. After one month of not drinking, 80% no longer met criteria for clinical depression.
This finding implies that for the majority, clinical depression was the result of heavy drinking and not a co-occuring depressive disorder. Of course there are explanations for these results....but the robust findings are remarkable given that standard treatments for depression, whether medications or psychotherapy, have a 50% reponse rate.

Depression and Anxiety 45

Anxiety is significantly more prevalent and impairing in high-income countries than in low or middle income countries.
The number of new cases of depression worldwide increased 50 % between 1990 and 2017. The highest increases in new cases were seen in regions with the highest income, especially in North America.

Dopamine 49

Dopamine is a neurotransmitter. It may play a bigger role in the motivation to get a reward than the pleasure of the reward. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches away from their mouth. Yet if the food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it.
With repeated exposure to the same or similar pleasure stimulus, in initial deviation to the side of pleasure (on the pleasure/pain see-saw) gets weaker and shorter and the after-response to the side of pain gets stronger and longer. A process scientists call neuro-adaptation. With repetition, we need more of our drug of choice to get the same high we initially got.
Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose is called tolerance.
People on high doses of opioid therapy (OxyContin, morphine, fentanyl etc) for chronic pain, find that their pain gets worse and worse over time. Why? Because exposure to opioids had caused their brain to resent its pleasure-pain balance to the side of pain. Now they find that their original pain was worse, and they had new pain in parts of their body that used to be pain free.
This phenomenon, widely observed and verified by animal studies, has come to be called opioid-induced hyperalgesia. Algesia means sensitivity to pain. What's more, when these patients tapered off opioids, many of them experienced improvements in pain.
55
Neuroscientist Nora Volkow and colleagues have shown that heavy, prolonged consumption of high-dopamine substances eventually leads to a dopamine deficit state. She compared the brains of healthy controls v the brains of people who had given up taking heavy drugs 2 weeks ago. In the healthy controls the reward and motivation part of the brain was able to light up (indicating high levels of dopamine neurotransmitter activity. In the people who recently gave up drugs that part of the brain was showing little or no activity.
57
In the two years in which I compulsively consumed romance novels, I eventually reached a place where I could not find a book I enjoyed. it was as if I had burned out my novel-reading pleasure centre, and no book could revive it.

The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.
My patients with addiction describe how they get to a point where their drug stops working for them. They get no high at all any more. Yet if they don't take their drug, they feel miserable. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia and dysphoria.
A pleasure-pain balance tilted to the side of pain is what drives people to relapse even after sustained periods of abstinence. When our balance is tilted to the pain side we crave our drug just to feel normal (ie get a level balance.)
Here's the good news. If we wait long enough, our brain (usually) re-adapts to the absence of the drug and we re-establish our baseline homeostasis: a level balance. Once our balance is level, we are again able to take pleasure in everyday simple rewards. 60

Once we get the anticipated reward, brain dopamine firing increases well abou tonic baseline. But if the reward we anticipated doesn't materialize, dopamine levels fall well below baseline. Which is to say, if we get the expected reward, we get an even bigger spike. If we don't get the expected reward, we experience an even bigger plunge.

How does cue-induced craving translate to our pleasure-pain balance? The balance tips to the side of pleasure (a dopamine mini spike) in anticipation of future reward, immediately followed by a tip to the side of pain (a dopamine mini deficit) in the aftermath of the cue. The dopamine deficit is craving and drives drug-seeking behaviour.

Dopamine Fast 79

(For instance stopping drinking, social media activity or gambling for a month.)
I never suggest a dopamine fast to individuals who might be at risk to suffer life-threating withdrawal if they were to quite all of a sudden (eg severe alcohol, benzodiazepine or opioid dependence.) For those patients, medically monitored tapering is necessary.
Sometimes, patients ask if they can swap one drug for another: cannabis for nicotine, video games for pornography. This is seldom an effective long-term strategy.
Any reward that is potent enough to tip the see-saw balance towards pleasure can itself be addictive, thereby resulting in trading one addiction for another (cross addiction) Any reward that is not potent enough won't feel like a reward, which is why when we're consuming high-dopamine rewards, we lost the ability to take joy in ordinary pleasures.
A minority of patients (about 20%) don't feel better after the dopamine fast. That tells me that the drug wasn't the main driver of the psychiatric symptom and that the patient likely has a co-occuring psychiatric disorder that will require its own treatment.

Gastric Bypass Surgery 98

One in four gastric bypass surgery recipients develops a new problem with alcohol addiction.
Most people who are obese have an underlying food addiction, which is not adequately addressed with surgery alone. These people don't get the behavioural and psychological interventions they need to help them change their eating habits. Hence many of them resume eating in unhealthy was, expand their now smaller stomachs, and end up with medical complications and the need for repeat surgeries. When food is no longer an option, many switch from food to another drug, like alcohol.

Genetic Inheritance & addiction 20

The risk of addiction increases if we have a biological parent or grandparent with addiction, even when we're raised outside the addicted home.

Honesty 205

I am convinced as a parent that I can and should emphasize honesty as a core value in raising my children.
For me honesty is a daily struggle There's always a part of me that wants to embellish the story just the slightest bit, to make myself look better, or to make an excuse for bad behaviour. Now I try hard to fight that urge.
Although difficult in practice, this handy little tool - telling the truth - is amazingly within our reach. Anyone can wake up on any given day and decide, "Today I won't lie about anything." And in doing so, change their lives for the better
224 If we are open and honest with our children about our struggles, we create a space for them to be open and honest about their own. We must also be ready to admit when we are wrong in our interactions with them and with others. We must embrace our own shame and be willing to make amends.
234 Honesty promotes awareness, enhances intimacy, and fosters a mindset of plenty.

Medication problems in the long term.

Patients with anxiety and insomnia who take benzodiazepines and other sedative-hypnotics daily for more than a month may experience worsened anxiety and insomnia.
Patients with pain who take opioids daily for more than a month are at increased risk not only for opioid addiction but also for worsened pain. (opioid-induced hyperalgesia.
Medications like Adderall and Ritalin prescribed for attention deficit disorder promote short-term memory and attention, but there is little or no evidence for enhanced long term improvement. Public health psychologist Gretchen LeFever Watson has written "Compelling new evidence indicates that ADHD drug treatment is associated with deterioration in academic and social-emotional functioning.
Recent data show that even antidepressants may lead to tolerance and dependence, and possibly even make depression worse over the long haul, a phenomenon called tardive dysphoria.

Mental Illness & addiction 20

Mental illness is also a risk factor for addiction, although the relationship between the two is unclear: Does the mental illness lead to drug use, does drug use cause or unmask mental illness, or is it somewhere in between.

80 Co-occuring psychiatric disorders should be treated concurrently with any form of addiction (or withdrawal from an addictive substance), Managing addiction without also addressing other psychiatric disorders typically leads to bad outcomes for both.

Mental illness in wealthy countries 37

Over the past 3 decades, I have seen growing numbers of patients who appear to have every advantage in life - supportive families, quality education, financial stability, good health - yet develop debilitating anxiety, depression and physical pain.

Moderation 86

Emerging evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way In my clinical experience, this has been true.

Older women and alcohol. 20

Between 2002 and 2013 diagnosable alcohol addiction rose by 50% in older adults (over the age of sixty-five) and 84 percent in women, two demographic groups who had previously been relatively immune to this problem.

Pain 148
Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli such as cold, heat, gravitational changes, radiation, food restriction and exercise.
Intermittent fasting has become somewhat popular as a way to lose weight and improve well-being. Not long ago fasting behaviours would have warranted the label "eating disorder, but in many circles it is considered normal and even healthy.
Exercise increases many of the neurotransmitters involved in positive mood regulation. Just walking for 30 minutes a day can effect mood, anxiety, cognition, energy and sleep, & has a more profound effect than any medication.
ECT is still practised today to good effect, although much more humanely than it used to be, with muscle relaxants paralytics to prevent painful contractions. Anaesthetics allow patients to remain asleep and mostly unconscious throughout the procedure. So, although not painful as such, ECT provides a hormetic shock to the brain, which in turn spurs a broad compensatory response to reassert homeostasis.

Prohibition verses Availability 20

Increased access to addictive substances may be the most important risk factor facing modern people. We all fall prey to the vortex of compulsive overuse. For instance the cigarette-rolling machine invented in 1880, made it possible to go from 4 cigarettes rolled per minute to a staggering 20,000
Prohibition - the ban on selling alcoholic beverages in the US from 1920 - 1933, led to a sharp decrease in the number of Americans consuming and becoming addicted to alcohol. Rates of public drunkenness and alcohol-related liver disease decreased by half during this period.
There were unintended consequences of course, such as the creation of a large black market run by criminal gangs. But the positive impact of Prohibition on alcohol consumption and related morbidity is widely under-recognised.
The reduced drinking effect of Prohibition persisted through the 1950s. Over the subsequent thirty years, as alcohol became more available again, consumption steadily increased.
By the 1990s, the percentage of Americans who drank alcohol increased by almost 50 percent, while high-risk drinking increased by 15 percent.

Trauma: Social Upheaval: Poverty

These also contribute to addiction risk. Drugs become a means of coping and lead to epigenetic changes - heritable changes to the strands of DNA outside of inherited base pairs - affecting gene expression in both an individual and their offspring.

Victimhood versus taking responsibility. 186

Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain unwell. They are too busy blaming others to get down to the business of their own recovery. By contrast, when my patients start telling stories that accurately portray their responsibility, I know they're getting better. Even when people have been victimized, if the narrative never moves beyond victimhood, it's difficult for healing to occur.
One of the jobs of a good psychotherapy is to help people tell healing stories. Even if we can take responsibility for the event itself, we can take responsibility about how we react to it in the here and now. We are then empowered to move forward with your lives.

White Working Class & death via addiction. 30

Middle-aged white Americans without a college degree are dying younger than their parents, grandparents and great-grandparents. The top three leading causes of death in this group are drug overdoses, alcohol-related liver disease and suicide.