The Thirteenth Step: Addiction in the Age of Brain Science

FOR ME, A general framework called motivational interviewing is a good bridge between the dialogue with the patient and the specific methods aimed at behavioral change. Motivational interviewing is, in its simplest form, a basic technique that should be used by anyone working with patients who have addictive disorders. Motivational enhancement therapy is an application of this technique toward specific treatment goals. Beneficial effects from these approaches are well supported by research.¹ In either shape, they are almost an antithesis to various confrontational methods. They bring together empathy and relationship-building principles that will be familiar to anyone with old-fashioned psychotherapy training, on one hand, and modern cognitive-behavioral strategies for achieving behavioral change, on the other.

Motivational interviewing and motivational enhancement therapy are based on the same principles. The first of these is expressing empathy. This may seem trivial, but here it takes on the specific form of reflective listening, expressing acceptance, and viewing the patient’s ambivalence or reluctance to change as something normal. The second principle is to help develop discrepancy. “You told me you are all stressed out about being able to pay the electricity bills this month. But you also said that you spend a lot of money in the bar every weekend. Can we talk about that?” The third principle is to roll with what appears to be resistance rather than pushing against it and building it up even stronger. Finally, everything that is done in treatment is done to support the patient’s self-efficacy. In the end, in order to succeed, people with addictions must take control of their own lives, just like a diabetic or any other patient with a chronic, relapsing disorder. In the long run, no patient can have a treatment provider help him or her make the thousands of decisions, big and small, that everyday life consists of. Avoiding immediate dangers, such as an overdose or suicide, can occasionally be coerced; long-term success cannot. Any treatment program that does not build on this insight diminishes people and is also less likely to be successful in the long run. People have to be in charge of their lives to change them. As one would expect, the feeling of self-efficacy is a good predictor of treatment outcomes.

That is all good and well as a start. But as most of us know, even with the best of motivations, behavioral change is hard. Motivational interviewing and strengthening self-efficacy are a general framework, and a starting point to set the scene for change. More specific tools are needed to address behaviors that prevent people from changing drug-seeking behaviors. I will discuss those tools shortly. For starters, however, let’s get something out of the way. Among specific intervention techniques to reduce harm from alcohol use in particular, some of the best data in the field are on a technique called brief intervention. This is as simple as it sounds. It could essentially consist of a physician seeing a patient, screening for alcohol use with a simple questionnaire such as the Alcohol Use Disorder Identification Test (AUDIT)² developed by the World Health Organization or a liver test, and having a single feedback session with the patient if there are indications of hazardous levels of consumption. Doing this in the context of a general practice has solid beneficial effects, both for drinking and for hard health-related outcomes, such as sick days or hospital admissions. Impressively, these effects may persist for several years. Research also shows that a single session is fine, and longer series of treatment sessions don’t necessarily add up to better effects, although to maintain benefits, there seems to be a need for booster doses after some years.

The caveat with brief interventions is that policy makers and insurance companies often see them as a panacea for people with substance use problems, for obvious reasons. Brief interventions do not require a lot of resources compared to specialized addiction treatments and continuing recovery management that may have to last for years. Now, outcomes are all that matters, and there is no inherent value to seeing people in treatment month after month or year after year. But the caveat is that studies in which brief interventions show significant effects are typically carried out in general practice, where people have not specifically sought treatment for an addictive disorder. And the effect sizes observed in controlled studies on brief interventions are on average small to medium in people consuming alcohol. More important, they increase quite a bit if individuals with more severe alcohol problems are excluded. That tells us that brief interventions work primarily in people who may be high consumers and therefore benefit from cutting down but don’t necessarily have an addictive disorder.³ So, to sum up, this approach has tremendous potential to positively affect public health if broadly implemented in the general health care system. It is highly cost effective. I am all for it. Let’s just not confuse it with addiction treatment.

How, then, can we bring together what we have learned about addiction—for instance, about mechanisms of reward, negatively reinforced drug use, impaired decision making, and relapse triggers—with effective treatment interventions? Describing in-depth specific, evidence-based approaches to treating addiction would obviously take up a whole book of its own. But all effective treatments have some key elements in common.⁴ First, they all specifically focus on drug seeking and taking. Once again, this may sound trivial, but think back to the days of Edward Khantzian and self-medication views of addiction. Implicit in that view, still applied by many clinicians, was that if, for instance, underlying depression drives a person’s alcoholism, then treating that depression will cure the alcoholism as well. It doesn’t. Studies show that treating depression in people with alcoholism or drug addiction does lead to improvement of the depression symptoms but does not improve drinking outcomes.⁵ Second, methods that focus on practicing changing specific behaviors do a better job than methods that talk about these behaviors, try to dissect intrapsychic conflicts thought to underlie them, or apply other complicated psychological constructs. Over my years as a clinician in behavioral health, I have learned a principle that applies quite broadly. If you want to help patients change the way they talk, help them talk. If you want to help them change the way they behave, help them carry out the behaviors. The modern version of William James’s theory of emotions is “move your body, and your mind will follow.” Third, all evidence-based addiction treatments intervene in the disease process in ways that make sense in the context of what we have so far learned about brain mechanisms of addiction and by doing so reduce the risk of relapse.

By now the chronic, relapsing nature of addictive disorders should be familiar, and so it should come as no surprise that preventing relapse is the central objective for addiction treatments that improve outcomes in measurable ways. This shines a bright light on an elephant in the room. There is an anomaly in the treatment of addictive disorders that simply will have to be fixed before we can do better than today. To the extent that addiction treatment is at all supported in the community, most of the resources continue to be devoted to “detoxification”⁶ and other ways of initiating abstinence. Yet research uniformly shows that these interventions do not have a measurable impact on long-term outcomes in addictive disorders.

At one time it perhaps made more sense to devote a lot of attention to initiating abstinence, because this could be anything but trivial. A hundred years ago, suddenly discontinuing heavy alcohol use carried with it a considerable risk for precipitating a delirium tremens, a condition characterized by severe hyperexcitability of the entire nervous system. Most people have forgotten this now, but the tremors, hallucinations, and disorganized behaviors of this syndrome, accompanied by a risk for seizures, once carried with them a risk of dying that was about 20 percent. Getting off opioids, although in fact less dangerous, could nevertheless be an excruciating experience, a combination of a severe flu-like syndrome and fluids escaping from all glands of the body until, occasionally, severe dehydration would result. By now, however, we have long had ways of successfully and safely initiating abstinence from alcohol, opiates, and other drugs. Proper use of medication tapers, combined with some simple principles of supportive care, render this part of treatment almost trivial if properly managed.

The techniques to successfully manage withdrawal and initiate abstinence are of course major advances of addiction medicine. If a person dies from delirium tremens, then there is not much point in thinking much about long-term recovery. But despite our ability to safely initiate abstinence, somewhere around two-thirds of patients continue to relapse to drug use over the course of a year after detoxification, whether we look at alcohol, opioids, cocaine, or other drugs.⁷ When they do, there is disappointment, frequently to the point that people—treatment providers, family members, patients themselves—give up. In fact, spending vast resources on repeatedly initiating abstinence and managing its early stages is most of the time a waste. What patients with addictive disorders need is chronic, perhaps life-long recovery management. And at the core of this long term disease management approach, they need methods that can help prevent relapse.

In fact, unless followed by effective long-term treatments, detoxifying people may make things worse. For instance, as mentioned in an earlier chapter, heroin addicts build up a high degree of tolerance while actively using drugs. To continue getting the desired drug effects, they progressively increase their heroin doses. When hospitalized or incarcerated and detoxified, they lose this tolerance within about a week. Yet when discharged after detoxification, patients, and in particular those among them who are young and not all that experienced, frequently return to the heroin doses they were using previously. Data from opioid addicts recently released from prison support what many of us have feared and suspected for a long time. When released after having lost their tolerance, these people run a much higher risk of dying from an overdose—sometimes as much as an eightfold increase—compared to people who just continued to use drug.⁸ Although less well studied, it seems that multiple cycles of detoxification from alcohol can also be deleterious. They seem to push along the brain changes that are part of the addictive process and so contribute to the increasing motivation for drug seeking and taking.

So safely and humanely detoxifying people and initiating abstinence makes sense if it is a component in a well thought through, long-term plan for managing their addiction. Detoxifying patients and then thinking what to do next, if anything, puts the cart before the horse. Right there, I believe we saved at least half the money needed to fund evidence-based addiction treatment for a majority of people who now cannot afford it.

Specific behavioral methods to reduce relapse risk in addiction come in many flavors, but it is probably appropriate to highlight the contributions of Alan Marlatt, who spent most of his career at the University of Washington until he passed away in 2011.⁹ Many others have of course contributed as well. Each variant of these techniques may have its own proponents who swear by it. To a large extent, however, these tools are, at least in principle, variations on the same themes taken from the playbook of cognitive behavioral therapy and applied to the various phenomena of addiction already discussed in this book.¹⁰ It will not take me long to explain the basics of behavioral relapse prevention treatments.

First and foremost, however, in an established tradition of behavioral therapy, we have to work with patients to break down the process that leads up to relapse into its behavioral elements. Frequently the patient perceives relapse as a black box, an incomprehensible disaster, or a lightning bolt out of a blue sky. When I go into an exam room, I frequently hear something along these lines: “Here I was, almost six months sober, thinking things were mostly back on track. And then this. It is terrible. I’ve lost it all. Don’t know what got into me. I am powerless. Might just as well give up.” Not a lot of self-efficacy there. A while later, however, the story often turns out to be rather different. “Things were pretty much fine. Then we got this big new order at work. No one wanted to say it, but we really didn’t have the capacity to take it on. After a while, the whole office got behind. As the deadline approached, there was more and more infighting, blaming, and finger pointing. One day somehow everyone ended up beating up on me. I didn’t take it too seriously at first, but then, on the way home, little things I normally don’t worry about started bothering me. When I just missed a connection, I thought I was going to scream. Once I caught the next one and finally got to my stop, I somehow decided to walk home from the metro instead of taking the shuttle bus. There is this bar along the way that I had totally forgotten about. I was really surprised to find myself outside of it. Then I thought, I’ll just go in and sit here for while and find some composure before I go home, or my wife will start to worry that something is wrong. I remember, after the first three drinks, I realized this is going to hell. Then I thought, it is pointless to try. I never came home that night.”

1. Identify your own relapse triggers. These tend to have common themes, but in the lives of real people, they always come with a personal flavor. If you are a socially anxious person, then the kind of antagonistic social interaction I just described tends to set you off. But even within that category, there is much variety. Our bonds with children, spouses, or colleagues can all be tremendously important social rewards. For that very reason, they are also potential sources of a terrible social threat, when the strings of attachment look like they are at risk of being damaged or severed. But not all relapse triggers are related to negative emotionality. Other people may be more sensitive to positive feeling as relapse triggers. In talking about this, a fascinating paper by my colleagues Kenzie Preston and David Epstein at the National Institute on Drug Abuse always comes to mind. To track people with addictions in the real world of Baltimore, they let their subjects use handheld electronic devices and had them continuously register what was going on. The idea was that if the subjects relapsed, it would be possible to analyze what events had preceded their drug taking. For relapse to heroin use, stress and negative emotionality indeed turned out to be the most common antecedents of relapse. But for cocaine, the research team identified a different pattern, one for which they coined the equally innovative and telling term “celebratory relapse.”¹¹

2. Once you’ve written the list of things that are your personal relapse triggers and written down the chains of small steps that lead from those triggers to drug taking, start developing a set of screenplays for the movie of your own life, screenplays that have another kind of ending. The famous Shakespeare line “All the world’s a stage, and all the men and women merely players” may be true, but you can also be the screenwriter and the director. For starters, develop a script, or in fact a number of them, that avoid the situations triggering cravings and relapse. Use your creativity to develop what that alternative plot will be, because it has to be one that works for you, and you are the expert on your own life. But the important thing is that once you have developed those scripts, you’ll have to do what any actor who wants to get really good must do: practice. And practice. And practice again. Remember, not talk about it, but rather do it. And because most of the scripts will be of interactions with other people, you will have to practice together with others. Hence relapse prevention lends itself unusually well to a group format. Group members can put each other to great use by practicing behavioral strategies in the form of role-playing. Incidentally, the group format also renders treatment highly cost effective.

3. You will not always succeed in avoiding relapse triggers. Life is, after all, not predictable to a degree that would allow you to prepare a script for every situation you may encounter. And even in familiar situations, your performance may not always be perfect. For that reason you will also have to prepare strategies for situations when cravings do get triggered. Of course, along the way, you will have to learn how to recognize them. By the time you actually think, “I need a drink,” it is probably quite late. In talking to spouses of alcoholics and drug addicts, I have been amazed how well they can see the early signs that cravings are on the rise even though the patient still does not seem to have an idea what is going on. There is perhaps some aimless wandering, and a certain degree of irritability. There may be a desire for sweets or other foods. There may be something else that is unique to you. Once you have learned to recognize those signs, learn how to pay attention to them. Bring them into your conscious thoughts and hold them there. Be mindful of them. And then learn to cope with them. One of the best coping strategies is learning to do nothing for a while. The secret is that craving, just as anxiety, dissipates over time. Patients with anxiety disorders discover that, if they can avoid being engulfed in panic and run away, their distress tapers off. This is an extremely powerful experience. It can initiate new learning that over time results in extinction of the fears. Craving is very similar in this respect. In fact, extinction of fear and cravings seems to be driven by brain circuitry that is closely interconnected.¹² As a standalone treatment, cue exposure and coping skills therapy, pioneered by Peter Monti at Brown University, is an example of this of approach. It uses techniques that actively elicit cravings to help patients learn the skills to successfully cope with them.¹³

4. It is never too late. Just because you did not stop after the first drink does not mean you have less reason to stop after the second, or third. And even a full-blown relapse is not the end of the world. Hopefully, if you have applied the techniques outlined above, it took longer from the last relapse to this one than it took between the previous two. That is actually a good sign. Now, let’s see how you can do better still. As unfortunate as a relapse is, it is only to be expected in a chronic, relapsing disorder. So anyone viewing it as a failure that invalidates prior treatment efforts is simply showing that they do not get what addiction is about. Once people—patients, family member, employers, those in the legal system—get past that level of ignorance, we will all be in a better place. Rather than ruminating over relapse as a disaster, we will be able to see what lessons can be learned from it each time. What was the chain of behavioral steps that led up to it? What are the screenplays—the behavioral strategies—that need to be written to come to a different ending next time? How can those be practiced?

5. Remember the principles of reinforcement. If drug effects are pretty much the only reinforcers available to you, no one, and you yourself least of all, should be shocked that sooner or later you will use drugs. So we need to work on finding other reinforcers that can compete. Once again, this can be a component of an integrated behavioral relapse prevention approach, or it can be developed into standalone treatments. In the latter format, several approaches have been established and evaluated, with some of the best results in treatment of addictive disorders.¹⁴ In one of these approaches, called voucher-based reinforcement therapy, patients receive vouchers with different monetary value for demonstrating sobriety or being abstinent from drugs. To promote continuous abstinence, the value of these vouchers is increased the longer clean urines or breathalyzer tests are produced. In another technique, called fishbowl reinforcement, clean urines or breathalyzer tests are reinforced by receiving draws, often from slips of paper kept in a fishbowl, for providing a negative biological specimen. Typically about half the draws just say “Good job!” The other half result in the earning of a prize, which may range in value from $1 to $100. Again, to promote continuous abstinence, clients receive bonus draws after a certain number of consecutive negative samples. While reinforcers must have a value that can compete with the reinforcement from drugs, that value does not necessarily have to be monetary. For patients in methadone maintenance, receiving take-home medication for longer intervals instead of coming to the clinic to receive medication every day is valuable because it allows them to live a more normal life. Other adaptations of this approach use housing or even fun activities as reinforcers.

In the end, the truly valuable things in life are of course outside of the treatment setting altogether. What really has value is family, friends, and all the other healthy pleasures of life. When relapse episodes no longer disrupt life on a regular basis, it is therefore time to get to work on setting up the right contingencies for a real, rewarding life. It is then about writing the scripts in which staying away from drugs and alcohol leads to greater rewards from real people who play the important roles in the screenplay of your life. Unless that happens, coming out of the haze of more or less chronic intoxication will just result in emptiness and sadness over things destroyed and things missing, rather than satisfaction. Take my word for it, if that is the case, then it will not be long before drugs start playing a major role in your life once again.

A key element of mindfulness training that might come in particularly handy in the treatment of addiction is to increase awareness of one’s own thinking. We have already seen how much of the mental processes that lead up to relapse happen almost automatically, outside of one’s awareness. Clearly, techniques that practice the ability to “be in the moment” and heighten awareness of one’s own thoughts could hold the promise of catching early stages of thought processes leading up to relapse and changing their direction. But as always when appealing concepts are held up as new cures, we need to be cautious and stick close to the data. It is one thing for me to find mediation helpful in dealing with the stresses of working for a government agency. It is something altogether different to provide evidence of treatment effects in addiction. In fact, the only area where some data on mindfulness-based treatments are beginning to emerge is depression. The first meta-analysis of controlled studies that applied these approaches to depression treatment came out in 2013.¹⁵ The conclusion was that mindfulness-based treatments may be as good as regular cognitive-based therapy, but there was no evidence that they would be any better. The evidence available so far was also deemed to be limited in amount and of low quality. In the field of addiction, there is even less solid data.

So what is, in the big picture, the future of behavioral treatments for addiction? My personal view is that the bottle is half full, half empty, and likely to stay that way. What I mean is that we have come a long way. The proper use of the evidence-based behavioral techniques reviewed in this chapter is clearly of help for people with addictive disorders. But more and more evidence suggests that increasingly sophisticated and intensive behavioral approaches, while costly to deliver, are not getting us much further. Perhaps a reasonable conclusion is that we may have gotten as far as it is reasonable to hope by applying behavioral treatments. We need to make sure that these are provided to people who need them. But we also need to look beyond them.