Walk Away from Temptation

The singer Paul Simon's composition, "There Must be Fifty Ways to Leave Your Lover," also holds true for leaving your addictive substances. If you ask a group of people who've gotten free of the monkey on their back what they do when they feel a craving coming on, you'll wish you knew shorthand to write down all the different solutions that work for somebody. "Take a deep breath!" "Count to 100." "Call a sober friend." "Go to a meeting." "Drink a glass of cold water." "Touch your sober talisman." "Do a meditation." And so on.

Now comes a roundup of studies in the New York Times -- thanks, Dr. Joe Mott for pointing me to it -- highlighting evidence in favor of one of the simplest ways to leave your demon: walk away. A series of studies completed in the past five years demonstrates the empowering effect of locomotion. A brisk but not strenuous walk of as little as 15 minutes enabled study subjects to turn their backs on substances they craved.

Why does walking work? The Times' science writer doesn't try to answer. Three hypotheses come to mind immediately: endorphins, distraction, and Aristotle.

Exercise, as is well known, causes the body's glands to manufacture and release endorphins. Endorphins are often called the body's own morphine; they are native opioids that take away pain and make you feel good. If you've seen the smile on the face of a bicyclist or a runner, you've seen a natural endorphin high.

So, taking a brisk walk as a device for rejecting an external drug makes sense on the theory of substitution. You allow the soft hand of your inborn neurochemistry to scratch your itch instead of the bloody claws that some liquor company, tobacco cartel, or other drug syndicate has cooked up to ensnare you. Substitution of a harmless, wholesome gratification for an addictive fix is a basic recovery strategy with a very wide range of applications.

But endorphin substitution may not be the whole story, or may not be the story at all. People vary in their rate of endorphin production, and the studies in the current report don't include blood samples that measure endorphin levels. Daniel Goleman, the brilliant popularizer of the Emotional Intelligence concept, highlights the famous marshmallow experiment, destined to take its place alongside Pavlov's dog as one of the foundational studies in psychology.

The experimenter puts a marshmallow on a dish in front of a child and says that he, the experimenter, must leave the room for a few minutes. The child is free to eat the marshmallow; but if the child waits until the experimenter returns, the experimenter will add a second marshmallow, and the child can have both.

In the original study, the children who ate the one marshmallow ended up, years later, dropping out of school, stuck in low-wage jobs, in trouble with the law, divorced, etc., while the children who resisted and waited for the double reward became valedictorians, chief executives, senators, etc. (I exaggerate wildly, of course, but that was the general drift of the results.)

Goleman's follow-up studies tried to find out how the children who waited for the two marshmallows were able to resist the marshmallow sitting in front of them. His results threw out various genetic and characterological hypotheses. Resisting the lure of the sugary treat, he found, is a teachable skill. The children who succeeded did so by distracting themselves. They took their eyes off the item and played some game or walked around the room. In short, they derailed the train of craving by setting their minds busy with some other concern. Goleman concluded that any child could learn to do this, vastly increasing their chances of success later in life.

So, the effectiveness of walking may be due partly or even wholly to the distraction effect. We set our minds to working our legs, keeping our balance, choosing a path, managing our breath, and all the other efforts required for effective ambulation, and in the process the craving fades away in the rear view mirror.

Then also, there's Aristotle, one of the ancient founders of the scientific method. Aristotle, not being an Athenian, could not own property there, and therefore taught his followers on a public walkway. His philosophical school came to be known as the Peripatetics -- the walkers. Ever since, walking has become linked in legend with stimulation of the inquisitive, analytical mind.

Why this should be so, if it is so, remains hazy, but we know that the mind and the body are a unity, and no one should be deeply surprised that ambulation might stimulate cogitation. And rational thinking certainly would lead one to avoid putting addictive substances into the body.

Does walking help avoid cravings because of substition? Or because of distraction? Or via the Aristotle effect? Or all the above? We don't have the answers yet. But we don't need to know why something works in order to benefit. For decades, doctors didn't know why Aspirin or acupuncture worked to relieve pain, yet both helped millions. Perhaps you can cogitate on the reasons as you amble.

Next time you feel a craving coming on, walk away from it. It works!

[Originally published in hellowellness.in]

Drug Mafioso Heads Afghan Anti-Narcotics Ministry

Afghan President Hamid Karzai nominated, and the Afghan Parliament overwhelmingly approved, the appointment of Zarar Ahmad Moqbel as Minister of Counter Narcotics this past January.  Moqbel is "associated with the drug mafia," according to U.S. Ambassador to Afghanistan Karl Eikenberry in a secret cable to Washington released Dec. 2 by Wikileaks.org, the whistleblower website.  Eikenberry wrote about Moqbel:

He is perhaps the worst of the candidates. Former Deputy Interior Minister and MP Helaludin Helal claimed to us January 11 that Moqbel was supported by the drug mafia, to include Karzai’s younger half-brother Ahmed Wali Karzai and Arif Khan Noorzai.

Moqbel received the highest number of votes of any of the cabinet nominees.  The 249 members of the Afghan Parliament, known as the Wolesi Jirga, saw the vote as an opportunity to solicit "donations" -- typically, in the form of envelopes containing cash -- to their upcoming re-election campaigns.  Druglord Moqbel, according to Eikenberry's sources, set a record for such donations, paying Jirga members from about $8,000 to $15,000 (in U.S. dollars) each.  Source.

Moqbel replaced  General Khodaidad, whom Eikenberry described in an earlier cable as "a very good partner for U.S. counternarcotics efforts."  Source.

Moqbel had previously headed the Afghan Interior Ministry, a "byword for corruption and incompetence," according to a British security official quoted in the London paper, The Guardian.  Source.  The Interior Ministry's "culture of corruption and incompetence" aroused an international uproar two years ago, forcing President Karzai to sack Moqbel.  Now Moqbel is back, heading the counter-narcotics effort in a country where opium and its derivative, heroin, is the No. 1 export, accounting for more than half of the country's GNP, according to United Nations figures.  Source.  Afghanistan is the source of about 90 per cent of the world's heroin supply.

Two weeks after Moqbel's appointment to the Counter Narcotics post, deputy-level U.S. diplomatic and military officials in Kabul met to consider "possible courses of action" that they may use "against criminal and corrupt Afghan officials in an effort to change their behavior."  The group, titled the "Nexus-Corruption Leadership Board," adopted a set of recommendations including:

(1) no public meetings with the official (and no photos), and no high-profile public visits from CODELs and other dignitaries; (2) no giving or receiving of gifts; and (3) restrictions on opportunities for corrupt officials to participate in U.S.-funded training, travel, and speaking engagements. 

These recommendations, according to Ambassador Eikenberry in a confidential cable released by Wikileaks, are aimed to "end tacit American support for corrupt Afghan officials" and to attempt to change their behavior.  Source.  Among the highly placed Afghan officials "believed to be corrupt," the cable names Colonel Abdul Razziz, who controls a major border  crossing with Pakistan, President Karzai's half-brother Ahmed Wali Karzai, and Asadulla Sherzad, the chief of police.  Eikenberry adds that more direct measures, such as firing the corrupt officials or putting them in jail,  are not on the agenda "due to lack of capacity and lack of political will."

The Afghan Major Crimes Task Force, which has jurisdiction over corruption cases, has only four vetted prosecutors and only a small number of investigators, Eikenberry complained in another cable published by Wikileaks.  Source.  Its limited capacity is a "major challenge to successful prosecution."  It has no influence in the provinces.  Source.  Aside from the narcotics traffic, Afghan officials are busy "embezzling public funds, stealing humanitarian assistance, and misappropriating government property," forming "a graphic picture of criminal enterprise masquerading as public administration."  Source.

Responsibility for protecting the opium traffic lies at the top, with President Karzai, according to General Dan McNeill, then commander of the international force supporting the Afghan government.  McNeill told visiting director of the U.S. Office of National Drug Control Policy John Walters in March 2007 that

the missing ingredient in the counter-narcotics effort was Karzai. Despite some public statements, he had failed to take a real stand. Karzai needed to keep his support base happy, and as a result, he placated many of those involved in the drug business, especially in the west and south of the country. However, by not taking the issue on, Karzai was tacitly signaling his OK for poppy production.

Source.  McNeill added that prosecution of high-level officials in the drug trade was useless under the circumstances.

To Walters’ question on going after high value targets, McNeill said it was necessary to prosecute a few to keep faith with the general public. But he was skeptical it would have any real effect on the trafficking networks, as those arrested would simply be replaced by others.

Source.  Efforts to eradicate poppy cultivation frequently became only another opportunity for corruption.  Asadullah Khalid, the governor of Kandahar province, used members of the police force to do the eradication work, allowing him to pocket the funds allocated to hire local labor for the job.  And, according to Major General Ton Van Loon, the Dutch commander in the province, Asadullah "has been careful to eradicate only those fields not controlled by powerful people in the Province." Source.

The total acreage devoted to poppy growing in 2010 remained unchanged from 2009, according to a September 2010 United Nations report.  Source.  Eradication in 2010  was at the lowest level since recording began in 2005.  But the amount harvested dropped by 48 per cent, due to a late-season fungal blight.  The drop in quantity led to a spike in prices, and observers predicted that the high opium price, combined with a drop in the price of wheat, an alternative crop, would attract many more farmers to grow opium in this coming year.

Alcohol: The Most Anti-Social Drug

This week's Lancet, the British medical journal, drives a silver spike into the heart of the undead myth that alcohol is the lubricant of sociability and good fellowship.  A systematic comparative ranking of 20 different addictive drugs found that alcohol is the most harmful drug, more harmful than heroin, crack cocaine, and methamphetamines.

The study, by an industry-independent panel of scientific experts, ranked drugs in terms of their harm to the user and their harm to others.

Heroin, crack, and methamphetamine scored higher than alcohol in harm to the user.  But alcohol's score on the scale of harm to others was double that of heroin and crack, the next leading chemicals, so that when the scores of harm to others and harm to self were combined, alcohol led the sordid parade of harmful consequences by nearly twenty points.

A key point in alcohol marketing is social bonding.  Alcohol is said to promote romantic linkups, male bonding, business networking, and general friendly togetherness.  It's sold as the antidote to the isolation, alienation, and competitiveness that make so many people feel lonely even in crowds.   The industry spends billions every year trying to persuade us that if we'd all drink together, we'd all be happy together.

Not so, found the panel of medical experts.  The group evaluated the harm each drug caused to others in terms of physical and psychological injury, crime, environmental damage, family adversities, international damage, economic cost, and damage to community.  The panel also ranked social harms such as the loss of tangibles and loss of relationships.

Alcohol led all other drugs in measure of injury to others, family adversities, economic cost, and harm to the community. In other words, the person under the influence of alcohol caused the most bloodshed, broken families, and other mayhem to economic and social life.

The Lancet study corroborates other, similar studies conducted by other scientists independent of the alcoholic beverage industry, and cited in the Lancet article.  This relatively recent group of studies moves beyond older research which looked at drug consequences more narrowly, in terms of a single factor, such as drug-related deaths.

The finding that alcohol is a more harmful drug in society than heroin and crack cocaine upsets some deep seated stereotypes.  We've been taught to identify the "drug problem" with hard drug users, and we've been led to believe that most of these are black and socially marginal.

This research says that society's drug problem is really first and foremost an alcohol problem, and that you'll find the most dangerous drug addicts among outwardly respectable middle class whites.

That isn't really news to those who have attended most any addiction recovery support group meeting.  How many stories of hospital visits, court dates, divorces, abandoned children, lost jobs, and other chaos do you need to hear before you realize that the slick TV ads for alcoholic beverages are lies?

Even in parts of the recovery subculture, the alcoholics have tended to turn up their noses at the heroin and crack addicts. This elitist bias underlies the segregation of the legacy support groups into separate alcohol and "narcotics" branches.  (Modern groups such as LifeRing include both alcohol and other drug users.)  Now science is turning this conceit upside down.

True, the heroin and crack users have nothing to be proud of.  But the drug that really tears apart the bonds of society doesn't come in a syringe or a pipe, it comes in a bottle.

[First published in hellowellness.in on Nov. 7 2010]

Motivating Motivation

[Originally posted on hellowellness.in on Oct. 29 2010]

Everyone concerned with addiction recovery knows the importance of motivation.  As Darlene, a heroin addict portrayed in Dr. Lonny Shavelson’s wonderful book Hooked, tells her psychiatrist, “You can talk at an addict until you’re blue in the face, but if they don’t want to get clean, they’ll tell you to f**k off.”  Almost every treatment modality works if the patient is motivated;  nothing works at all if the patient isn’t.  

A group of counselors and researchers grouped under the umbrella label of Motivational Interviewing has been working for a couple of decades on cracking the secret of motivation, and they’ve shown a series of positive results.  Their latest success comes in the highly challenging area of weight loss.  

Weight control is probably more difficult than getting free of alcohol and other addictive drugs because abstinence is not an option.  You can very well live without alcohol and other addictive drugs, and abstinence creates a bright line that can guide your every step.  But you can’t live without food, and threading your way through the maze of conflicting nutritional advisers can defeat the most dedicated mind.  

Doctors, the researchers noted, frequently talk to their patients about weight.  But how the doctor talks to the patient makes a crucial difference.

Doctors who assumed the traditional role of authority, who used a confrontational approach, who appeared to judge the patient, or who pushed unasked-for advice, had no positive effect whatsoever on patients’ motivation, the study found.  Their weight was almost exactly the same as patients whose doctors never raised the issue with them.  In other words, doctors who used the conventional authoritative approach were wasting their time.  

By contrast, doctors who used an approach based on Motivational Interviewing fired up their patients’ motivation, and such patients registered a weight loss of 3.5 pounds at follow-up three months later.

A basic principle of Motivational Interviewing is that real change in feeling and behavior can only come from the patient, not from the doctor.  The key to success, therefore is to elicit and to support the patient’s own inner desire to change.  The doctor accepts the patient’s shortcomings without judgment.  The patient’s successes, no matter how small, merit recognition and praise.  The physician does not pose as an authority, but as an ally and collaborator.  

Dr. Kathryn Pollak, Ph.D. of Duke University, lead author of the study, commented that the physician’s traditional role as expert dispenser of pills or advice has its utility in treating acute distress, but is ineffective in changing patients’ attitudes and motivating long-term, sustainable behavior change.  

“When it comes to behavior change, the patient is the expert, not the doctor.  The whole point is to help the patient solve the problem himself.  Doctors have to see the difference between behavioral counseling and the rest of their job,”  Dr. Pollak said.

The study appears in the October issue of the Journal of Preventive Medicine.

LifeRing groups are abstinence-based, but the Motivational Interviewing approach is deeply congruent with the LifeRing pathway to recovery from alcohol and other drug addiction.  The strategic pathway to recovery is empowerment of the sober self, which means recognition and support of the recovering person’s own inner desire to change.  I’ve written about this approach in detail in my book Empowering Your Sober Self, for those who wish to know more about it.

Sliding into Iraqistan

[Originally posted 29 Oct 2010 on hellowellness.in]

Drug use among the Karzai government forces in Afghanistan is old news. That country is, after all, the world’s leading producer of opium, and high government officials, including the President’s brother, are widely believed to be among the kingpins in the heroin trade.  Now comes a report, in Monday’s New York Times, that government troops in Iraq have been sliding in the same direction. Reporters Timothy Williams and Omar al-Jawoshy write from Baghdad:

“A growing number of Iraqi security force members are becoming dependent on drugs or alcohol, which has led to concerns about a significant addiction problem among the country’s armed services as the insurgency remains a potent force and American troops prepare to depart at the end of next year.”

The reporters’ sources estimate that in some regions of Iraq, as many as half the officers and soldiers, including high-ranking officers, use drugs and/or alcohol while on duty.  Based on dozens of interviews, they write that alcohol and drug use among Iraqi police and military “has become increasingly common and appears to have grown significantly during the past year or so.”  

Some of the troops use drugs “to help us forget that we are hungry.”  Others use drugs to subdue their anxiety, fatigue, and boredom.  Officers look the other way because drug use makes some of the fighters fearless in combat.  It also makes them reckless.  Drug use was believed involved in recent incidents where Iraqi forces massacred civilians and also turned on one another.  Generally, the growing drug use contributes to lack of discipline and cohesion.  

The units with the biggest drug habits appear to be those with the most challenging assignments: manning checkpoints in contested areas, and members of special forces teams that do night raids, assassinations, and other “counter-terrorist” work.  The article leaves the impression that Iraqi forces are not prepared to perform this kind of work when their minds are clear.  

The Times article says nothing about drug use among American and other allied forces in the country.  We already know from other sources that numerous GI’s have come home from the Iraqi theatre with serious substance abuse problems.  Significant drug use by British troops has also been documented.  

The Times’ reporters unfortunately have nothing to report about the drug situation among the “insurgent” forces, other than to speculate that some “insurgent” groups are helping to import the drugs from Afghanistan and other countries, with transparent motives.  But commerce is not necessarily also consumption.  Are the resistance fighters, unlike the government forces, capable of doing what they do with minds unimpaired by addictive substances?  It would be an interesting chapter in the study of guerrilla warfare to know how the use of addictive substances by one side or another, or both, affects the methods of the struggle and its ultimate outcome.  

The spread of drug use on the scale that the Times article reports could not occur without the complicity of the highest command.  Iraq does not have the domestic drug production capacity of an Afghanistan or a Colombia, but abundant opportunities for profit exist whenever there is widespread consumption.  To the bulging catalogue of corruption already compiled by the principals of the current Iraqi ruling groups, a new chapter on drug trafficking will need to be added.  

Looking at world events through the lens of the addiction issue is, for an American, a bitter experience.  Here I sit, more than 18 years clean and sober, having invested the better part of my life in building a new roadway out of addiction, and I see my government spending my tax money  (and the blood of my compatriots) propping up a set of foreign regimes that grow fat on building more roads into addiction.

Recover and Be Killed

[Originally published 29 Oct 2010 on hellowellness.in]

Trying to get clean and sober is a pathway to a new life in most places, but in some cities of Mexico it’s a ticket for getting killed.  Gunmen believed to be narco gangsters this week stormed into a drug rehab center in Tijuana, found 13 patients watching a movie, lined them up on the floor, and murdered them with machine gun fire.  

A few days later, masked gangsters invaded a car wash in the central Mexican city of Tepic, not far from the tourist destination Puerto Vallarta.  They sprayed employees and customers with automatic weapon fire.  Most of the murdered car wash workers were recovering addicts.

The border town Ciudad Juarez has seen a streak of massacres in drug rehab centers.  Minutes after the mass murder in the rehab center in Tijuana, a narco voice was heard on the police radio saying that this was “a taste of Juarez.”

Public speculation as to the narco gangster’s motives in targeting people in recovery ranged widely.  A New York Times reporter guessed that the rehab centers were used as a refuge by former gang members trying to get away from the criminal syndicates.  A Mexican official speculated that the Tijuana attack was retaliation for the authorities’ seizure and burning of 134 metric tons of marijuana the previous week.  El Blog del Narco, the semi-clandestine online kiosk for narco-related information and disinformation, is silent on the topic of motive.  

A more likely explanation is commercial.  One has to remember that the drug business is a business, and a business depends on customers.  From the narco standpoint, people who seek recovery from drug use are dissatisfied customers who not only step outside the market but stand as living testimony, human Yelps, for the defects of the product.  In the supercharged atmosphere of the Mexican drug war, that’s reason enough to kill them.  

I write this in Oakland, California, a city whose city council this year approved a far-reaching measure to regulate and tax medical marijuana.  City leaders are also on record in support of Proposition 19 on the California state ballot, a measure that would legalize, regulate, and tax marijuana possession and cultivation, medical or not.  The measure has drawn worldwide attention, including notably in neighboring Mexico.  

Both the Mexican government and the U.S. administration under President Obama have come out against Prop. 19.  Obama’s position appears to be part of his general unfortunate slide toward appeasement of the conservatives.  Mexican President Felipe Calderon’s position is an understandable reluctance to make a 180 degree turn from his efforts at military suppression of the wars between his country’s drug cartels.  If one of the major export crops he is trying to stamp out suddenly becomes legal in its primary market across the border, he will look at first like a fool.  

Legalization of marijuana in circumstances like these has never been done before, and nobody can say with assurance what will happen.  Political leaders prefer the devil they know to the devil they don’t.  But many analysts believe that legalization in California will deal a harsh commercial blow to the Mexican cartels.  California already grows its own marijuana, said to be of much higher potency and quality than the Mexican variety. If the local cultivation is legalized, the Mexican product may become practically unsaleable here.  The Mexican president may find that the passage of Prop. 19 puts him for the first time in the driver’s seat.  

For myself, I have long ago made the choice to abstain from alcohol, marijuana, tobacco, and other addictive drugs, and I persist steadfastly in that decision.  In my experience, the vast majority of people who have personal experience with these drugs have gotten free of them, or wish they could (and they can).  Nevertheless, in the upcoming California election, I will cast my vote in favor of Prop. 19.  The prohibition of marijuana has not worked.  Young people can score marijuana more easily than alcohol.  Prosecutors have used the laws not to break the distribution networks, but to persecute minority youth for petty infractions resulting in major prison terms.  The “war on drugs” has been a scandalous waste and abuse of taxpayer resources that would be better devoted to education, prevention, and treatment.

Pain Relief Without Addiction: Walking the Tightrope

[Originally published on hellowellness.in on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

If Alcohol Were Invented Today

[Originally posted on hellowellness.in 29 Sept 2010]

The word 'alcohol' was coined around 1540 by an Arabic chemist to describe the fine powder, or 'kohl,' used to stain or paint the eyelids.  Two centuries later, British writers borrowed the word to describe the intoxicating essence of wine -- an ironic twist, since the original Arabic chemist was very likely a Muslim and, as such, forbidden to drink it.  

If alcohol were invented today, international law would class it with the controlled substances, alongside opium, heroin, cocaine and the like.  The World Health Organization (WHO), in its most recent comprehensive report, writes:

Alcohol is a psychoactive substance with a known liability to produce dependence in humans and animals. If considered in the frame of the 1971 Convention on Psychotropic Substances, alcohol would qualify for scheduling as a substance that “has the capacity to produce a state of dependence, and central nervous system stimulation or depression, resulting in hallucinations or disturbances in motor function or thinking or behaviour or perception or mood”, and for which “there is suffi cient evidence that the substance is being … abused so as to constitute a public health and social problem warranting the placing of the substance under international control.”

The propensity to produce "dependence" -- a bland synonym, in this context, for the more controversial term "addiction" -- is the red flag that sets apart this relatively small class of drugs, including alcohol, from the millions of other known chemical compounds.  They are addictogenic.

The exact molecular mechanism of addictogenesis is still the focus of scientific investigation in several countries.  But the fact of its occurrence is beyond dispute.  The WHO report says, "The direct actions of alcohol on the brain and sustained alcohol exposure lead to longer–term molecular changes in the brain known as neuroadaptation."  That is, a number of neural pathways in the brain are altered to form a strongly self-reinforcing habitual behavior pattern that leads to adverse consequences for the organism.  

Among the pathways by which alcohol enters the brain is the brain's indigenous opioid system -- the same doorway by which the opiates such as heroin and codeine pass into the neural network.  

Wherever alcohol is introduced into a country on a large scale, there one finds the rise of alcohol addiction (alcoholism).  The WHO world surveys find a strong correlation between the level of alcohol consumption in a country, and its prevalence of alcohol dependence.  Statistically, more than three quarters of the dependence rate is correlated with the level of consumption, and this trend is even stronger in "developing" countries, among which the WHO report specifically names India.  

Alcohol marketing generates alcohol use.  Alcohol use generates alcohol addiction.  Alcohol addiction then sustains the alcohol market. 

In any country where alcohol use has become established, writes the WHO, a small minority of drinkers consume the bulk of the alcohol sold.  "A typical finding is that half of the alcohol consumed is consumed by 10% of the drinkers."  In the U.S., some reports indicate that 10 per cent of the drinkers drink 80 per cent of the alcohol.

Imagine, then, that by some magic pill you could  convert the 10 per cent into non-drinkers.  The alcoholic beverage market would crash more profoundly and disastrously than the mortgage and financial markets in our recent meltdown.  

The alcoholic beverage industry worldwide is absolutely built on alcohol addiction.  One has to say it; there is no way to sugarcoat it.  

Recently, after I outlined these economic facts to a person newly in recovery from alcoholism, she exclaimed, "But that's so illogical!"  

Of course, it's utterly illogical.  We have grandfathered alcohol and tobacco into the category of legal substances, even though the combined death toll from these two drugs is perhaps 15 times greater than the toll from all of the drugs proscribed as illegal.  

So, we have prisons full of people caught using or selling negligible quantities of drugs whose total impact on society is relatively small, while the pushers of mega-quantities of lethal addictive substances that kill as many people each year as die in major wars, floods and earthquakes sit in luxurious offices with princes, prime ministers, and police chiefs on their speed dials.  

Meditation can provide lucidity at times of mental turmoil.  My friend who exclaimed at the illogicality of current addiction policy became agitated and, for a while, I feared that the mental stress would tilt her toward relapse.  I suggested meditation, and she calmed down.  The next day we met and I asked for her thoughts.  

She said that after thinking it through, she was more determined to remain free of addictive substances than ever.  Said she, "I don't like being used."

The Easiest Way to Quit: Don't Start

[Originally posted on hellowellness.in 29 Sept. 2010]

The placid canal that winds through Paris' Tenth Arrondissement is a social gathering place for the young.  On the warm nights of early September, we saw hundreds of twenty-somethings, or perhaps a bit younger and older, sitting in small groups on the banks, chatting, flirting, and in some cases smoking and drinking. There also we saw uniformed Paris police officers, unarmed and with a relaxed gait, ambling among the groups, chatting, and passing out some literature.  I got a copy. The main item is a 16-page pamphlet titled "Alcohol" (in French, of course), almost small enough to fit into a pocket, and liberally illustrated with cartoons in a popular style showing characters speaking in Parisian argot.  The pamphlet is an easy-to-digest, humorously presented short course in the physiology and psychology of alcohol.  It doesn't try scare tactics, but it asks hard questions, and concludes with information on where to get help.   The pamphlet appears to be the product of a wide collaboration between a number of nonprofit groups together with the French Ministry of Health. There are several French associations concerned with alcoholism:  Alcohol Assistance (http://www.alcoolassistance.net), Croix Bleue (http://www.croixbleue.fr/), and Vie Libre  (http://www.vielibre.org/) are among the best known.  Each of these combines recovery support with prevention work; that is, they provide mutual aid groups for the already addicted and also engage in advocacy and education efforts to prevent addiction in the first place.   We happened to be present in Berlin on the "Day for Alcohol-Damaged Children."  Unprepared, we missed all of the day's events, but the plastic grocery bag from the local supermarket carried, on one side, a big ad for the cause,  "Alcohol for kids -- not in our bag!"    Berlin is a "sobering" city in many ways.  Museums and many other public buildings still show pockmarks and craters of bullet hits on their facades.  Plaques and statues honoring resistance heroes murdered by the Nazis dot the city.  A main attraction is the Holocaust Memorial.  It consists of rectangular blocks of dark gray concrete, a bit larger in surface area than a coffin, hundreds of them, of varying heights, with narrow passageways between.  This stark minimalist simplicity goes on for a full city block. Walking among these endlessly repetitive monoliths conveys the monstrosity of the genocide more powerfully than any baroque monument of the 19th century ever could have done.  Berlin knows how to build monuments! In the United States alone, we lose nearly six million lives to addictive substances every decade.  The holocaust from tobacco alone exceeds the grim toll of the death factories at Auschwitz and Birkenau.  At 50 bodies to a car, it would take a freight train more than 2000 cars long to carry each year's victims of alcohol in the U.S. alone.  The worldwide totals are untallied.  It's important, of course, to provide support to those whose brains have already been hijacked by the addictive substances.  If caught early enough, treated effectively, and given unfailing support, all can recover.  But providing recovery support alone is like rescuing the survivors of the concentration camps.  The larger social task, one that takes the cooperation of a broad range of nonprofits, for-profits, and government, is prevention.   As Jane Brody, health editor of the New York Times, pointed out earlier this summer, the most effective way for an individual to escape addiction is not to commence using the substances in the first place.  A life free of addictive substances brings numerous benefits in terms of wellness, prosperity, and longevity -- and it means never having to quit.

The Drive to Thrive

[Originally published Sept. 4 2010 on hellowellness.in]

The great majority of young people who experience the death of a parent, divorce, emotional or physical abuse, substance abuse, mental illness, developmental disabilities, and similar ordeals end up OK.  They recover, form healthy relationships, have good marriages, and become productive citizens. That, at least, is the finding of numerous studies in a diversity of cultures, summarized by the researcher Bonnie Benard at the outset of her book on Resiliency.  

I shouldn’t have been surprised.  I lost my father before I was born, I survived bombing raids, childhood malnutrition and diseases, numerous changes of home, several addictions, and I’m OK.  And I’m not alone.  I know lots of people with worse experiences who survived -- we all do.  

How did we manage?  What is the secret of our marvelous ability to spring back from adversity?  

Resiliency, writes the author, is a creature with four legs.  First, the resilient person is able to win approval from others.  Perhaps only from one other, but that is enough.  Second, the resilient person is resourceful, inventive, able to solve problems, to make and execute plans, and adapt to changed circumstances.  Third, the resilient person displays autonomy.  They are goats rather than sheep.  Finally, the resilient person has a sense of purpose.  It may be a spiritual or secular purpose, but it gives them a sense of orientation in space and time, a reason for being alive.

With this in mind, I reflected back on my experience in overcoming my addictions to alcohol and other drugs, and I began to understand more deeply how I succeeded in freeing myself from these shackles.

In my recovery from addiction, I participated in a support group network that systematically provides its members with social approval, the first leg of resiliency.  In these groups, the basic principle is that all participants have a sound and healthy core, which we call the Sober Self, and that our work consists of affirming and empowering that positive quality within ourselves.  In the jargon of social science, our groups are “strength-based.”  

I was surprised, early on, that nobody in these groups wagged a finger at me and told me what I had to do.  On the contrary, I was expected to figure it out for myself.  I was advised to think, to marshal my inner resources, to be inventive, to solve my particular problems, to make a personal recovery plan, and to adapt my personality to clean and sober living.  Motivated in this way, I developed the second leg of resiliency.  

My group work always aimed to enhance my power to survive as a clean and sober person outside the group.  I came to believe that the group was a useful support, and I enjoyed -- and still enjoy -- the fellowship and good humor that prevails within the circle.  But no one ever tried to make me dependent on the group, to substitute group addiction for substance addiction.  On the contrary, my group experience was and is a school for personal autonomy, the third pillar of resiliency.

Finally, my participation in my support group network restored to my mind a sense of purpose, mislaid somewhere during the depths of my addiction.  I began to feel that I was useful in some modest way to others who had been similarly lost.  I developed connections with other people, the key ingredient of a sense that one’s life has meaning.  

Thanks to Benard’s book, the secret of my recovery from addictions -- a journey which I thought impossible before I began it -- is no longer so mysterious. Benard writes that the qualities that make up resiliency are hardwired into the human makeup, and all that is required to foster more recoveries is to remove the barriers and enhance the protective factors for our innate drive to thrive.

Stone Sober -- and Absolutely Fascinating

[Originally published Sept. 4 2010 on hellowellness.in]



Jerry was at dinner with his ex-wife and his 12-year old daughter.  A fragile web of emotions spun across the table.  He felt delighted to be with his daughter, who looked happy to be with him, and his ex, for once, was not interfering. The waiter suggested a glass of wine.  Jerry demurred.  He so enjoyed being exactly as he was that he didn’t want even the mild alteration in mood brought on by a glass of Chardonnay.

Jerry is an emotionally intelligent man who knows from experience that even a small amount of alcohol will induce emotional and cognitive distortions. He does not drink because he treasures the natural chemistry of his feelings.  

The talk show host Dick Cavett once asked Katherine Hepburn whether she had ever used drugs or indulged alcoholically.  The actress’ reply is a classic:  “Cold sober, I find myself absolutely fascinating.”  

This sounds a bit narcissistic, which is only natural for a famous actress, but it has a core meaning with universal validity.  Cold sober, we are all of us worthy of esteem and interest, if we only take time to get to know ourselves.

Gillian E., a British artist living in San Francisco, recalls an idyllic moment: a beautiful beach, a glorious setting sun, a gentle breeze, a charming man beside her, and a glass in her hand.  In the glass:  fresh sparkling water. She asked herself, would I rather have alcohol instead?  The answer came back to her loud and clear: “No way.  This is just perfect the way it is. Drinking alcohol would interfere with this beautiful clarity that I feel, and would just get in the way.”  

Some time ago, I made an illegal left turn and got caught.  In traffic school, the instructor showed a video of people driving their cars on an obstacle course that required precision steering and quick reaction times.  They did well.  Then they were given one drink.  Their performance deteriorated, big time.  They were surprised -- they didn’t feel drunk.  But the trail of knocked-over traffic cones behind them didn’t lie.   

Such anecdotes are among the small building blocks of an emerging secular argument for complete abstinence from alcohol.  I mean, abstinence for healthy people, for everyone, not only for people who are already addicted to the stuff.  A secular case for abstinence is called for because it’s obvious that great numbers of people ignore religious prohibitions against alcohol, where they exist; and such prohibitions are altogether lacking in most flavors of the Christian faith, as an excellent article on Christianity and Alcohol in Wikipedia points out.  

Not so very long ago, the media were filled with advertisements for the supposed social and psychological benefits of cigarettes.  We were given to understand that if we smoked, we would relieve our stress and we would become more attractive to other attractive people.  Cigarette smoking was painted as an essential glue of happy social relationships.  We now know better.  Most educated people in the U.S. no longer smoke.  

A similar awakening needs to happen with alcohol.  Alcohol as stress relief -- bunk.  Alcohol as social lubricant -- more bunk.  Alcohol as a sex magnet -- nonsense.  Alcohol as an essential part of pleasant social togetherness -- not true.  All lies, promoted by a multi-billion dollar industry totally lacking in ethics.  

Alcohol and wellness are polar opposites.  Wellness includes emotional intelligence, self-esteem, mental clarity, and fine coordination of the senses with the muscles.  Alcohol is a poison with a destructive impact on all the above.  It’s time for a cultural awakening, for a new appreciation of our sober selves, for an affirmation of our inborn capacities for healthy and happy living.

Exercise for the Choice Muscle

[Originally posted Sept. 4 2010 on hellowellness.in]

My friend Alex saw the Light.  He made the Big Decision not to drink any more.  Ever.  On the way home from church, he passed his favorite liquor store.  He made the small decision to turn into its parking lot. 

My friend Sandy had had it with drugs.  While walking in the park, she made the Big Decision to get clean.  At the edge of the park, she could turn left or right.  She decided to turn left, where she usually ran into her dealer.

Moral:  the Big Decisions need the support of the small decisions, or they crash.  The old alcoholic support groups came close to this lesson with the slogan, “One day at a time.”  But at the beginning, it’s more like one minute at a time, or even one second.  What matters is the choices we make while the clock ticks.  The small decisions.  

Addiction is the enemy of decision-making.  Addiction is dictatorial.  As we saw in my previous blog entry, chronic use of addictive substances impairs the brain’s synaptic plasticity.  Major brain circuits become rigid, sclerotic, like arthritic joints.  Our decision-making muscles become enfeebled. 

De-addiction, it follows, must exercise the choice circuits in the brain.  We need to give the prefrontal cortex, the center of executive functionality that makes our brains anatomically human, a steady progression of challenges to think, weigh, and choose.  Repeating slogans and formulas or reciting memorized life stories won’t do a thing for our decision-making organ.  Only persistent decision-making exercise will strengthen its capacity. 

Let’s begin with the body.  Do I have externally visible marks of my substance use?  Do I have red veins in my face, drug stains on my fingers, receding gums, puncture marks, etc.?  Do I have hidden body damage, such as liver damage, heart problems, malnutrition, etc?  Is my diet what it should be?  Am I getting the exercise I need?  Are my teeth properly cared for?  Is my mental state satisfactory?  And if not, what exactly should I do about all of that?  What is my plan? 

Let’s consider my immediate surroundings.  Are there drugs (including alcohol) in my home?  In my car?  At school or work?  Do I have objects that trigger thoughts of drinking/using in my environment?  Where are the ‘hot spots’ of danger in my daily travels, and how can I avoid them?  Make a map!
 

How do I spend my time?  What about the people with whom I associate?  What is the condition of my emotional life?  Is my lifestyle helpful to my recovery, or not?  What aspects of my personal history are assets to my new life, and what aspects drag me back?  Am I prepared to handle the many mixed messages about drinking/using in my culture?  Is my treatment and support group program optimum for my needs?  Am I prepared to handle near-relapse situations?  Make a plan! 

Our LifeRing meetings focus on the small decisions that people make from day to day.  In my years of attending LifeRing meetings, I’ve heard literally thousands of detailed, particular questions that have challenged all kinds of people in recovery.  I’ve distilled and organized these questions into nine major topic areas and put them into a workbook, Recovery by Choice.  It’s an exercise book for the prefrontal cortex.  It’s like a body-building gym on paper.  Your sober self enters as a 90-lb weakling, and comes out as buff as Aniruddha.  

[The reference is to Aniruddha Bose, a founder of hellowellness.in]

Stiffness of the Mind

[Originally posted Sept. 4 2010 on hellowellness.in]

If the brain is like a muscle, then the onset of addiction is like rheumatism -- a growing stiffness and pain with movement.  That, at least, is the finding of a group of international researchers based in France, and published in a recent issue of Science.  

The scientists studied what happens in the brains of rats when exposed to various addictive substances.  Rats and scores of other species from the great apes down to tiny worms and fruit flies, can be turned into addicts by infusing their bloodstreams with the addictive substance.  Researchers either hook up the animals to intravenous tubes that inject the drug, or they confine the animals in a vapor chamber where the air is infused with the substance.  It doesn't take long before the animals display a set of behaviors and physiological symptoms that we humans know all too well, if we have alcoholics or other drug addicts in our family or friendship circles.

The fact that animals can readily be turned into addicts, by the way, is important evidence that it's the substance, and not some qualities in the person's psychology, that makes addicts of us. Despite the creative work of Walt Disney's animators, rodents don't have human personality profiles, and they probably don't suffer from spiritual maladjustment.  Quite a few theories blame the person's emotional and spiritual deficiencies for the onset of addiction.  The animal experiments teach that there's a neurobiological process at work.  The molecules in the substance are like so many little vandals in the brain, hammering, bending, mutilating and wrecking the intricate circuits of the most complex apparatus on earth -- one that we all carry between our ears.

What long-term use of the addictive substances does, the researchers found, is to decrease synaptic plasticity.  Synapses, of course, are the connections between brain cells.  Connections are the rails on which our thoughts and feelings run.  When we process a new experience, the brain cells rewire themselves to integrate the new elements into our existing web of ideas and emotions.  The power of brain cells to form new connections, their plasticity, is the foundation of all kinds of learning. A brain with high synaptic plasticity is like a body that's flexible, loose, limber, toned -- the kind we love to see jogging in the park or performing acrobatic feats on television.  

So, the next time you hear somebody use slang terms like "let's get hammered" or "stupid" or "stoned," take it as a neurobiological reality.  The chronic use of addictive substances such as alcohol, cocaine, etc. creates stiffness in the brain cells, even while it tends to take away men's stiffness elsewhere in the anatomy (but that's another story). A kind of mental rigidity sets in; the ability to learn and to adapt declines; the person's mind becomes unresponsive to new ideas and feelings.  Does this describe anyone you know?

[For more details, read Kasanetz et al., "Transition to Addiction is Associated with a Persistent Impairment in Synaptic Plasticity," Science 328:5986 pp. 1709-1712.

Genetics: DNA Causation Unravels

In several earlier posts here, I quoted from scientific journals reporting on the findings of modern genetic research -- or rather, the surprising absence of such findings.  For the first time ever, science has the tools to find out exactly where the genes are that we have long believed underly major diseases.  What the tools are telling us is that the supposed genetic causality isn't there, or it's much weaker than previously thought.  We can now say with confidence that the "alcoholism gene" does not exist; that the genetic contribution to alcoholism, such as it is, is spread over an as yet unknown number of genes, each of which has only a minute influence, and that this influence is profoundly mixed up with and moderated by environmental factors.
Now the current issue of Scientific American (Oct. 2010) reports similar findings for genetic research into a broad range of other diseases.  In its article, "Revolution Postponed: the Human Genome Project has failed so far to produce the medical miracles that scientists promised,"  the journal describes a growing realization in the scientific community that the old model of genetic science, where variations in specific genes cause specific illnesses, has very limited validity.    The journal quotes David Goldstein, director of the Center for Human Genome Variation at Duke University, one of the major research centers:

It's an astounding thing that we have cracked open the human genome and can look at the entire complement of common genetic variants, and what do we find? Almost nothing.  That is absolutely beyond belief.

Another researcher, David Botstein of Princeton, describes the effort to map disease-causing genetic variations as an experiment that had to be done in order to know that it did not work.  It was, he said, "a magnificent failure."

Walter Bodmer, a pioneer of the modern genomics research effort, says that the effort to find genetic variants that cause major diseases is a biological dead end.  "The vast majority of [common] variants have shed no light on the biology of diseases."

These findings are profoundly upsetting long-held beliefs about genetic causality and forcing scientists to rethink the whole model of what genes do.  The old model which saw DNA as a kind of computer program that determines the fate of the organism is out the window.  The processes are much more complex and involve a great deal more interaction with the environment than had been previously thought.

The takeaway for people who have serious issues with alcohol and/or other addictive substances is:  don't blame your genes.  Your genes are OK.  Your DNA will be just as happy, and very likely much happier, when you stop hammering your brain cells with addictive substances.

Some Progress on Campus

I happened to be visiting Ramapo College in New Jersey the other evening and, in a hallway outside a counseling office, passed this display of literature aimed at reducing college drinking.  Didn't have a chance to meet the counselor or ask questions, but it looked like a big step forward from my college days (eons ago).  The bulletin board display points out that a large majority of students think that college students are heavy drinkers, whereas in fact, most students drink lightly.  The false expectation likely promotes heavy drinking behavior and the accurate survey tends to put on the brakes.  The display also includes handouts on alcohol and related issues. If material of this kind, backed by a proactive counseling staff and supported by the administration, had been available in my day, I might (might) have been spared three decades of alcoholic drinking.  

Empowering Your Sober Self -- the Class

As I noted here earlier, Prof. Arthur McCullough in Belfast announced a class on Empowering People Against Addictions at Queens University's Open Learning Centre. Now Prof. McCullough kindly sent me an email with a short report on how the session went:

Dear Martin,

The course Empowering People Against Addictions - 5 weekly two-hour sessions at Queen’s University Belfast Open Learning Centre – was completed last night. Its main inspiration is its recommended text Empowering Your Sober Self.  ...

As described in the Open Learning Programme, for Spring  2010: OLE1097 -  “This course is about how and why people get into addictions, and about how to get out of them. It covers major areas of addiction such as alcohol, drugs, gambling, sex; and related ones, such as isolation, suicide, physical and mental illness. Discussions involve perspectives in science, culture and society, and will focus on the recovery model.

There were 16 students mostly community, care and social work professionals or semi-professionals. About a quarter had had addictions. It’s been an exciting and interesting course, with LifeRing a point of departure all along. Two of the students say they are interested in a LifeRing in Belfast, and are in touch with Dennis Stefan (Dublin), who is interested and very willing to help. I think it could be very valuable here.  Every member of the course thinks so. ...

I thank Prof. McCullough, who appends this short bio:

Arthur McCullough was a Researcher in Organizational Studies at the University of Bradford, and Bradford Management Centre. He was Senior Lecturer at the University of Ulster, and later Head of its Department of Sociology and Social Anthropology. He is currently an Open Learning Tutor at Queen’s University Belfast providing courses on World Cinema, Tribal Art, Irish Art, Sacred Places Objects and Art in the Province of Ulster, and Empowering People against Addictions.

Needless perhaps to add, I hope that other educators find a place for Empowering Your Sober Self in their addiction-related classes.