Craving (12 page)

This suggests that the collective experience of NA members—many of whom have managed to stay clean for decades—is that, in general, the similarities are more important than the differences. Of course, it’s precisely the diversity of the stories in these fellowships that enables newcomers to connect, to finally hear their own story told by someone else, which then creates the opportunity for them to begin seeing the similarities between themselves and all the other members. These members focus on what has worked for them and are unencumbered by the requirement that interventions be rigorously and academically studied prior to implementing them. In my countless conversations with NA members, I have not gotten the impression that they eschew intellectualism; on the contrary, they simply note that they don’t have the luxury of waiting for the scientific community to test their conclusions. They rely on their collective experience to make progress. For example, these members will not wait for the FDA to classify something as a scheduled (abusable) drug before determining they should avoid it, and they won’t wait for addictive disorders to be added to diagnostic schedules before taking action to recover from them. Many of these members had figured out, for example, that the sleeping pill Ambien and the pain reliever Ultram were addictive and dangerous to them long before the medical community did. One phrase commonly heard among their membership is “a drug is a drug is a drug.” The emphasis on the similarity of various drug addictions is core to their approach. Although there is some controversy about this, and not all Twelve Step adherents consider prescribed medication to be as dangerous, most members acknowledge that the use of intoxicating medications is very risky.

Additionally, most of the better treatment centers addressing process or behavioral addictions emphasize a multipronged approach that includes most of the same techniques used to treat chemical addictions (Twelve Step approaches, cognitive-behavioral methods, medications for chemical addictions that are starting to show some success with process addictions, and so on). Clearly, these disorders are very addiction-like, even if they are not officially classified that way right now. And in all of these conditions, people suffer from intense craving, which is another reason for us to address them together. I believe that while these process or behavioral disorders are different, there are enough core similarities to allow us to explore them together and to use proven methods for addressing the cravings that cut across the diagnostic differences.

Differences in Process and Behavioral Addictions

Nevertheless, there
are
some fascinating differences between addictions that are also worth exploring. For example, people with addiction are prone to developing depression, but in opiate addicts the type of depression is often very different, with more self-criticism, worthlessness, and shame than in non-opiate addicts.
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One theory for this argues that these addicts initially begin using opiates in order to provide relief from a harsh, tormenting conscience. In these people, success has been identified as a trigger for opiate use, since for these people success, strangely enough, is connected with guilt and shame.
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Over the last seven years, I have focused on the assessment and treatment of addicted health care professionals and other high achievers, and I have certainly observed this dynamic quite frequently. In this group I’ve seen a triad of compulsive work, opiate addiction, and perfectionism, which are precisely the opposite traits of what people usually think of when they use the term “alcoholic.

Many other differences have been observed in people who suffer from different addictions—so numerous, in fact, that it isn’t entirely accurate to say that addiction is addiction is addiction. There are racial and ethnic differences in how widespread the abuse of various intoxicants is. Certain drugs, like stimulants used in the treatment of attention-deficit/hyperactivity disorder (ADHD), are more commonly abused in young adults than in older adults. High-risk sexual behavior is often seen in adult inhalant abusers and in the gay male methamphetamine-abusing population. Various medical conditions often co-occur with addictions, including HIV, cardiovascular disease, and hepatitis C, and the prevalence of these conditions varies depending on the substance used. There are genetic differences in the probability of developing these addictions, neurochemical differences in which neurotransmitters are affected, and brain differences regarding which regions are affected by different addictive substances and different addictive behaviors. More complex differences exist, too, having to do with the emerging discipline of epigenetics, the study of changes in the expression of your genes that occur without changing your DNA. Many of these effects are due to the impact of the environment on how your genes ultimately become proteins. The typical age of onset, the number and type of other mental illnesses that people with particular addictions tend to develop, the impact on physical and social health, and the response rates to treatment all vary among the numerous addictions. These are just a small number of the types of differences between various addictions. There are countless others.

Even within specific addictions, the conditions themselves are incredibly diverse. For example, alcoholism is a remarkably diverse illness, and there have been many attempts to classify it. Perhaps the most popular division is type 1 versus type 2, where type 1 alcoholics have a later onset, and these two types vary by gender, genetic and environmental influence, and the presence of other psychiatric conditions and personality traits and disorders. Other classifications based on personality and even response rates to treatment have been proposed. One thing is becoming clear about alcoholism: it isn’t one disorder, but a spectrum of conditions whose development is influenced in varying degrees by genetics and environment and that vary in terms of their co-occurring psychiatric illnesses, personality structures, age of onset, gender-related factors, and even prognosis. Much ongoing research is committed to clarifying the variations of alcoholism and clinical characteristics of this diverse spectrum of disorders.

There are also certain medically induced cravings that don’t seem terribly similar to addictions and may involve different mechanisms. Certain psychiatric medications (such as olanzapine and valproic acid) can produce intense carbohydrate cravings. Iron deficiency can produce cravings for eating clay, ice, or tomatoes. Certain brain tumors and conditions can produce odd or bizarre cravings, and these seem only marginally related to addiction.

Currently, the most popular approaches to addiction treatment treat all addictions the same or, at most, slightly different from each other. This unfortunate approach has been helpful to many, but not all people with addictive disorders. I have visited many centers that pay lip service to individualized treatment, assuring payers and families that the person’s care will be individualized, only to learn that this really isn’t the case. I have treated some people with very complex addictions (anabolic steroid dependence, or the combination of stimulant addiction and narcolepsy, or any number of other complex problems) that cannot be expected to respond to a cookie-cutter approach. Success can be measured in many ways, but if you look at abstinence at one year after treatment, you will generally find that anywhere from a third to half of patients who completed these treatment programs have relapsed. If we continue to emphasize core components in all addiction treatment (which really is very important), but also further individualize care to address differences, we would surely see some improvements in this metric.
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***

This book is about the core, addressing what is universal to all addictive processes and compulsive, self-destructive behaviors: craving. In this chapter you have learned how the various conditions that involve cravings, while different in important ways, are remarkably similar. It’s this similarity that will enable you to use what you learn in this book to reduce or eliminate your own cravings, and it’s the differences that will require you to tailor what you learn to your specific situation. Later, you’ll see how you can take specific actions to relieve the burden of your cravings. First, let’s see just how your actions, thoughts, and experiences can change the source of your cravings—your brain.

…

5

Plasticity

How Thoughts, Actions, and Experiences Actually Change Your Brain

Though it seems counterintuitive, your brain develops by killing itself. At birth, your brain has billions of nerve cells, but only around half of them survive into adulthood. The overproduction of neurons, and later “pruning” them, is a hallmark feature of brain development in mammals. Many of your neurons are programmed to die if they are not used, in a biological process called “apoptosis” (from the Greek word meaning “a falling off”). This results in greater efficiency, as your brain directs its resources to those connections that are actually needed. There is a popular sentiment that the brain cannot change, but this could not be further from the truth. Your brain is always changing. The real question is how can you direct that change in a favorable way?

Another common misconception is that your brain’s development is determined entirely by your genes. We know beyond a shadow of a doubt that this is not true; many decades of research confirm that environmental influences (your relationships, what you eat and are exposed to, what you do) all affect how your brain will turn out. Child development experts and others have directed much attention to figuring out what will give children the best chance at becoming bright and leading happy, fulfilling lives.

It’s very easy to feel lost when faced with the dizzying array of suggestions in the media about your brain and your health. Eat more of this, don’t eat that. Drink a little. Don’t drink at all. Do this type of exercise. Don’t do that type of exercise. Further complicating matters is the fact that public health recommendations, while very valuable for the wider population, may not be on target for you.

As with most areas of behavioral science research, there is a gap between what we know helps and what we actually do at a public health level. The reasons for this are many, including political pressures and how some recommendations are perceived that can interfere with how evidence-based approaches are applied at the public health level. For example, in 2010 the U.S. Department of Agriculture (USDA) issued dietary guidelines that dramatically underemphasized the role of meat in a healthy diet, and the response was overwhelming pressure from the beef industry to revisit the issue.

Another great example of the rift between politics and research is the gradual reduction (and, in some cases, elimination) of recess from school schedules. There is a preponderance of evidence pointing to the benefits of recess in children’s attention, social interactions, and academic performance.
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However, numerous competing (including political and, in some cases, legal) pressures have gradually squeezed out the relative time children spend in recess. That is nothing short of tragic.

There are a number of reasons why you might want to consider going beyond public health recommendations to give yourself the best chance at success. Many governmental and other recommendations directed at large populations are designed to be cost efficient. If the importance of your goals outweighs how much someone else thinks you should be willing to pay for them, you might choose to take different steps to improve your health than what is generally recommended. By sticking to the evidence rather than what’s popular or in fashion, you can give yourself and your family the best chance at healthy brain development, despite what current governmental or public health recommendations may be. Before we address specific suggestions about how to change your brain, we should review what we know versus what we think might be true.

Part of the trouble in applying the best evidence to your daily practice is that it can be very difficult to discern between “causation” and “correlation.” Another way of putting this is that many studies will show a correlation between a behavior and an outcome; it’s much more difficult, however, to demonstrate that a particular behavior
causes
a certain outcome. Let’s look at an oversimplified example of this. Consider all of the cars at the local shopping mall parking lot. If you measured how clean the cars are (interior and exterior), and then you measured how well the cars were running, you might find a statistical correlation between those two measures. If the local newspaper learns of the research, the headline might read “Cleaner Cars Run Better.” Now, while that might be true, it’s very unlikely that cleaning your car
causes
it to run better. A more likely explanation may be that cleaner cars are newer and so are more likely to run better, or that owners who clean their cars are more likely to service them appropriately and get the oil changed regularly, and so on. Thus, there’s a
correlation
between cleanliness and engine performance, but one isn’t causing the other.