Craving (2 page)

And yet the solution can’t be simply removing cues. I learned that years ago when one of my patients, an IV heroin addict, checked out of treatment after a friend had accidentally spilled talcum powder on a table. His brain was activated by the image of the powder, and the next thing you know he was out of there. Another patient of mine, an alcoholic Vietnam veteran with post-traumatic stress disorder (PTSD), could not drive anywhere without seeing tall trees along the road that reminded him of the jungle. He described the feeling he got when seeing those tall roadside trees as “proof that I would never fully return home.” There is obviously no way to identify and remove all the cues that trigger our cravings, though it is helpful to remove the big ones if you can. This is why bartending is usually
not
a good job for a newly sober alcoholic and why working at a bakery is not wise for someone trying to lose a lot of weight. We’ll never get rid of all the trees and talcum powder in the world, however. It’s our brains that need to change.

Members of Twelve Step addiction recovery programs figured this out a long time ago. In 1939, the founders of Alcoholics Anonymous described a “strange mental twist” and “curious mental phenomenon” that occurred in
sober
alcoholics that tricked them into taking another first drink. A Japanese proverb states, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” But if this cycle happens over and over, with dismal consequences, what makes a person take the first drink again?

Members of Twelve Step programs have learned that changing their behavior affects both the intensity and the frequency of cravings, as well as the likelihood that they will act on their cravings. Many long-sober members of these fellowships note that it has been years, or even decades, since they craved their drug, alcohol, or addictive behavior. Even when they do experience such cravings, they don’t act out on their addiction. Why? What makes them and others who have been successful different?

The short answer is that cravings originate in the brain, and behaviors can and do change the brain. Our experiences, actions, and thoughts produce changes in areas of the brain that are responsible for craving, choice, and decision-making. In fact, the emerging discipline of the neurobiology of spirituality demonstrates that key components of spirituality also affect the brain in remarkable ways. We are learning that spirituality changes the brain and is experienced there. His Holiness the Dalai Lama has focused significant recent efforts, in collaboration with neuroscientists, on the specific ways in which “the mind changes brain matter.”

People trying to overcome cravings, whether they are related to an addiction or to another compulsive behavior, can benefit from these same changes. To begin, we need to set aside the naïve assumption that our future decisions and choices will not be affected by our current experiences or that we can usually trust what we think. Indeed, changing our thoughts, actions, experiences, and spirituality—and in the process changing our brains—is what will help us to finally feel satisfied and free from the desperation of not being able to get enough.

The Chapters Ahead

Why do cravings matter? In
chapter 1
, I’ll answer that question specifically. Why is so much advertising designed to create cravings? As you’ll learn in this book, many of the strategies people use to reduce their cravings backfire and
actually lead to more cravings.
Cravings matter because they have the potential to lead to behaviors that undermine success, contentment, and joy. Cravings can wipe out months or even years of hard work. Cravings can lead people to throw away all the things that really matter to them in exchange for a short-term fix that is often over before it even starts. Cravings matter because they are powerful, unexpected, and seemingly out of our control. But to understand how that is not entirely true, how we really can eliminate our cravings, we need to understand how decisions are actually made.

Chapter 2
focuses on how your brain drives your decisions. Most people have a basic understanding that chemicals in the brain, called neurotransmitters, affect our moods. What you may not know is that, in addiction, the shape, structure, and function of your brain cells actually change in response to your experiences. Addiction is
not
just a chemical imbalance. Addiction is the result of many complex changes in the circuitry of the brain. The neurotransmitters change, the proteins change, the cell structures change, and the centers of activity (networks of cells) change, making our thoughts and feelings change too. Some of these changes are temporary, some are longer lasting, and some appear to be permanent. In
chapter 2
, you will learn which parts of your brain are involved in craving and decision-making when it comes to compulsive, self-destructive behaviors. We’ll discuss the chemistry of the brain and its relationship to craving, as well as the way thoughts, behaviors, and actions are linked to changes in the brain.

If we never acted on them, cravings would simply be unpleasant, extraordinarily uncomfortable experiences. But it’s the related self-defeating actions that lead to so much pain, heartbreak, and misery. In
chapter 3
, we’ll review the link between cravings and actions. We’ll answer questions such as, “What makes some cravings lead to behavior changes, while others are just nuisance thoughts?” and “How closely are cravings linked to behaviors, and how do the more subtle cravings affect behavior?” To complete the cycle, we’ll explore how destructive behaviors themselves actually lead to increased craving.

People use the word “craving” to mean all sorts of things. We may crave attention, success, love—but we also crave sex and chocolate, or for those with chemical addictions, alcohol and drugs. Are all these cravings the same? What properties do the basic cravings for healthy behaviors and cravings for self-destructive behaviors share? How are cravings for chocolate similar to cravings for crack cocaine, and how are they different? Addiction treatment programs have learned long ago that alcoholics generally cannot safely use other intoxicating substances for long without often succumbing to relapse with alcohol, and the same goes for those who were primarily addicted to drugs. They often say “addiction is addiction is addiction.” But many programs for drug addiction allow coffee consumption and nicotine use. Are recovery programs themselves addictive?
Chapter 4
examines the relationships between various types of cravings and explains some of the key differences between craving chemicals and craving behaviors. The bottom line is that there are key differences; nonetheless, many of the approaches used to manage cravings in addiction are also successful when working to manage other types of cravings.

Many people do not realize that their experiences, thoughts, and actions change their brains. And these changes are not simply increases or decreases in certain brain chemicals. Experiences and behaviors have been linked to increased sizes of brain regions, increases or decreases in key proteins involved in responding to neurotransmitters, and even changes in the structure of brain cells (neurons) themselves. How does this happen? What do we really know about how thinking changes the brain? A study of monks who practiced compassion meditation demonstrated changes that occurred during meditation. No surprises there. But when researchers went back and studied the monks’ brain activity between periods of meditation, they found
persistent
changes—alterations in their brains that continued even when they weren’t meditating. Behaviors, thoughts, and experiences have
residual
effects on brain function, which are partly due to changes that occur in the brain.
Chapter 5
explores the neuroscientific concept of “plasticity”—specifically how the brain changes in response to input. These changes are critical to long-term freedom from cravings.

Members of Twelve Step programs are intimately familiar with the relationship between craving and relapse, and in this book I emphasize that much can be learned from the collective experience of people in these programs. Many recovering addicts in Twelve Step programs have struggled with cravings for much of their lives while using, and yet so many of them report that it has been months, years, or in some cases decades since they’ve craved their drug. How have these people managed to dramatically reduce or eliminate their cravings? Successful, long-time-sober Twelve Step program participants have discovered a relationship between things that wouldn’t seem to be connected. For example, reviewing your own “character defects” reduces the urge to drink. Making amends, social connectedness, an awareness of powerlessness, and a sense of a “higher power,” altruism, service to others, and meditation eliminates or severely reduces cravings. Twelve Step members have learned that these elements must be done together to work. Skipping a few results in relapse in many cases; thus, there is something about the interplay between all these actions that produces the changes needed to eliminate cravings. Furthermore, it seems that, at least when it comes to addiction, a sustained, ongoing effort is needed to prevent a return to earlier patterns of craving and relapse. Why is that? We’ll explore the answers to these questions and provide a framework for understanding the basic brain science of Twelve Step recovery in
chapter 6
. Addiction is a brain disease, and recovery is in part a brain phenomenon, and what we know about just
how
that works is the focus of this chapter.

Whether it’s weight-loss support, group exercise, Twelve Step recovery, or even online communities like Twitter and Facebook, people who succeed at changing negative behavior often discover that a group can do what the individual cannot. Even the most strong-willed, determined people can do more when buoyed by the power of a group. Feeling a powerful sense of belonging, identifying with others, and experiencing hope when we see others succeed are just some of the reasons why groups help. In many cases, a healthy sense of competition spurs us to greater success; in others, the self-worth that comes from helping others in the group who are still struggling makes the difference. Each of these social experiences changes us in profound ways, and in most cases, we aren’t aware that we are changing. Sure, some of us may feel better in groups (and many people don’t), but what we don’t realize is how, days or even weeks after attending a group meeting, we behave differently, think differently, and make decisions differently, simply because we connected with others. Each of the various ways that we form connections with other people has a correlation in the brain. In the early 1990s, a special type of nerve cell was discovered in nonhuman primates called the “mirror neuron.” These nerve cells, located in parts of the brain involved with planning actions, seem to be responsible for the way that we imitate behaviors we observe in others. In a classic research paper, the Italian neuroscientist Giacomo Rizzolatti and colleagues discovered that some neurons become active whether a monkey performs an action itself or sees someone else perform that same action. More recent human research suggests that these regions of the brain link actions with the observation (or even the sound!) of actions in others. In other words, when others act in certain ways, and we observe or hear them, our brains change. In
chapter 7
, we’ll explore the science behind the power of the group and its influence on behavior. We’ll begin to understand how groups influence people in a way that individuals simply cannot.

Over the years, I’ve treated thousands of addicts, many of whom were downright brilliant in every sense of the word: neurosurgeons, physicists, even addiction psychiatrists who just couldn’t stop using. Keep in mind, these are people who are bright, clearly motivated, and in some cases, possess more knowledge about addiction than 99.999 percent of the population. In my early career, even though
I
was treating
them,
they knew much more about addiction than I did. Even so, they just couldn’t stop using. Whenever I encountered someone like that, I always asked the same question: “What were you thinking?” That’s a question that sounds different to different people. Some consider it to be criticizing, while others hear it as curious. But the answer I got, in nearly every case, was the same: “Doc, I was so
stupid.
” Now, I had tested these people; I knew their IQs. Psychologists may disagree on how to measure intelligence, but one thing was absolutely clear: no matter how you measure it, there was no way to describe these incredibly bright addicts as “stupid.”

In other words, the best explanation these brilliant addicts could offer to explain their addictive behavior was
the one explanation that could not possibly be true.
Why is that? How do people who are so intelligent and successful in other areas become convinced that their behavior is caused by something that makes absolutely no sense and cannot be accurate? In
chapter 8
, we investigate how and why that happens. The correct explanation—that their brains have been hijacked by the disease of addiction and their decision-making with respect to addictive behaviors is not consistently under their control—is so profoundly unacceptable to them that they unconsciously reject it as impossible. In many cases, these men and women had never met a mountain they couldn’t climb, and yet they were brought to their knees by a chemical. They cannot accept the notion that they are not in control, and so prefer the explanation that they were “stupid.” They believed, at their very core, that they were immune to the effects of the disease. The extraordinarily naïve perception of immunity is at the heart of addictive behaviors—and of craving. It is extremely difficult for people to accept that forces are influencing their decisions without their awareness. And yet, with craving, that is exactly what is happening.

In the mid-1980s, psychologist G. Alan Marlatt, Ph.D., proposed that apparently irrelevant decisions (AIDs, he called them) impact relapse. For example, an addict who finished residential treatment three weeks ago might decide to take a familiar route home from work and, in doing so, bumps into an old friend who suggests they get high together. The addict’s brain tricks him into believing that this time things will be different, and so he gives in and gets high. Three days later, when he is lying in a bed on the detox unit of the local hospital, he wonders, “What happened?” As he reviews the events leading up to his relapse, he concludes that he never should have let his friend talk him into getting high. He never concludes that he bumped into his using friend because he walked home the same way he used to go when he was actively using drugs. He never becomes aware that the familiarity of the route was precisely the warning sign. He never realizes that the feeling of comfort was itself the red flag! The apparently irrelevant decision of taking a familiar route home remains outside of his awareness. He trusted his gut. And so, four weeks later, it happened again.