There are many reasons addicts engage in their addiction, even after a period of sustained abstinence. We previously discussed the disease aspect of addiction, emphasizing the power of reward, or “magical connection,” as well as eventual deficits in memory, learning, and decision making. In addition, problems with mood, boredom, and painful feelings play a triggering role in addiction. Khantzian (1997) has written extensively on his self-medication hypothesis. He made a compelling argument that addicts often have difficulty with intense feelings and their regulation. He observes that addicts experience their affects in extreme: they feel too much, or they feel too little or not at all. Recognizing these addicts’ inability to put feelings into words, Khantzian noted addicts often suffer with vague discomforts with relationships, self-esteem, and feelings of emptiness they are barely conscious of that can drive their addiction. This difficulty with feelings can combine with the disease of addiction to create the need to self-medicate these uncomfortable feelings. Khantzian described how the properties of certain substances can specifically interact with an addict’s particular problems with certain feeling states. For example, opiates have been known to reduce feelings of anger and rage (often not consciously experienced) in some addicts. This is in part because of the pharmacologic properties of opiates. Therefore, addicts with difficulty in dealing with anger may gravitate to opiates as a drug of choice. Similarly, stimulants like cocaine can counter boredom or intensify pleasurable experiences in those addicts prone to those types of feelings. Alcohol and other sedatives can improve self-esteem and help overcome shyness because sedatives can reduce social anxieties and feelings of emptiness. Other drugs and addictive behaviors (e.g., sexual compulsivity, overeating, gambling) can “self-medicate” a number of feeling states, states of mind, and sensory experiences. It is critical that there be continued vigilance regarding these states. As recovery evolves, one can relax and trust intuition as a guide. However, a life of sobriety will always require a certain degree of vigilance and reflection, and as such, an addict needs different strategies in early and longer-term recovery.
There are a number of theories regarding craving states and why addicts return to use after a period of abstinence. Newton and colleagues (2009) review five such theories:
- negative reinforcement (“pain avoidance”),
- positive reinforcement (“pleasure seeking”),
- incentive salience (“craving”),
- stimulus-response learning (“habits”), and
- inhibitory control dysfunction (“impulsivity”).
The Newton study, the human subjects for which were methamphetamine addicts, found that the greatest number of respondents (56%) stated pleasure seeking as the reason for use, followed by 27% stating impulsivity as a primary motivator.
In the Dutch article “A Three-Pathway Psychobiological Model of Craving for Alcohol” (1999), Verheul and colleagues separate craving into “reward craving,” “relief craving,” and “obsessive craving” and pair each state with an underlying neurotransmitter system: reward involving dopamine and internal opioids, relief involving GABA, and obsessive craving involving serotonin. This study placed an emphasis on medication strategies targeting the underlying neurotransmitter process.
The following descriptions emphasize the return to use following some stable period in sobriety, hence the assumption that there is some distance from the “gravitational pull” of the disease. The longer one is in recovery, the more evident the motivation to use can become—if one carefully explores this motivation.
Early and Longer-Term Recovery
We define early recovery as the first year of abstinence and working a program of recovery. Remember, abstinence alone will not facilitate positive sobriety. The first few weeks of abstinence are particularly difficult even after the detoxification period.
Addiction can cause permanent brain damage, but this damage is the exception. There is a potentially permanent change in how the brain processes reward (specifically, how it synthesizes proteins). The brain has enormous regenerative properties. This includes “plasticity,” or the ability to create new pathways and heal damaged ones. But the brain needs time to heal from the assault of addiction. Over time this occurs in most abstinent people. Working a program, like going to 12-step meetings, meditating, and exercising, will facilitate and accelerate this brain-healing process.
The healing addicted brain can then accommodate a central element of positive sobriety: improved decision making. The ability to choose is what addiction compromises and recovery facilitates. This is not only about choosing to use or not. It is also about the ability to choose how we live our lives, how we think, act, and feel. Recent research has suggested that there may be a predisposition in decision-making capability along with an inherited reward incapacity in the addict. In their research, these authors suggest that addicts also inherit some of their reactive tendencies.
The importance of moving away from reactive patterns, or “automatic pilot,” cannot be overemphasized. We know through studying posttraumatic stress disorder that traumatic memories get stored in the limbic (deep emotional) areas of the brain. When these memories are triggered, they are much processed much faster than our reflective ability to process what is really happening. This is similar to the reactive, automatic responses involved in addiction. So, we need to buy time for the brain to heal and provide greater capacity for reflection. The strategies used in treatment and provided in this book will help with that.
After approximately a year of abstinence and recovery, the strategies to enhance reflectivity can become more natural to us. This allows for refinement of these efforts with often greater benefit. Here, the question, “What am I looking for?” may be more subtle. With greater reflective capacity, there is increased ability to move beyond a predominately biologically driven process to a deeper psychological and spiritual one. One needs to ask, “What am I looking for?” in greater depth. This involves some discernment between states of mind, body, emotion, and spirit.