On a friend’s recommendation I checked out The Biology of Desire.  The author has the somewhat unique qualification of being both a neuroscience professor and a former drug addict.  The book is an exploration of the neuroscience of addiction, mixed in with the stories of various addicts.  I think it has interesting lessons not just for helping people with addiction, but also for milder habit issues, like overeating, habitual phone-checking, or repeatedly staying up late browsing the internet.  The book builds useful mental models for what is happening when someone gains and then later moves past an addiction.

I should note that the author’s opinions appear to be somewhat controversial, and I don’t yet understand the strength of the dissenting arguments.  What follows is information from the book that I thought was interesting and relevant:

What is addiction?:

Some experts think of addiction like a disease, while others think of it as a behavioral problem, and still others think of it as an issue of environmental stressors.  In reality, it’s a mix of all three, and thinking of it too much like a disease leads to notions of helplessness on the part of people who are struggling with addiction.  The author also notes that “recovery” is not a good word for describing moving past addiction, as it implies that moving back to an old life before the addiction is the end goal.  Usually there was something wrong with the person’s old life that drove the addiction in the first place, so the real goal should be transformation, not recovery.

The neuroscience of addiction:

“Liking” and “Wanting” are two separate pathways in the brain.  Sometimes they’re connected, but often they’re not.  You can want something without liking it, and vice versa.  In addiction, they’re very disconnected and sometimes in direct opposition, where someone is drawn to repeat a behavior that brings little joy.

Different regions of the brain handle high-level planning, reward seeking, and rote behaviors.  In addiction, the reward seeking areas (often the nucleus accumbens in particular) gets hijacked by a superstimulus that can provide a flood of dopamine.  That superstimulus might be a drug like cocaine, meth, or heroin, or even something more mundane like food, porn, video games, or a pile of notifications on social media.

In general, rewards are good, and the high level planning part of the brain (the dorsolateral prefrontal cortex, among other regions) is usually deciding on goals and making plans with various rewards in mind.  However, addictive superstimuli can override the high level planning region’s other goals and other rewards of interest, creating a black hole of motivation that sucks in all other behavior toward it.  In an addiction scenario, the reward seeking part will build a strong network of associated stimuli that all point toward the reward of engaging in the addictive behavior.  Even distantly related stimuli that are several steps upstream of the reward, like seeing an object with the same color of the drug dealer’s house, can be enough to trigger a strong craving in an addict.

Once an addictive behavior has been happening for a while, the situation gets even worse, as the parts of the brain that handle rote behaviors learn to automatically perform the behaviors needed to abuse the addictive substance whether it is wanted or not.  Alcoholics may find themselves topping off their drink just because the bottle is there and not because they’re enjoying the experience or even wanting more alcohol.

Treating addiction:

Getting the high level planning part of the brain to override the reward seeking or rote behavior parts is usually a losing strategy for a brain modified by addiction.  Telling an addict to “just say no” or “just apply some willpower” is setting them up for failure.  This battle usually leads to a high level of stress that exhausts the high level planning part of the brain and can cause the connection between this part and the reward seeking part to weaken, at which point the addicted person can find themselves engaging in behaviors that they desperately don’t want to do anymore.

Environmental changes, on the other hand, can have a big impact in reducing addiction.  If an addict checks in to a treatment center or sequesters themself in a cabin in the mountains, they know that they cannot acquire the addicting substance, so the high level planning part of the brain doesn’t have to work as hard to rein in the reward seeking part.  Many drugs do have a difficult withdrawal period that may have to be addressed separately, and that’s usually specific to the drug and out of scope of the book.

Removing environmental cues is often not a long term strategy though, as when the person returns to the stressors and stimuli of their previous life, they will often relapse.  Instead, this period away from environmental cues should be used as an opportunity to address the root cause of why the person sought the addictive substance or behavior in the first place.  This is often hard psychological work that requires a therapist or close friend that can help them through the process.

In general, most addictive behaviors are initiated and driven by some sort of stressor.  The addictive behavior is often taking the place of a relationship in the person’s life, providing some level of comfort, even if it’s a harmful dissociative form of comfort.  If a person is fighting an addictive behavior, fighting harder will just make it worse, as doing so generates more stress, which increases the desire for the addictive behavior.  Instead, the person needs to find something else that can fill a similar role to the addictive behavior, but in a more healthy way.

“12-step” programs or other peer groups of people suffering from the same addiction can tend to have mixed results, where they help some people but don’t help others.  On the positive side, they often give people an opportunity to open up to others about their addictions for the first time, and expressing their stories and emotions can help with the healing process.  These programs can also give people a new vocabulary for recognizing their unique experiences and challenges.   However, these groups also often provide constant reminders of the cues that can trigger the addictive behavior.

People struggling with addiction can sometimes make the hard choice to permanently remove the environmental cues that trigger the addictive behavior.  Environmental cues are also often hard to disentangle from social ties, as in the case of a group of coworkers who have a habit of taking morning cigarette breaks together.   Consequently, changing environmental cues often involves trying to change social activities with existing friends, finding a different group of friends, moving to a different town, or eliminating the stressor that is driving the addictive response whenever possible.

As a side note, adverse childhood experiences (eg chronic stress, war, abuse, other traumas) can dramatically increase the risk of addiction.  People who undergo these traumas often need to develop intense and sometimes dissociative coping mechanisms to deal with these traumas, and this leads to disconnection within the brain regions that would normally handle executive function.   The author doesn’t say it, but I imagine it’s likely that people who are non-neurotypical in ways that increase baseline stress are also at increased risk for addiction, even if they didn’t have anything that would obviously get labeled as a trauma from an outside perspective.  I was easily able to find a study that supports this hypothesis.

The book doesn’t go into this, but recent research strongly suggests psychedelic treatments for addiction appear to work well.  The mechanisms for why this is the case are currently unclear, but the book provides some hints.  Since psychedelics tend to increase neuroplasticity by promoting synapse formation, it’s likely that they help loosen up rote behaviors as well as provide opportunities to disrupt the tight network of reward-seeking connections that drives the addictive behavior.  Additionally, they may provide opportunities to strengthen connections between the high level planning and the reward seeking areas of the brain.  Basically, psychedelics likely open a door to mental change, but the person still needs to choose to walk through it and lay down new neural pathways that are different from the ruts built by the addiction.  I should emphasize that this paragraph is all hypothesis on my part based on the mental model of addiction provided in the book.

The book is a relatively short and compelling read, where the neuroscience is interwoven with the personal stories of people who have had their lives destroyed by addiction and have had to put them back together again.  It’s definitely worth your time, even if you don’t know anyone struggling from a severe addiction.