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The Thirteenth Step
- The Book Brigade talks to neuroscientist Markus
- Jun 29, 2015
- 6 min read
The Book Brigade talks to neuroscientist Markus Heilig, M.D., Ph.D.
Post published by The Book Brigade on Jun 18, 2015 in The Author Speaks
There have been many advances in the science of addiction in the past 25 years, yet patients are still offered approaches to recovery that were laid down 75 years ago.
There are a lot of books out now about addiction/recovery.
What makes yours different?
Addiction treatment and addiction research really live in different worlds. I have been active as a physician, seeing and treating patients with addictive disorders for some 25 years. I also run one of the largest addiction research programs in the world. This has given me a lot of frustration: Why is it we are not offering patients what science has taught us? But it also gives me a unique opportunity to relate the scientific advances to phenomena patients and their families will easily recognize. I think I simply have a better opportunity to be a bridge builder than most, and that is what I have worked hard to do—build those bridges.
The title of your book seems to imply that you are aligned with the AA model of addiction and/or treatment. Is that a correct assumption?
No, not at all. In fact, I started out writing the book terribly upset that we had made all these advances in the science of addiction in the past 25 years, yet patients were still offered approaches to recovery that were laid down 75 years ago. To make it worse, I saw a lot of resistance against scientific advances, such as anti-craving medications, and also a lot of facilities claiming to adhere to 12-step principles but making terrible profit off of people made vulnerable by their addictions.I softened some of my criticism in the course of researching and writing the book. There are many values in the 12-step movement that people on the outside may have a hard time appreciating. And most 12-step-based recovery is done for free, in peer groups, or at serious institutions, such as Hazelden in Minnesota. But a lot of my criticism remains, and there is clearly a spectrum at one end of which recovery is a big business that offers services with no basis in scientific evidence.
What popular ways of thinking about addiction are now outdated by the findings of new science?
Any number of them. That addiction is one thing; there are so many different trajectories and biological mechanisms that can lead people to lose control over, for example, alcoholuse. That people need to declare themselves powerless to recover; just the opposite is true. That complete abstinence is the only outcome worth achieving. That taking a single drink is just as bad as taking 10.
What ways of treating addiction are outdated by new science?
Most of them! Staging confrontations is probably among the worst; it actually most likely promotes relapse. Or it ties for worst place with admitting people, detoxing them, and then sending them back out on the street. With heroin, that leads to many people simply dying from overdose. With alcohol, we’re learning that is one of the most effective ways of pushing along the brain changes that keep people addicted.But many things continue to be done despite total lack of evidence, and despite that they don’t make sense from the perspective of modern brain science. Providing addicts witheducation about the negative consequences of drug use. Doing old-fashioned talktherapy, as opposed to practicing behaviors to prevent or manage relapse. I could go on. The book gives a rundown of things that work— modestly, I should say— and tries to explain why it does, by looking at the underlying brain mechanisms.
What do you believe are the best ways of treating addiction, and why?
Cognitive behavioral therapy and, in the cases where we have them—for alcohol, heroin,nicotine—antirelapse medications. Why? Because they have the data to support that they help. And because they happen to make sense in the context of how addiction works in the brain.A very broad array of substances and experiences (like love) stimulate thedopamine reward system in the brain.
Is that enough to explain addiction?
No, it doesn’t even suffice to begin. Dopamine is just a signal that a reward was encountered. As I describe in the book, the fact that drugs are able to artificially activate this signal does play a role in the early stages of addiction, when people initiate their drug use. But in fact, by the time people seek treatment, that ability has pretty much completely lost its importance; other things—being miserable in the absence of drug, being overly sensitive to stress—take over.
Behaviors like gambling can be addictive. What does that tell us about the role of brain processes?
Well, the circuits overlap to some extent, and so does the neurochemistry. Some of the same medications may be beneficial. In the end, all behavior is driven by brain processes, so I am not sure what that tells us.
What brain processes do substances like alcohol trigger that result in addiction?
More of them than I can count! I list some of the most important ones in the book, but alcohol is really, really complicated. That is why “alcoholics” can be so different. It is probably not really meaningful to talk about that as a single disease. If you have a dad who was alcoholic, are a daredevil yourself, start heavy drinking when you’re 15, and get a strong kick out of drinking, the biology is obviously very different than if you’re a social phobic, drink because you discover that is what helps you get to the grocery store, and build a heavy consumption that has you hooked by the age of 50.
What is reward prediction error and what role does it play in addiction?
Humans are the most adaptive animals on the planet. To achieve that, we have evolved a phenomenal ability to learn. For new learning to happen, you have to have a signal that tells you that something new you did just had an unexpected desirable outcome. That is how you learn to do it again. That is one of the things the brain’s dopamine system does. When you encounter an unexpected good thing, that is the signal. Once you’ve learned how to get that good thing—I use a burrito as my example in the book—you don’t need the reward prediction error signal, and so it fades away. Drugs seem unusually effective at maintaining the activation, and so one of the theories out there has been that this results in pathological learning. I do think there is something to that concept, but there is more to it than that.
What led you to write this book about addiction?
Because it is so important. Because it is so fascinating. Because it taps into who we are as humans, why and how we feel what we feel and do what we do. And, I have to confess, because I just couldn’t take all the quacks out there hitting up vulnerable people for piles of money.What is the most surprising thing you discovered in writing your book?Writing the book is telling stories of things already discovered, mostly by others. One thing I did discover while reading the work of the amazing scientists in this field was how fascinating and important I still find it all, after all these years of being in the field.
What is the most important point you want to get across?
Addiction can be understood in terms of its brain processes, and much help that taps into those brain processes is already out there. We need to start making use of the knowledge we have.
If you had one piece of advice, what would it be?
If you struggle with addiction: Don’t take out a second mortgage to pay for a course of “treatment” at expensive institutions. Read up on what we know about what works, which is usually cheap; seek help; and never give up, because no one gets “cured”, but you can learn to achieve a productive, meaningful life
If you’re one of the rest of us: Don’t judge. Read up on what we know about what works, which is usually cheap; support your loved ones to seek help; and never give up, because no one gets “cured”, but they can learn to achieve a productive, meaningful life
What would you like to see happen as a result of your book?
The $35 billion or so spent annually in the U.S. on addiction treatment put to better use.
About THE AUTHOR SPEAKS: Selected authors, in their own words, reveal the story behind the story. Authors are featured thanks to promotional placement by their publishing houses.
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