Dr. Alexander Goumeniouk by trade is a neuropharmacologist, and by profession is a psychiatrist at The Orchard Recovery’s addiction treatment centre on Bowen Island. He is also a professor Emeritus at the University of British Columbia’s department of undergraduate medicine and currently holds a senior position at Vancouver-based Aequus Pharmaceuticals Inc. as their Chairman of Clinical & Scientific Advisory. He sat down with RTAD to discuss the psycho-social, chemical, and behavioural aspects of addiction.
Tracy: Tell me a bit about The Orchard Recovery Centre, what your role is there, and how you got involved.
Dr. Goumeniouk: I was the founding medical director at the Orchard Recovery Center in 2001 and enjoyed it very much, but I had to stop working there because we attracted clients from so many different countries. I wrote to our insurer at the time, the Canadian Medical Protective Association, and they said, "If you get sued in Venezuela, we can't cover that." I ended up getting a written opinion that anyone who wasn't a Canadian resident wouldn't be covered for. Now, touch wood, I've never been sued in my life and I've never sued anybody, but I still didn't want to bet the farm. (We live on a really nice 25 acres of waterfront on Bowen Island and thinking about losing that to an American from Texas [for example] wasn't my idea of clever.)
Then in February of 2013, I went back to the Orchard to have lunch with Lorinda Strang who is the proprietor. I asked Lorinda, "How are things?" and she said, "We're lined up." I asked what the non-Canadian rate was and she told me, "We're 100% Canadian." Since I live on Bowen Island [where the recovery centre is] I asked her if they needed a dual diagnosis psychiatrist. I'm a neuropharmacologist at UBC and a psychiatrist (so brain chemistry and behaviour is my area of interest), but that's not really my job at Orchard. My job there is ferreting out other psychiatric diagnoses that contribute to substance use disorders and/or relapse. Now, I have to say that I probably have taken away more psychiatric diagnoses than I've handed out.
You have your own ideas on the root causes of addiction that my work has found to be true as well. Can you tell me a bit about this?
The interesting observation I've made about addiction is that while the popular data says that 80% of people who end up in rehab centres have trauma from childhood or otherwise, my experience is that 100% of our patients do. Sometimes it stares you in the face like PTSD, and sometimes it doesn't. But there is always an adverse childhood event. A brilliant neuroscientist, Helen Mayberg, can look at a PET scan of a 45-year-old woman and tell you whether she's had sexual abuse as a child or not, and I think that's just remarkable. Charlie Nemeroff, who's the head of the University of Miami's Behavioural Science and Psychiatry, has done a lot of work on looking at the input of adverse early childhood events on outcome, and it's clearly there. I have also lectured about it before.
This is an under-appreciated component of addiction; that part of the [person's] history is very important. I have a two-page pro forma that I use, not because I'm getting old [laughter], but because it reminds me to be thorough and not miss things. I have one section in it on early childhood development which I break into 0-5 yrs., then elementary school, high school, and up to age 20. Not that traumas after age 20 can't lead to substance use disorders: I do have a patient who was at the Orchard, who was basically held captive, beaten, and tortured during the years of 25 and 26, and became a drug user after that. It can even be later.
But those earlier, formative years are highly critical?
Exactly. There are other things that trauma can result in too: addiction isn't just drugs and alcohol. Addiction to sex, gambling, the Internet, etc. are also what can happen. I'm astonished that the new DSM in psychiatry doesn't have more elements of addiction in it than it does. From my perspective, the idea is that a lot of these behaviours of substance abuse are anxiety-based which clearly come from trauma. If you take someone who was a former bulimic, is now an alcoholic, and you fix their alcoholism, guess what?
They become addicted to something else?
That, or the bulimia comes back. It's an anxiety-reducing activity for them. I've worked with eating disorders as well, so that's another advantage that I have in treating the 10 to 1 ratio of female versus male addicts who also happen to have eating disorders.
Looking at childhood trauma, we can point to abuse absolutely, but we also need to look at neglect. I've often heard, "I wasn't abused but I have addiction problems." Or that they "got over it." But if neglect was experienced in infancy, it's hard to remember. Infants need affection just as much as they need food. Neglect in the developmental years can have impacts later in life, like social anxiety or depression because the stress response is affected. The danger in this is that addictive things release "soothing" feel-good endorphins: the same ones that human affection does. [Endorphins are the brain's natural opioids.]
De facto they have not gotten over it because they are in a rehab centre or they're still addicted. The proof is in the pudding. It can also vary; I remember seeing a 65-year-old woman, not for alcohol or drug use, but for depression and anxiety because she was getting divorced. That's a hard circumstance. I took a thorough history and she'd been abused as a young girl, but when I suggested talking about it, she said, "No, we don't need to. That's all behind me." So really, for some people at best it can be a waste of time, and at worst, it can be anxiogenic to dig up stuff that they've sealed over successfully. Because the cause of her anxiety may have had far more to do with her divorce and how traumatic an event like that can be. Regardless of how one needs to [heal through] it, trauma is not something that doesn't leave emotional and neurological scars. As I said, Helen Mayberg can look at a PET scan or functional brain imagery and see the results of trauma. So the "just get over it" school of thought is not one that I espouse.
Certainly: our sympathetic nervous system is chronically heightened by traumatic events like abuse and neglect in adult relationships, as well as childhood ones.
They are. Without getting into a lot of neuroanatomy, there are certainly two structures that are critical in this area. One is the hippocampus which is part of the limbic system but also the home of memories. The other is the amygdala which is an almond-shaped part of the brain, responsible for generating fear signals. Right now, both your and my amygdala are sending fearful images to our hippocampus, which is just swatting them away. Saying, no thanks, not gonna happen, no thanks, no thanks, no thanks. But if a car comes through that window and kills someone sitting beside us, all of a sudden our cortisol levels go way up, and that's what tips the balance in favour of the amygdala being allowed to imprint fearful images in the hippocampus: the memory centre. We think this is part of the neurophysiology of PTSD.
For example, if you look at Lima, Peru after an earthquake killed 84,000 people, everyone had PTSD. At the time it wasn't called PTSD because it wasn't post-traumatic. It was called acute traumatic stress disorder. The terror and horror created enough cortisol secretion for the 'fight-or-flight' response [beginning in] your adrenal gland, to go to your brain in order to allow the amygdala to send signals into the hippocampus. That's really a critical thing. The response to trauma varies from person to person, because in order to activate that hypothalamo-pituitary-adrenal axis, your brain needs to process the incoming stimuli and identify it as being horrific.
Talking experiences: our surroundings in our developmental years heavily impact us. If you were chronically yelled at if you spoke up, then later as an adult something as simple as speaking up to your boss could induce tremendous stress. Physiological memories of that yelling heighten cortisol, as you said. Since this needs to be soothed, you'd be more likely to reach for a drink after work, or cigarettes, or junk food. But, if you were received positively when you spoke up as a child, addressing your boss likely wouldn't induce such an intense stress response.
You're right. One of the questions that I worked into the early childhood experience is, would you call your mother nurturing? Because I think the things you described are very important: a sense of abandonment or lack of safety and reassuring human connection; those sorts of things are critical to feeling soothed. They're all really important. At The Orchard, as a partner to my colleagues who are excellent addiction [workers], I'm happy to be there because I do stuff that they don't have time to. They're busy processing and detoxing. I have more time to sit and talk to clients about their childhood experiences. You know the expression that if you enjoy what you do, it's not really work? Well, I have tremendous pleasure from doing what I do because--if you can excuse my foul language here--I'm regarded as somebody who gives a shit. That's what people need, especially those with addiction issues. I walk through the cafeteria and I'll tell people, "If you need anything, just tap me on the shoulder and we'll talk."
Do you think this is missing from most treatment plans? It seems a bit too medical, where we ignore social aspects. I spoke to an addict diagnosed with depression in her teens who was told, "The neurotransmitters in your brain aren't firing, so we have this pill that will get them firing across synapses again." But often neurotransmitters aren't firing for a reason. If Doctors asked people about their experiences, they could find out what's causing those changes in neurochemistry, not just prescribe a pill.
Absolutely. There is no doubt in my mind about this. I'll tell you a couple stories that are relevant to this. First, I don't do formal dream analysis, but [other professionals at The Orchard] tell me that if you squash your brain's REM sleep with drugs, alcohol, or benzodiazepines and then you come off of them, all of a sudden you get a lot of REM rebound, so you have dreams. When people ask me why they're dreaming so vividly, I ask them what they're dreaming about. One fellow told me he had distressing vivid dreams because he was always left behind or running to catch up with his friends. I told him, "You're behind because you've been isolating yourself for so long shooting heroin. Now you're running to catch up with your friends because you're getting sober and seeking those connections again. That's a pretty reasonable dream to have."
Another thing to consider that can attest to your point is this: a group of researchers took a rodent and put it in a glass tube like this [holds up a four-inch diameter glass cup] which is of insufficient diameter for the rat to turn around. It had a screen at both ends, so it could get fed at the mouth end, and get its poop cleaned out at the rear end. They left it in there for 30 days (but it gets fed). Of course, it tries to go forward, hits the screen, tries to back up and hits the screen. It tries to turn its head and can't. Eventually, it does nothing because there's no point. It has learned there is no point in trying. It has learned helplessness. That's actually the model called "learned helplessness". If you then take and measure from the cerebral spinal fluid for the neurotransmitters dopamine and serotonin, you'll find they're depressed. Now, in our field, there are four things you can do to restore brain chemistry: drugs, shock therapy, and something called transcranial magnetic stimulation, which is high-intensity magnetic pulses over the prefrontal cortex. Or you can take the rat and reintroduce it to a social environment where it can develop nurturing relationships. This will restore the neurotransmitters. That's as antidepressant as shock therapy, drugs, or transcranial magnetic stimulation.
Clearly, that doesn't refute the idea that there is disrupted brain chemistry, but it does refute the idea that the only way to fix this is by giving more chemicals and not looking at the environment. It also shows that you can get disturbed brain chemistry from your circumstances that might prompt you to want to use drugs as a way out [mentally] of those situations. For example, let's say you're a senior executive of a company and your boss is giving you a hard time or asking you to do things that aren't in your terms of reference with your contract. You have two choices to deal with the stress. One is palliative and the other is direct action. Direct action is going straight up to your boss and saying, "Here is my contract. I don't have to do these secretarial duties." The other choice is the palliative one, and that is to go and drink at a bar after work--or even to go play squash until you can no longer stand up. But that's still sublimation. It's taking a psychic problem and trying to soothe it with something else.
Which explains why people can develop non-substance addictions: shopping, gambling, compulsive eating, over-exercising, etc.
Yes, I'm entirely with you on this. Also, human contact is necessary. [At The Orchard] we have an excellent masseuse because there are some people within whom it's so painfully obvious that they've been alone for too long. They need human contact [of touch]. This masseuse, a wonderful woman named Rita, is a significant therapeutic component to recovery. Some people look at the extra expense and want to say it's not that important, but I always say, "It's an additional expense but you ought to try it." Everyone who does, notices that it makes a difference.
George Monbiot at The Guardian once wrote, "For the most social of creatures, who cannot prosper without love, there is no such thing as society, only heroic individualism ... we are entering a post-social condition our ancestors would have believed impossible."
I agree completely. I think that our ability to respond to social situations plays a large role in how we deal with the anxiety those situations generate. In the old days, if you didn't get the affection you needed from your parents, there were others to turn to. We can't really do that with such ease anymore. Back then you couldn't survive living on your own, but these days it's not only a way of life, it's more and more common. This [past] September, [marked] 40 years I've been with my wife. So I've always had that. I've gone from a nurturing mom to a very nurturing woman, Lise. It's been a huge component of my happiness and my success.
A key phrase that frames those powerful concepts of loneliness is a 'sense of abandonment'. I have a current client right now who clearly had four different phases of abandonment in her life and the last one tipped her into an alcoholic stupor. This last event was her husband going out on a boy's trip for three weeks and she was on her own. No pets, no kids, and she crawled right into a bottle. She had no other way of coping because she was alone, abandoned again. So I think [isolation] is a reasonable tier to have when looking at addiction.
So many addicts are addicted for reasons that were out of their control. We shouldn't be throwing people in jail if addiction is actually a symptom of trauma. A neglected wife abusing her Effexor prescription is going through addiction as well, but the street addict goes to jail, while the housewife gets ignored by society. Neither is an appropriate response.
Another point that goes to this, is how the drug industry (for whom I work, in full disclosure), has managed to call what happens when you stop an antidepressant "discontinuation syndrome" instead of withdrawal. Withdrawal is a substance-specific syndrome; a collection of symptoms that occur on the cessation of, or reduction in, the ingestion of a compound. If someone is taking Effexor and they stop cold turkey, they'll experience withdrawal. It's that simple. I often tell people, "You can call it discontinuation, but you're really talking about substance-specific syndrome that occurs on the cessation of ingesting a compound. I'm in correspondence with the Right Honourable Prime Minister Justin Trudeau over this right now.
Very glad to hear. My next question is about addiction treatment centres themselves. While there, you have a support network and you're away from your cues: your drug dealer's door, or the fluorescent "Liquor Store" sign around the corner. But once you're back in the environment of use, don't those powerful sensory cues that are still there, offset your brain and send you back on the quest to obtain the drug?
This is why treatment of 60 rather than the typical 28 days is important. With more time away, those [cues] have less of that steering power. There's an interesting story to highlight an issue in regards to this. I initially worked at The Orchard in 2001 through 2004, then again in 2007 through 2010. I helped open the [residential] Eating Disorders Treatment Centre on Bowen Island. The government tried to tell us that we were providing a medically necessary service, but charging privately. I had to reply that they were not providing a medically necessary service. They were [allowing] 24 beds in a province that had 27,000 anorexics.
To the point, The Orchard has an aftercare system: you're there for 28 or 42 days, then you go for 48 more days to a six bedroom house where you have sober living. Once you leave the centre, you stay connected to The Orchard by what's called 'O Connect'. Now I'm not just promoting The Orchard, because any good place would have this. The discharge planning in terms of having a sponsor, knowing where the meetings are, making sure they have a family doctor and a counsellor, should be thorough.
For those who don't have a psychiatrist, I've gotten permission from management to see them privately (provided they are still clean and sober) until they get a psychiatrist, if they need one. Another story that fits your question is this: we had a 38-year-old [Indigenous] woman who happened to be from a reservation in the prairies who came to us for 42 days and got sober. But when we sent her back to her reservation, it took about a day for her to fall back into [her alcoholism]. This goes to your question because those cues were on every corner: her reservation had nothing but liquor stores, and that's just unacceptable.
Looking at brain chemistry, with any behaviour repetition (or what's called "conditioning"), I know that dopamine is responsible for motivating and driving you towards a drink, and after you take a sip of that drink, endorphins are activated. (Again, endorphins being the brain's natural opioids, giving you that happy, soothing sensation: that "ahhh" feeling.) New York Times columnist Charles Duhigg wrote a fascinating book about this, detailing what he calls the "cue-routine-reward" circuitry. The intense power of reward-seeking behaviour can take place even without heavy narcotics.
Yes, and this brings forth an interesting counterpoint to the chemical addiction stuff. The long-standing belief about smoking has been that nicotine is the motor that drives cigarette addiction because it releases dopamine. As you mentioned dopamine is responsible for drive, motivation, attention, but also mood and other things. However, you'll notice that if you give people who are long-time smokers a choice between an intravenous injection or bolus of nicotine, or a cigarette with no nicotine in it whatsoever, they take the cigarette with no nicotine. Because there's a psycho-behavioural component to the act of smoking. There is a habituation that takes place that's part of addictive behaviour that has nothing to do with the chemistry of how nicotine affects the brain. People take Ativan (benzodiazepine) and put it under their tongue for anxiety. Then, 40 minutes later, they have some relief from anxiety. But after about the 20th dose, when they put it under their tongue, they instantly have relief from anxiety. That's not a pharmacological response, that's psycho-behavioural.
Dr. David Kessler also wrote a book about this. He was the US FDA Commissioner in the 1990s who was tasked with reducing smoking rates. He decided to tackle the 'cue' of the allure of smoking: trendy advertisements and the Hollywood glorification of cigarettes. Now he's doing the same with the fast food industry. He says the allure of McDonald's initially is the taste, but after time has more to do with seeing the golden arches, walking into the red and yellow room, opening the package, etc. All these sensory cues are releasing dopamine as you're getting excited to take the first bite.
Absolutely. If you look at the research on heroin, people get high just preparing the heroin to inject. There's an anticipatory component of drug use that contributes to drug addiction. Triggers [or 'cues'] play an important role: there is interesting work looking at the environment in which drugs are used. In the 1970s, Vietnam Vets who were using heroin would fly back [to the US], and many of these planes went to an Air Force Base in Oakland. There were a lot of dead Vietnam Vets in the bathroom stalls there because using heroin on the battlefield (with all the adrenaline that's going on) and using heroin in the Oakland Air Force Base are two different situations. The same amount of heroin was lethal in a different setting. Since they brought it back with them, they knew what they were using, so it wasn't a narcotics purity issue like the media dramatized, it was, in fact, the environment.
Nora Volkow at NIDAR does a lot of work on Salience. Salience is the meaning we attach to an event or thing. It's why smokers will take a de-nicotine-ized cigarette over an intravenous injection of nicotine. We attach a meaning [positivity] to doing something, like opening the package, lighting the cigarette, and then puffing on it. The propensity to have dopamine released becomes easier. Now I can't say whether dopamine levels actually go up, but I can say that. The propensity for dopamine to be released is easier. You can't do human studies on whether dopamine went up without sticking a microdialysis probe into the person's brain. [The studies doing this] have all been animal studies, which is a weakness to start with when talking about human behaviour. For example, if you give a nicotine blocker called Mecamylamine to humans that blocks nicotine receptors, they smoke more.
They're trying harder to get what they anticipate should be happening?
Yes. If you give a nicotine blocker to rats who are habituated to smoking, they just quit smoking. The behavioural habituation for rats smoking isn't there, but for humans it is. Humans will try to overcome the blocker.
Dopamine can be released more easily through [habituation]. If I were to start using heroin, the first time I did it, I'd be frightened. I wouldn't get high until the heroin hit my brain. But the 50th time, I'd be high before the heroin got in my arm. The release of those compounds is definitely facilitated by the repetition. Your McDonald's example of this is good. The de-nicotine-ized cigarette example of this is good. The principle itself is sound: there certainly is a behavioural component to addiction.
You can also have 'adverse conditioning'. For example, you couldn't get my wife who would drink white wine at any big occasion (like when I take her out for her birthday) to have a shot of tequila. Because when she was 17, in Montréal, she got sick on tequila. Really sick. So now she won't get near it; she won't even have it in the house. That adverse experience made tequila much less Salient. When she took it the first time, at some point during that night her nucleus accumbens [the brain's reward centre] and her dopamine levels were heightened, but the adverse "meaning" so early on made sure that now she won't go near it.
What I've noticed when speaking to current and former addicts is that many of them admit to having a tough attitude. Drugs are often part of this "badass" mentality because there's risk involved: they're illegal. Many will say that their coping mechanism for fighting back against abuse or neglect was wanting to act tough. "I just wanted to ride a motorbike and drink." Victims of broken homes and addicts are actually some of the strongest people I know. But they're susceptible to drugs because drugs have this "Rock 'n Roll" effect: again, that positive reinforcement and meaning.
Absolutely. I see this in many of my patients as well. Once again this is that fascinating area of salience. The meaning attached and associated with performing the act, which is what normally defines salience: it is so powerful and exemplary. I think it's a very interesting component. The people that I would suggest to your readers as best to check out, for salience is Nora, and for brain circuitry and neurotransmitters, is Eric J. Nestler. He's got some brilliant diagrams about brain chemistry and connectivity. He can show why opioids enhance dopamine, for example.
Even with the power of conditioning, salience, and trauma's effect on the stress system as culprits of addiction, I disagree with the burgeoning notion that drugs don't cause harm, which I want to make clear.
Yes. Since 2003 my dear friend Nora Volkow whom I mentioned earlier, has been the director of what's now called NIDAR, the National Institute of Drug and Alcohol Research. (Before it was called NIDAR, it was NIAAA which was the National Institute for Alcoholism, Addiction, and Abuse, but no one could remember what the acronym stood for so they called it NIDAR.) Nora does frontal lobe imaging in recently abstinent alcoholics and cocaine addicts. This shows how active the brain is in utilizing oxygen and glucose.
My daughter, who is a Medical student at Queens [University] and who is working with Nora, does something called LORETA [Low Resolution Brain Electromagnetic Tomography] scanning, which looks at brain activity, but also looks at brain connectivity. It plots out 64 different points to show if the activity is the right amplitude and the right frequency. I asked Nora in Barcelona in April 2015 if she would be interested in combining her functional brain activity imaging with brain connectivity via LORETA scanning. I thought it would be incredible to see. [At The Orchard] we have people who say, "I'm taking cocaine because I have ADHD. I'm just self-medicating." The fact is, they don't have ADHD. They've just polluted their frontal lobe (which is where attention and motivation are focused) so badly with cocaine or alcohol that they feel like they have ADHD. If you wait six months and then take a look, which is what [my daughter] Natasha is doing with me at The Orchard, we can show patients imagery of what happens to their frontal lobe activity with no treatment whatsoever: it comes back online. You can get the pollutants out of there, but it takes a bit of time to see that. Knowing this, you begin to understand that a 28-day [abstinence] program is useless. 28 days is an insurance company number; that's all they want to cover. But again, at 60 days something happens. You can see it.
Incredible. Well we have to end here Dr. Goumeniouk. I can't thank you enough for your time, and to your wife Elise for coordinating this. Keep it up; we're lucky to have you here in Canada.
This interview has been edited and condensed for clarity.