Couple Michael Pond and Maureen Palmer talk to Tracy about their journey into discovering how addiction takes place in the brain, why willpower and shame simply do not work, and how seeing fMRI scans proved to them that we need to approach both the criminal justice system and the medical system in a vastly different way.
Tracy: You two are fresh off from filming your documentary Wasted, which is mirrored off your book Michael, that tells the story of your own journey through alcoholism. I want to start with discussing addiction in general and what the word means to you both.
Michael: Yes, addiction. I once read that the word is Latin for "to be enslaved by." We're enslaved by this substance or by this behavior. So whatever that is: eating [highly palatable] foods like chocolate, or drinking coffee. These things can affect our lives so powerfully that we can't function or focus properly on our lives without being in pursuit of them - of course there are varying degrees of this. Addiction is on a spectrum; it's all based on how severely the substance or behavior is negatively affecting your life.
Maureen: Right now there are a lot of competing theories as to what the cause of addiction is. Is it a learning disorder? Is it a habit? Is it brain disease? Is it genetic? Is it a lack of willpower?
We can rule that last one out immediately, "poor willpower" because decades of academic and scientific research on addiction prove that idea is as false as Columbus determining the content of America was India: it's been proven false.
Michael: Yes thank you. There's a big push right now, especially with Maia Szalavitz's latest work, saying that it's a learning disorder, or that it's a learned behavior. Marc Lewis' new book, The Biology of Desire also details how desire, and the behaviour of pursuit that alters our focus, is a form of maladaptive learning that ultimately can affect a life in such a negative way that we lose everything outside of that narrow path that is under our intense focus.
Maureen: We've always felt that we don't actually care too much about how you define addiction. Our concern is when you get really ill, just like you do with any other illness, you should have access to the best evidence-based compassionate care. I do start wondering about things Szalavitz's book because if it is a learning disorder, you learned that behavior, so then it's kind of your fault, right?
Michael: Well, in some ways and some ways not, because a lot of times you are born with a different brain that has a learning disorder. Whether it's genetic or however it happens: a virus or the like, you still come into the world with a different brain: a brain that is altered. A lot of addicts have had this problem. They'll say, "When I was a kid I was really hyperactive." Or, "As a kid I was ostracized." Or, "I was one of those behavioral problem kids." Or, "I was always bullied." My own grandfather was a severe alcoholic, so was his father, and so was my dad. I'm the oldest four and three of us have struggled with this problem. So the last thing I wanted to be was like them. I vowed never to be a problem drinker. But then it ended up that I turned into that. My plan to avoid that path didn't work out, I never stuck to it.
That brings me to another question. Why our actions sometimes can't be controlled by our thoughts and intentions no matter how hard we try. I'm going to direct the conversation in a controversial way. I've read a ton of academic journals on how our early childhood environments shape our brains, so let me know if this resonates: We are all born with the very basics of the primal brain - the limbic system which is impulsive and reactive (it's part of our nervous systems). As infants grow, the more consistency of skin-to-skin touch, eye-contact, and sound of soothing voices that the infant gets, the more their cerebral cortex develops. The cerebral cortex is the outer, 'grey matter' of the brain that is responsible for careful, calculating, thoughtful decision-making. So if the infant did not receive sufficient levels of those necessary developmental conditions from their caregivers, the grey matter (and therefore careful impulse-control) doesn't develop enough. So the limbic system will then still determine most of the person's behaviour.
Maureen: Yes, so Dr. Gabor Maté has a similar theory: that all addiction is rooted in childhood trauma. With respect, where I would disagree with Gabor Mate, is that I don't think all addiction is rooted in trauma. I know people in my life, who I know pretty well, and I'd be really surprised if there was that type of trauma. They've had great lives and yet they struggle. Then I have other friends who have had horrible lives and don't struggle. It's just not that clean-cut in my mind, and I don't think that you can unilaterally blame all addiction on that childhood trauma. I think there is more to it.
Agreed - there is certainly also "operant conditioning", where repetition will actually increase the reward (release dopamine & endorphins) of any given substance or activity. You can see it right on fMRI scans. Michael, you also had an fMRI scan done in the documentary?
Michael: Yes, I had one done. The documentary for The Nature of Things, so it was neat to look into the science behind addiction, and you're right, you can actually see the difference between an addicts' mind on an fMRI scan and a non-addict or non-alcoholic. A fascinating part of filming the documentary was seeing the study by Doctor Bianca Jupp at the University of Cambridge in the UK. She talks about how they have this whole population of rats that are very impulsive. All of these rats have a low level of dopamine activity in their brains. If you give them alcohol or drugs, they use more than those with healthier levels of dopamine activity, so they use more because they need more. So in fact they have to have it perhaps even just to feel like the "normal" less impulsive rats. Doctor Jupp thinks that it's likely everybody in my family was born with a low level of dopamine receptors, and so we have lower dopamine activity. You use so that you can actually activate more dopamine receptors.
Maureen: Not according to [a school of thought that] says that it's all epigenetics. It's not genetics, it's epigenetics. Epigenetics suggests that the experiences of our parents, and especially our mothers when they are pregnant with us, have a profound impact on us. So there are those who swing into the complete nurture realm while others are in the complete nature realm. Personally, I see it as genetic and epigenetic.
Does the genetic inheritance argument become tough when people point to one specific set of research? When I interviewed neuroscientist Dr. Carl Hart and asked him about the genetic element of addiction, he looked me dead in the eyes and said sternly, "The evidence just does not hold up - there is no data. None. And believe me, I spent 25 years looking for it." For myself, when looking at the work of Dr. P. Read Montague, Dr. Guy Winch, and John T. Cacioppo, among others, they all point to how a lack of secure social connections (as well as social exclusion and rejection) from the early years onward, significantly impacts our dopamine, serotonin, and endorphin receptors, and in the case of infants, these things can actually kill off our receptors, and slow the growth of the prefrontal cortex responsible for impulse control. On my end, I’m still looking for a professional who can prove that genetics are more powerful than the developmental research.
Michael: I see what you're saying, because as someone who has struggled with this problem, to me it's definitely in-between. It's nature and nurture. Not nature versus nurture; I believe it's both. There are all kinds of reasons that are evidence-based about why I have this problem. If I talk to geneticists, they can give me their theories. But if I talk to trauma specialists or behaviouralists they'll give me the same reasons you just did - they'd say it was all about my social experiences, my interpersonal relationships, the primary caregivers in my life and the conditions under which I was raised.
And this is also featured in Bruce Alexander's work with his "Rat Park" study. He looked at how people can have problems with addiction because of isolation like you brought up. He looked at how the opioid-addicted rats that were used to initially study compulsion were all in cages by themselves. They were sterile and socially deprived; relationally deprived. So while yes, there is huge merit to that type of research, if you want to look at the genetic factor a bit more, but Dr. Bianca Jupp's studies definitely answered a lot of the questions I had about genetics and the inheritance of addiction. Right from birth, some of these rats and humans of course too, seem to want to consume opioids [more than others].
For me, what I do know for sure, is that when I was in prison--because of the impaired driving charges and my conviction--that 75% of people in there had substance abuse problems of some kind. We actually just did a talk about this at Riverview. A lot of their clients and patients, have been through the criminal justice system, and that's something we need to look at.
Absolutely. That is another extremely critical discussion. It becomes hard to partake in the reprimanding culture of "right" and "wrong" - especially when you look at how differently all of our brain’s impulse control centers develop. Michael, you had a psychotherapy practice? They say those who are the best at understanding addiction are often those who have experienced it themselves. How do you approach your work knowing what you now know?
Michael: Yes, I think we do our best in our advocacy work surrounding addiction, as well as in my practice, I do my best to draw from every single legitimate, valid theory and approach. But a good example, is that because of my book and everything else that I've learned along the way in writing it (and doing the documentary version of the book), I've been identified as the anti-Christ within AA. When looking at how their specific method works, I didn't refrain from saying the things that I found didn't work for myself, and some of those things may have challenged their approach or their beliefs.
Maureen: I wish I could read some of the emails we got. I mean, 95% of the emails we receive out of the hundreds we got (and still continue to get) were incredibly positive. Most were people writing to tell us things like, "Thank you, this book has really helped me understand my dad" or, "This helped me understand my brother." or, "This book gave me a moment of peace, and it's the first time I've ever felt that."
Michael: We get correspondence from 12 year-old girls right up to 90-year old grandmas, and great grandmas, saying the same thing. So maybe 5%, or maybe not even that much--the negatives always impact you--that are derogatory and very mean-spirited, and most often they come from the AA camp who don't want to let go of the heavy restrictions against being around alcohol, which to be fair has been the only way they've been able to abstain. I just don't happen to find that it works the best for me.
Maureen: One thing we want to emphasize is that the best science on AA suggests it only works for 30 percent. We are so happy it works for those people, we just want more for the majority for whom the program does not work. We have a website, AddictionTheNextStep.com where Mike put an answer to the AA criticism. We wrote a blog post using AA founder B. W’s own writings to counter some of the assertions. And Mike said, "This is not me talking, this is the man who founded your organization."
Michael: I took about eight quotes from him right from 1935 up to around the time he passed in 1971. He was pretty consistent all the way through. He said how we need to draw upon the experts: the professionals, the doctors, and the researchers. He pointed out to how they don't want to aim for a monopoly on the matter, and unfortunately within AA circles today, that seems to have all been put in the closet. Some, who are very open minded, wrote and said, "Yeah, I see why people struggle with this organization sometimes."
Maureen: But then other people wrote saying, "Why on earth did you put that bottle of wine in the fridge?! You had to know what that would do to him! You just had to know that was going to just destroy his life again."
Michael: Yes, they said, "That bottle of wine in that fridge, that's what made me drink again. Don't you know that? It's all her fault."
Which is far too much of an extreme based in dogma more so than in the science of why he was triggered by that bottle of wine. Tell that story again Michael. I know it happened pretty much right after a motorcycle accident?
Maureen: Mike said to me that if he really wanted to drink that day--which he really did obviously--he would have walked up to the closest [liquor] store or bar and bought something to drink.
Michael: I got in an accident with my motorbike, and when I was in the hospital, all of a sudden I had sensory flashbacks of when I would be there as a severe alcoholic - the lights, the way people were reacting, everything. I had been to the ER before, tens of times when I was in the worst throes of my addiction, so this just triggered me. So even though I was writing this book and had been sober for years, I opened the fridge and there was that bottle of wine sitting and I almost drank the whole thing. Now I know why I did that.
Maureen: If I could pick up here, Mike you started by talking about what you think would be real support. Systemic support, but I think if I could quote you, "the most important support is after you drink again. When you "fall off the wagon" as is said. So what does that look like?
Michael: Yes, after the so-called 'dreaded relapse'. This is where we run into problems in how people are dealt with when going through relapse. For one, they get shunned. The person is still being shamed and feels ashamed because they're considered a failure. And of course they already feel like they're a failure. The shaming aspect permeates the whole system of addiction help, and in my mind, that's what has to change. I'd say very few of our doctors and our physicians, or our treatment 'specialists' know anything about addiction. They think they know what to do, and they don't - they mean well, but unfortunately without the knowledge, they're doing the wrong thing. Until they're told that there is great medication that works and that is currently available, people will continue to live in pain and people will remain in suffering. But if I go and take this medicine under the current method of shaming addiction, people who don't know [how the brain works] will say, "Oh he's taking the soft way out." So it's all embedded within this judgement and this shame. That is where the problem is.
Aside from AA, do they use the shaming methodology in other places?
Michael: Yes, Betty Ford is another example of a treatment center that [reacted] this way for years. But we were down there just last month and happy to see that they no longer kick people out of treatment for relapsing.
Maureen: As far as we know. At the Phoenix Center, you relapse, you're out.
Personally I believe that, just like how we discovered the world is round not flat, my generation is coming to an understanding that the willpower school of thought and the shaming approach to addiction is, quite frankly, backwards.
Maureen: Yes, we're trying to highlight that too, and we're seeing some change. It's good to hear there are so many others on board. We also have a section on the website under 'resources' where if you click on the menu item, the science behind the documentary you’ll see all the studies I cite in the film.
Since I brought it up before, to what extent did loneliness play a factor in your story? I'll be cheesy here and say that I think the two of you finding each other (and understanding each other) has quite likely played a role in Michael's success of coming back from such dark corners.
Michael: [Laughter] Thanks. For me personally, when I was the bottom--the very bottom--I didn't have my family, I didn't have my sons. My 3 boys that I love more than anyone else in the world, they left my life. I'd essentially been shunned by everyone that I loved and that loved me. Of course, they all did this for reasons that make total sense. They just couldn't bear to deal with what I was doing to them any longer. anymore. It's heartbreaking to watch someone you love destroy themselves - people can only take that for so long. But I'm sure that had its part in why I found myself drinking to the extent I was. When alcohol is your only solution and you're dealing with shame, embarrassment, and sadness, you're not going to try to keep reaching back out to fix things with your family, because as you said rejection is excruciatingly painful, and someone can only take so much of it, so you're going to find solace in the bottle. And when you sober up and realize that's where your life is at, you only know how to escape it with more drinking again. So yes, loneliness plays a massive, massive role.
I also want to emphasize dopamine because a lot of your work surrounds that, and I think it holds a ton of weight. There's a book by Dr. David Kessler, andanother by New York Times columnist Charles Duhigg; they both talk about the reward circuitry and the power of dopamine as the 'motivator' and 'drive' biochemical.
Maureen: He's got it down to a science, right? It narrows your focus, and increases your drive?
Michael: Yes, there are cues, right? Sensory cues that set off dopamine in the brain? It's like me with the "Open" sign, or the neon sign pointing to the bar, or the one flashing at the liquor store. So I didn't even realize what those signs were doing to my brain until after I saw the fMRI scans showing my heightened dopamine activity, or the reward centres of the brain light up when I was 'cued' by images that had previously pointed to [liquor consumption].
Yes, and in Kessler's book he talks about a medication that can halt the abnormal intensity of dopamine being sent off in response to these sensory cues in addicts or alcoholics, (and in his case overeaters). You feature a medication of the sort in your documentary, correct?
Michael: Yes, so the one we found is called Vivitrol which is a 30 day injectable [medicine]. It’s not available in Canada yet. I received the shot in the states.
Maureen: Naltrexone is what it's called in its pill form, which has been available in Canada since 1994. So you get the shot and you're good for 30 days.
Michael: So all of these medications go straight to each of those neurotransmitters and like you said, can help regulate them in an addict’s brain. I really believe in addressing the brain chemistry, because I see the results and I've felt the results when nothing else worked.
Maureen: It was kind of eerie, actually. We weren't even an hour out of Bellingham after getting the first shot and while driving back into Canada Mike turns to me and just says, "I feel different."
Michael: Yeah, I remember that. I just said, "This stuff's working." I just knew it. I felt the agitation go down, I could feel that [constant desire] just fade away. There was a settled feeling that I had. It wasn't an altered state; it was just a feeling that felt like just easing off the gas pedal.
Which makes sense because again, dopamine is literally called the 'drive' chemical in the neurosciences.
Maureen: [Laughter] You know what? We're going to make some T-shirts that say, "The dopamine made me do it."
I believe it, I'll buy a shirt!
Maureen: So here's where I think genetics come into play. A lot of the studies that are still going on, are ones that aren't looking for the addiction gene or the alcohol gene. They're looking at the different personality characteristics - traits that might be genetic like impulsivity and sensation seeking: risk taking.
Michael: These are all traits I have. They're all traits my grandfather had which I know because I heard stories about him.
Maureen: There was something I didn't have time to get in the documentary, which is fascinating. We interviewed Dr. Marc Schuckit who's one of the leading genetics researchers at the University of California San Diego. He calls this trait low responding. He followed 450 families for 35 years - so half is the control group and half wasn't. Each family had a father or family member who'd been an alcoholic. The young men who started drinking at an early age could drink everyone else under the table, and they were all low responders. Low responding means they developed a high tolerance.
Michael: So it's not even about tolerance, it's about response. I need more alcohol to get the same effect as a person who might need half as much to get a similar effect. When I started drinking as a teenager I was a tiny little guy, but all my buddies were bigger - football players and basketball players, but I could drink them all under the table, and that was my badge of honour. However, little did I know that this was a predictor for alcoholism.
Maureen: Schuckit conducted this really neat experiment just a few years ago: he sent a questionnaire to about 500 freshmen. He figured out who were the ones drinking everyone under the table (the low responders) from the questionnaire, and half of those guys got targeted videos, 1 every year for 4 years. At the end of graduation, the half-group of the identified low responders that didn't get the videos well, they're still drinking everyone under the table. But the guys that got the videos of targeted education had a dramatic reduction in drinking.
Maureen, you're a journalist, you worked for the CBC, and you were behind this documentary. Is that what you've always wanted to do as a journalist? Tell story through film? Talk a bit about your experience filming this documentary.
Maureen: Yes, I've always loved documentaries, but this one in particular, it was the worst and the best experience of my life. It was the worst in the sense that it dawned on me too late in the process that the more we took Mike back to these places, the more painful it was going to be for him. We thought to film in front of a recovery house, or to go back to Pentiction, [BC] and I was asking him to show me where he passed out, and show me where he got impaired. But in hindsight, I see that of course that was going to be really painful, but I don't think we both realized how much pain it would bring back.
Michael: Yes, because writing the book was completely therapeutic. But recreating it for TV was something that actually increased my risk of relapsing, of drinking again. It was very difficult with all those visual cues and all those same stimulants.
This is exactly what Pavlov's Dog Theory is all about: the dogs, after being 'primed' by a bell right before getting food, eventually began to salivate at just the sound of the bell, not even the sight or smell of the food! Which is why taking an addict out of their environments, 'curing' them in centers, and then sending them right back to their old neighbourhoods, is just not going to work.
Michael: Yeah it's the most ridiculous idea ever. And to me it comes with the insanity of these theories that seem to suggest, "Well, if your really wanted to, you would just quit." We need to realize how powerful the "anticipatory response" is. So just myself thinking about having a drink, well the research is pretty clear that this anticipatory response is more powerful than just reasoning. Thinking, “Oh maybe that isn't the best idea in the long term", well that’s just not going to work for someone with my brain.
Absolutely. The dopamine starts surging before you're even near your substance of choice.
Maureen: When they scanned Mike's brain at the Medical University of South Carolina, they flashed all sorts of pictures of intoxicating drinks as well as pictures of water. And after I said, "Honey, did you feel any cravings?" and he relied, "Nah, barely even felt an urge." But then we saw the brain scan and showed how his brain was experiencing something that he was not even aware of.
Michael: That was probably one of the most transformative moments for me in understanding my own actions. To look at my brain, long after the worst years of my alcoholism, and see with my own eyes how much was going on in there at a deeper level than my own consciousness, it was just unreal. It really proved that this wasn't just having poor willpower or making stupid choices. So looking at that motorcycle accident and my 'relapse' as they say, well now I know that when I opened the fridge and saw that bottle of wine (that had been in there for 5 and a half years), I couldn't just "make a decision" not to drink it. There's a whole bunch of other stuff going on inside of my brain that subconsciously controls way more than we realize.
Anticipatory response is at the root of a lot of our undesirable behaviours that we try so hard to control, but can't seem to. Food for many is a big one. A lot of people look at alcoholics with a moral superiority, but then they can't stop eating certain food.
Maureen: Yes it's true! I remember being in yoga last week and coming out of class thinking, "I'm at Park Royal; there's a Whole Foods here." Those juju stars they have at Whole Foods are my favourite candy of all time, and I start craving them before even seeing them! So just the thought of getting them--that anticipatory response-- of a pleasure I know I'll get from them gives me the focus and drive to head in that direction towards the Whole Foods. I couldn't wait to get over there!
Michael: It's similar to somebody that may live on the streets and is panhandling to get enough for his next heroin fix. The closer he gets to whatever the amount of money he needs to buy that drug for that hit, the more agitated he gets, so maybe he gets more aggressive and mad when someone won’t give him money: that's the anticipatory response. You can start to understand those behaviours once you know what's happening on a subconscious level - it gives you more empathy.
Maureen: I couldn't agree more.
Well that's a fantastic note to end on. You both do incredible work, and I think that once people start to discover it, they'll also begin to show more empathy as well. Keep it up!
Maureen: Thanks Tracy!