‘Let’s confront the challenge of addiction together’

In the summer of 2016 my wife called my parents to tell them that I couldn't make a flight. As usual, she was covering for me.

In some important ways though, this time was different. She couldn't just make a vague excuse because the social and financial cost of my failure to show up was too great. In fact, because the stakes were so high, we'd finally decided to tell everyone the truth about me.

The truth is that for the past 10 years I have struggled with alcohol use disorder (AUD). The previous day, 12 hours after the onset of painful abdominal cramps, my wife drove me to Accident and Emergency. I am a science teacher, and the cramps had begun as I sat doing my last bits of marking before going away. The cramps had intensified throughout the day, and eventually my wife insisted that we go to hospital. By the morning, we had an explanation for the pain: chronic liver failure and acute pancreatitis.

AUDIT

During my first full day in hospital, the specialist nurse administered an Alcohol Use Disorder Identification Test or AUDIT to gauge the severity of my mental health condition. I remarked upon the World Health Organization's good fortune that the first letters of these five words spelt such an appropriate acronym. She smiled kindly at my feeble humour: we both suspected that the AUDIT would also spell bad news.

The AUDIT is a valid and reliable psychometric test of an individual's risk of developing 'alcohol abuse problem behaviours'. It is made up of 10 questions, each scored on a scale of 0–4, with low scores indicating a low risk of alcohol disorder, and high scores indicating a high risk. Dennis Donovan and colleagues' 2006 assessment of its validity found that individuals who score between 20 and 40 are 'markedly different with respect to severity' and that members of this group should consider 'an abstinence goal more strongly'.

I scored 40.

To be honest, I don't think it's possible to score 40 and be surprised. By definition you've accumulated years of evidence that your drinking is 'disordered'. However, the test forces you to confront your own memory – or in the case of question 8, lack of memory – in a way that is clinical and relentless. As you search for an honest answer to each question, specific instances come spontaneously to mind:

How often during the last year have you failed to do what was normally expected from you because of drinking? – The call to my parents… Calling in sick for work… Failed exams… University Disciplinary Committee…
Have you or someone else been injured as a result of your drinking? – Black eye… MRI… Bruised wrists… Resisting arrest…
Has a relative or friend or a health worker been concerned about your drinking or suggested you cut down? – Tears and pleading eyes… Wife… Mother… Father… Sisters… Friends…

If your relationship with alcohol verges even on the 'complicated', you might want to honestly take this test.

The compassion of others

I developed sepsis while in hospital, which is when the body's response to an infection injures its own tissues and organs. While this posed an acute threat to my life, it also forced me to stay bed-bound under strict supervision for a fortnight. This afforded me some time to evaluate the damage I had done to my own life and to the lives of others. It was a painful experience.

Perversely though, one of the hardest things to accept even now is the amount of kindness I've received, perhaps because I don't feel like I deserve it. Obviously, it's for each of you to decide how much kindness and compassion you feel addicts deserve. For my own part, I'm deeply grateful for every drop of kindness shown to me.

Some well-meaning people have also said to me that I'm suffering from a disease, and this point of view is gaining some traction. The USA's National Drug Control Policy Director, Michael Botticelli, recently told the TV Show 60 Minutes that 'Addiction is a brain disease… not a moral failing… we don't expect people with cancer just to stop having cancer...'

Now, I'm not a medical expert, and my psychological training has a long way to go, so I offer my opinion based only on my own experience. Furthermore, it's not my intention to destabilise anyone currently confronting addiction in any way. However, I think that equating drug addiction with cancer invites misunderstandings. We can say with some certainty that there are neurobiological correlates of addictive behaviour involving the dopaminergic reward system, and that medication has a role to play in changing the relationship between an addict's brain and their problem drug (see George Koob and Eric Simon's The Neurobiology of Addiction). For example, I am almost certain that I would have kept drinking if I had not been afforded a fortnight under supervision in hospital to 'dry out'. However, it seems to me that there are neurobiological correlates for all of the behaviours that we engage in. There must, therefore, be more stringent conditions if we want to call a set of behaviours a disease.

Changing behaviour

Discussing the problem of criminal behaviour, David Eagleman describes a useful continuum. On one end are people unlucky enough to have a condition like frontotemporal dementia (FTD), which is a neurodegenerative disease… with atrophy and neuronal loss in the frontal and temporal lobes of the brain…. Sufferers cannot control their impulses, and so engage in behaviours that violate social norms, such as shoplifting or public nudity. On the other end of the spectrum might be a common criminal, stealing cars say, who we find completely culpable for his actions.

The similarity with addictive behaviour is that there may come a time when we are able to fully explain criminal behaviour at the level of the brain. Conceivably, we could then diagnose these unfortunate people with 'criminal behaviour disorder (CBD)' and call this a disease. Either way, the more important question remains: What would treatment for CBD look like? Once we have described the biochemical brain events that lead to a stolen car, we have to ask ourselves how we can manipulate a person's brain so that they no longer engage in such behaviour. Fortunately, there is existing technology that allows us to tackle this problem head on. It's called conversation.

The conversation that helped me to stop

A few days after being admitted to hospital, I was visited by a surgeon. He told me that he didn't know for sure, but that my newly misshapen pancreas might make my next drink fatal. I haven't had a drink since.

From my unique point of view, the thought that another drink might kill me forced me to decide whether or not I wanted to die. As a rational actor, I decided that I did not, and from that moment life has become the quotidian quest for meaning and fulfilment that we're all familiar with. And yet this neat summation doesn't quite do justice to my subjective experience. I can't profess to have had a flash of inspiration, but I can attest to the development of an immediate and previously unimaginable sense of resolve. It didn't seem to emanate from me as such, but appeared almost like a wonderful gift from elsewhere. I have thus found it odd when reading about psychological treatments like CBT, which are designed to induce behavioural change. Evidently they are profoundly useful for professionals who seek to understand the condition their patients present with and devise appropriate treatments, but when it comes to encapsulating the meaning of my subjective experience, they seem meagre somehow. I suppose this speaks to the adroitness of practitioners who can successfully effect change in their patients' lives. Put bluntly, my study of psychology has been of use to me in understanding the psychological processes involved in my AUD, but only after the fact of my recovery.

So can addicts behave as rational actors? Sally Satel argues that the behaviour of addicts can be incentivised by both rewards and penalties. For example, she attributes the impressive rates of recovery demonstrated by addicted physicians in the US to the surveillance they must undergo from their state medical boards, which includes random urine testing, unannounced workplace visits, and frequent employer evaluations. In fact, after five years, between 70 and 90 per cent are still employed with their licences.

The neuroscientist Carl Hart has explored this issue using experiments in behavioural economics. In one experiment, Hart recruited addicts who did not wish to quit, but who were happy to spend two weeks in a hospital research ward. Each day, Hart offered the participants a sample dose of their preferred drug. However, later in the same day, he gave them a choice between the same amount of the drug, a voucher for $5, or $5 cash. They collected their chosen reward at the end of the two weeks. The participants preferred the $5 voucher or cash over the drug, unless they were offered a higher dose. However, the participants chose the money every time when Hart increase the value of the reward to $20.

Hart's experiment employs a version of the 'intertemporal prison dilemma' first proposed by the psychiatrist George Ainslie in his 2001 book Breakdown of Will. It helps to illustrate the trap many addicts find themselves in. In the standard prison dilemma, two criminals must choose whether to defect or cooperate, with differing incentives and punishments following their choices. Ainslie's model replaces the criminals with past and future versions of an addict, this time facing a choice between using a drug and abstaining (Figure 1). From the point of view of the addict's present self, Option B is the worst possible outcome, as they abstain today, losing out on the reward of taking the drug, but failing to accrue the benefits of long-term abstinence. Option A shows the addict deciding to use both today and in the future, and is thus a slightly better option (from the addict's point of view), in that the addict does remain addicted, but hasn't wasted the opportunity of a short-term reward now. Option D is the best option from a rational outsider's point of view, in that an addict abstains permanently, but one must remember that in this case the addict would need to overcome an overwhelming physiological urge not to use, as well as the tragic logic of Option C. In the case of Option C, the addict 'benefits' from using the drug today, postponing the difficult business of abstaining until tomorrow. The tragedy, of course, is that tomorrow, the exact same set of choices is faced by the addict, and they inevitably choose to take the drug ad infinitum.

I find this paradigm very compelling, because if we tweak the incentives to reflect my situation a year ago, it becomes clear why I chose to stop drinking. I also suspect that the advice of Alcoholics Anonymous to 'take one day at a time' is an unconscious attempt to orient their members away from the appeal of Option C.

However, it is unclear what the value of my experience is to other drug users who have not been visited by a Dickensian 'surgeon of Christmas future'. I also think this model promotes the autonomy and dignity of the addict, while leaving room for creative approaches to help each unique individual who is suffering to find a way into the sweet-spot of Option D. I would therefore like to finish this article with an invitation to addicts and experts alike. Please be brave and share your experiences: let's confront the challenge
of addiction together

- Caomhán McGlinchey is studying for an MSc in Educational Research at the University of Exeter
[email protected]

Illustration: Nick Oliver