Addiction and Cue-Triggered Decision Processes

Very interesting to see this article from Bernheim and Rangel in December's AER on addiction and decision making. In addition to coming up with a nifty model presenting the notion that drug use among addicts is a "cue-triggered mistake", the authors then expand into policy prescriptions based on their model.

My confusion, however, starts in the abstract: "use among addicts is frequently a mistake" To back this up the authors give us a story about how we can't infer preferences from observed behavior:

There are plainly circumstances in which it makes no sense to infer preferences from choices. For example, American visitors to the U.K. suffer numerous injuries and fatalities because they often look only to the left before stepping into streets, even though they know traffic approaches from the right. One cannot reasonably attribute this to the pleasure of looking left or to masochistic preferences.

Well, sure, the first time you step into the street I could call that a mistake. But someone who keeps getting run over repeatedly has some additional problems. The authors go into a Hedonic Forecasting Mechanism which is disrupted by the addictive substance to skew the perception of the addict that he's going to get much more pleasure from the addictive substance than he actually will.

Maybe.

Another explanation might be that when someone is addicted to a drug they get an abnormal amount of pleasure from it (as opposed to someone who is not addicted) due to the relief from the craving. In that case there is no skewed perception at all. The person is forecasting correctly that he will greatly enjoy getting the monkey off of his back.

This also fits in to what we know about the effects of attentive/reward drugs on neurotransmitter receptors. When your synapse is flooded with a particular neurotransmitter, the neuron can remove some of the receptor sites that neurotransmitter is binding to. In a nutshell, that means that such a neuron is less receptive to that neurotransmitter.

Fewer receptors mean that when you're not on drugs you're actually feeling worse, which is what results in cravings. The choice becomes one of inter-temporal substitution. Drugs now which will have an immediate relief of symptoms and generate direct reward, or abstain, suffer now, and get an indirect reward sometime in the future.

So getting back to this concept of skewed perception, the non addicted user might go from 0-60 on the Hedon-O-Meter, but because of the down-regulation of receptors the addict is starting at a negative value. Suppose that utility is function of the cubed root of opioids:

The non addicted user has a normal level of 0 for opiates and is getting a 'net' utility of 0 from them. Let's say the drug taken increases opiates by a level of 40. The user now gets utility of 3.4. Repeated use, however, down-regulates the opiate receptors so that when the user is not taking drugs, they are experiencing a -20 level of opiates and a utility of -2.7 (withdrawal). This user takes the same dose and moves from -20 to +20, and a utility of +2.7, but the total change in utility is from -2.7 to +2.7, or 5.4 which is greater than 3.4 received by the non-user.

The model of Bernheim and Rangel has recovered addicts (their receptor levels have returned to normal) being stimulated by usage cues (hanging out with drug buddies, Jimmi Hendrix, etc...) activating the motivational circuitry to seek out drugs. I guess so, but maybe the activation is in response to something else. If you buy into the notion that addicts use drugs in response to cravings, it could be that the cues are associated with the craving rather than just the motivation. As any smoker trying to quit will tell you, they start to crave cigarettes when they are presented with smoking cues (usually hanging out in a bar). It makes much more sense that it is the craving that stimulates the motivational behavior rather than the cues alone. Even though the 'underlying preferences' may be to stay clean, the individual experiences disutility from the craving now and is motivated to satisfy it.  And if the craving is stopped by using the drug,  that's not a mistake, it's the a rational decision to satisfy a craving.

Comments

[Mercedes]

Addicts become addicted to drugs for myriad reasons. This may or may not have anything to do with the article, but it is quite possible to return to baseline, be clean and not be motivated by cues or cravings derived thereof.

In the case of recovering cocaine and other stimulant addicts, there is a point where ingestion of the drug results in an almost immediate cortisol response - one of the symptoms of 'coming down' from stimulants after a long night out, resulting in mere panic and no 'high'. No cravings.

There is a saying, "I didn't quit the drugs; the drugs quit me."

Why? The repeated use of stimulants results in a release of adrenaline similar to a heightened fear response. Over time, this results in a rewriting of the hypothalamus similar to that found in veterans suffering PTSD.

So instead of peripheral stimuli (needles, etc.) resulting in cravings or providing cues, it actually instigates a fear response in some cases. This could also be the brain's way of self-regulating.

On the other hand, opiate addicts often self-medicate not for 'fun' but for relief of emotional pain due to undiagnosed or untreated neurochemical imbalance.

To be honest, I haven't read the attached study. The only reason I'm writing in response to this post is because my other half overdosed on heroin on April 19, 2005, when this entry was posted. He wasn't doing it for 'fun' or 'hedonism'. He was simply trying to quell his own demons. You know, 'pain relief.'

I believe a lack of proper psychiatric care, empathy from doctors, the intrinsically flawed and politically motivated studies promoted by the DEA and published in 'respected' medical journals, the FDA's political agenda, the rehabilitation industry (which would not exist if it actually *cured* people, would it?) and the total lack of understanding from his own family that resulted in his death. It irritates me when studies neglect to address this aspect of drug addiction when making ridiculous blanket statements about its nature.

Ninety-nine point nine (nine) percent of scientists are unable to address the subjective nature of an individual and evolving psychosocial problem - of which the pathology is too quickly mutable.

Most likely, they believe that having smoked weed as an undergrad or - at most - taken some ectasy qualifies them as being able to address the subjective nature of 'drug addiction'.

Journals like 'Addiction' are often lopsided, politcally inclined and promote a victim psychology of recovery, much like the outdated 12-step methodology (sure, it may work for some, but not for a lot of people).

There are so many opiate addicts because those drugs are far more effective at treating depression than SSRI's. So would it be so off the mark to ask just who is working to research its ability to relieve depression and working on a non-addictive anti-depressant based on this? (and why not?)

Serotonin reuptake inhibitors are largely ineffective as a cure for depression, have side effects that are often violent and a mortality rate from direct or indirect applicaiton. They often do not treat the cause, only the symptoms - if they work at all.

For instance, addiction and recovery experts would be able to save a lot of people from self-medicating with street heroin if they could see that treating the underlying modern psychosocial disorder (like ADHD or dyslexia) would help with the depression caused by the inability to function or cope today's society - even if the medication is Schedule II.

But even long-recovered 'addicts' are not to be trusted with Schedule II substances, even if it a) doesn't get them high (like many ADHD drugs) and b) saves them from a repeating cycle of dangerous street drug abuse. Not to mention it would cure the patient - not help continue the 'rehabilitation' industry.

To ignore all possible avenues is immoral, wrong, a farce- and very, very tragic. All stemming from public ignorance and fear. This pharmaceutical-law enforcement-political-'rehabilitative'-medical complex (DEA, related institutions and the politics and 'research' surrounding it) often kills more innocent people and destroys more families than lives they claim to be 'saving'. Some have the best of intentions. But the most intelligent members of this emergent cabal know what they're doing wrong.

"Cognitive dissonance, [Senator/Officer/Director/Doctor/Counselor]? Here's some morphine. This will help you forget all those people whose lives you are destroying - make you comfortably numb."

R.I.P. Pawel Malkowski, 1980-2005.

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