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major depressive disorder.
Schuckit, a professor of experimental psychology at San Diego State
University, is best known for demonstrating that biological sons of
“alcoholics” have an increased genetic risk of developing an alcohol use
disorder, compared to those without this genetic load. I had the pleasure of
learning from Marc, a gifted teacher, at a series of conferences on addiction
in the early 2000s.
The depressed men in Schuckit’s study went into the hospital for four
weeks, during which time they received no treatment for depression, other
than stopping alcohol. After one month of not drinking, 80 percent no longer
met criteria for clinical depression.
This finding implies that for the majority, clinical depression was the result
of heavy drinking and not a co-occurring depressive disorder. Of course
there are other explanations for these results: the therapeutic milieu of the
hospital environment, spontaneous remission, the episodic nature of
depression, which can come and go independent of external factors. But the
robust findings are remarkable given that standard treatments for depression,
whether medications or psychotherapy, have a 50 percent response rate.
Naturally I’ve seen patients who need less than four weeks to reset their
reward pathway, and others who need far longer. Those who have been using
more potent drugs in larger quantities for longer duration will typically need
more time. Younger people recalibrate faster than older people, their brains
being more plastic. Furthermore, physical withdrawal varies drug to drug. It
can be minor for some drugs like video games but potentially life-threatening
for others, like alcohol and benzodiazepines.
Which brings us to an important caveat: I never suggest a dopamine fast to
individuals who might be at risk to suffer life-threatening withdrawal if they
were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine
(Xanax, Valium, or Klonopin), or opioid dependence and withdrawal. For
those patients, medically monitored tapering is necessary.
Sometimes, patients ask if they can swap one drug for another: cannabis for
nicotine, video games for pornography. This is seldom an effective long-term
strategy.
Any reward that is potent enough to overcome the gremlins and tip the
balance toward pleasure can itself be addictive, thereby resulting in trading
one addiction for another (cross addiction). Any reward that is not potent
enough won’t feel like a reward, which is why when we’re consuming high-
dopamine rewards, we lose the ability to take joy in ordinary pleasures.
A minority of patients (about 20 percent) don’t feel better after the
dopamine fast. That’s important data too, because it tells me that the drug
wasn’t the main driver of the psychiatric symptom and that the patient likely
has a co-occurring psychiatric disorder that will require its own treatment.
Even when the dopamine fast is beneficial, a co-occurring psychiatric
disorder should be treated concurrently. Managing addiction without also
addressing other psychiatric disorders typically leads to bad outcomes for
both.
Nonetheless, to appreciate the relationship between the substance use and
the psychiatric symptoms, I need to observe the patient for a sufficient period
of time off high-dopamine rewards.
M Stands for Mindfulness
“I want you to be prepared,” I said to Delilah, “for feeling worse before you
feel better. By this I mean, when you first stop cannabis, your anxiety will get
worse. But remember, this is not the anxiety you’ll have to live with off
cannabis. This is withdrawal-mediated anxiety. The longer you can go
without using, the faster you’ll get to that place where you’re feeling better.
Usually patients report a turning point at around two weeks.”
“Okay. What am I supposed to do in the meantime? Do you have any pills
you can give me?”
“There’s nothing I can give you to take the pain away that’s not also
addictive. Since we don’t want to trade one addiction for another, what I’m
asking you to do is tolerate the pain.”
Gulp.
“Yeah, I know. Hard. But it’s also an opportunity. A chance for you to
observe yourself as separate from your thoughts, emotions, and sensations,
including pain. This practice is sometimes called mindfulness.”
—
The m of DOPAMINE stands for mindfulness.
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