Adding Cream To Coffee

Is It Your Fault? (A mini-blog series.)

In a recent blog post, I wrote about adding cream to coffee as an analogy to adding chemical substances to the brain’s synapses: you can’t just take the stuff out again because the trillions of synapses in your brain are cosmically interconnected and react to each other like forests of falling dominoes.

A synapse is a switch between neurons, and once you have switched the billions of freight trains onto other tracks you can’t just call for a do-over and bring them home again. (I am overdoing these metaphors; telepathy from somewhere.) But try adding something like sugar or cream (or heroin) to an almost unimaginably complicated system. Is the human brain the most complex thing in the known universe? At the philosophical bottom, this all has to do with entropy, probability, and time: it is extremely unlikely (but not absolutely impossible) that a broken glass of water will jump back on the table and be whole and full again. (I’ve been browsing Brian Greene’s Until The End Of Time).

Does this mean that it’s always too late to do anything? No, because the same complexity means there may be workarounds and there may be resilience and there may be genetic resources or social experiences that can also have corrective impacts on a bad situation. In living things, there is usually a bell-shaped curve with a smaller number of people at the extreme ends, and with more people clustering in the middle. I’ve heard some say they’ve tried to sip alcohol and “didn’t like the feeling”; or others have been prescribed oxycodone for pain and it caused nausea or weird feelings or had “hardly any effect”. At the other end of the curve, I know people who, seconds after their first taste of bourbon or Percocet, had an unforgettably positive experience, something life-changing or mystical. Mostly genetics, partly expectation, and social context. The majority of people in the middle will develop other patterns depending on their vulnerabilities and experiences and the family and culture they live in, and at what age they are, and how often they are exposed to the substances.

Most chronic smokers have had to go through coughing and nausea and bad tastes and regular use before the nicotine produced that cycle of feel good, feel bad, “I need it to relax me”, “I feel bad [withdrawal] without it”, etc. And still later, as if totally unaware of the cycle of good and bad caused by nicotine: “It’s just a bad habit” or “I need something to do with my hands”. No, it’s the nicotine.

The bell curve also suggests that some people will be able to get rid of an addictive pattern pretty easily (“I remember he just threw away the pack and never had another one”) and others will still be puffing while carrying their portable oxygen. We are entering the era of Precision Medicine research in which the above factors are taken into account, instead of just the usual randomized clinical trials (RCTs) in which, for example, one drug does better than placebo in two static matched groups. We are just beginning to improve the individualized selection of patients with psychological/psychiatric and addiction disorders, leading to the idea of “personalized medicine” which will include ideas such as “When all else fails, listen to the patient” ( Lenze, Rodebaugh, Nicol: A Framework for Advancing Precision Medicine in Clinical Trials for Mental Disorders, JAMA Psychiatry July 2020).

To summarize the above: Psychiatric problems and habit-forming substance use are indications that your unique brain connectome or wiring diagram is changing.

One change leads to another and it is usually not possible to reset or restart or go to default. We are learning how to figure out which treatments (including self-help) are best for which individuals. Also how to adjust treatment depending on your unique response (feedback). It’s a matter of keeping up with science and keeping up with yourself. I will try to share my keeping up with you, and learn from you about your keeping up.