S1 E14: Dr. Kevin McCauley on How Neuroscience Could Help Beat Addiction

For this season finale episode, Meadows Senior fellow Dr. Kevin McCauley unpacks the complex social and psychological forces that perpetuate addiction and the emerging brain science that offers hope for recovery.

Podcast Transcript

David Condos: I’m happy to welcome back Dr. Kevin McCauley. Thank you so much for being with us.

Dr. Kevin McCauley: Thank you. It’s my pleasure.

David: In the last part of this conversation, we covered your story, your journey. We left off where you were in prison, military prison, researching all you could, trying to figure out, “How did this happen to me and what is it? How can I do something about it?” Let’s pick it up right there. You get out of prison with all this knowledge. What was your mission? What were some of the first steps you took?

Dr. McCauley: Sure. Well, the first mission was to try to stay sober, [chuckles] to not succumb now that the basic incarceration period was over and the danger had returned. I went directly from the front gate of Leavenworth into treatment. I wasn’t in treatment more than about two weeks when, all of a sudden, all these cops came rushing into my treatment center to arrest me. [chuckles]

David: Oh wow.

Dr. McCauley: They had little blue windbreakers on and glocks drawn and two extra clips on their belt and the badge that was embroidered on their jackets said medical board police. “Did you know that there were medical board police?” I had no idea they were medical board police. Trust me. They were medical board police. They came and they basically arrested me. Again, I was guilty.

David: In treatment?

Dr. McCauley: Yes, in treatment. They came into treatment, held me off out of there in handcuffs for all of the prescriptions that I had forged which, again, I was guilty. There was no doubt about that. The DA in Orange County was very keen on putting me back into prison. It was like everyone wanted their piece. He didn’t get that, but he did get the opportunity to have me on formal probation for five years. That put a certain sharpness, I would say, on the process because I had to stay sober.

I knew the Medical Board of California. They might understand one trip to prison, but they were never going to understand two trips to prison. That really loaded up to the need to stay sober. It became clear to me that sobriety was going to be about more than just having facts in my head. Those were great. If they increase my motivation, terrific, but recovery is much, much deeper than just the acquisition of information. That would not save me is what I’m saying.

David: It wasn’t over now that you just knew all this stuff?

Dr. McCauley: Exactly.

David: Looking at all the research that you pulled together about the neuroscience, the genetic component of addiction and brain chemistry, talk us through some of those factors like scientifically, medically.

Dr. McCauley: Sure. I think just for a point of reference, if a person wants to know more about addiction, the first thing I would have them read is the American Society of Addiction Medicine’s definition of addiction. It’s about an eight-page document and it’s a quick and dirty way to get a good picture. I think the thing that will stand out for anyone who reads that, and it certainly stood out for me even when I was back in Leavenworth, is that addiction is not just one or two systems in the brain that are failing.

It’s at least five that we know of. It’s important to understand that we’ve got at least five different systems that we have to understand if we want to understand what’s really behind the symptoms of addiction like loss of control, persistent drug use despite negative consequences, craving, all of those symptoms that define addiction.

David:What are the systems that you’re talking about?

Dr. McCauley: I would say the first one is to understand what’s going on at the level of genetics and how this runs in families and how there are probably several hundred different genes. You either have them or you don’t and they make up your risk profile, your vulnerability to addiction. They’re just waiting there, depending on what the environment presents to you. This is a task I think of anyone who’s giving this lecture to patients or families. How do you explain the family history, the heritability of addiction without people getting depressed to the point that they say, “Well, why even bother? This is in my genes.”

 David: It doesn’t have to be a death sentence?

Dr. McCauley: It doesn’t. The genes really determine a risk profile. They don’t doom a person. Genetics itself is not the cause of addiction. Now, the epigenetics of addiction is increasingly understood and it is absolutely fascinating. It can explain the short-term heritability mechanisms that go along with addictions. For instance, smoking a cigarette can create certain epigenetic changes that are quite measurable that are found at very specific loci on particular chromosomes. Those changes can increase your risk, for instance, of cocaine addiction. That’s important.

David: Some things that you do can change or tweak the profile?

Dr. McCauley: Exactly right. It’s interesting, and this little disquieting is that if I go to more AA meetings, right, that creates epigenetic changes that turn off some genes, turn on other genes, change my proteome. In other words, what proteins am I making at any one point? That determines whether I go to more meetings or not. We like to think that these are decisions that are completely within our conscious control, but even fields like epigenetics show us that, no, it’s a little bit more complex than that. They don’t undermine free will as a concept. They deepen it. That’s just one.

Understanding what’s going on then at the level of early reward learning processing in the brain, that’s important. What’s the contribution of dopamine? What does dopamine actually do? All intoxicants use dopamine at some point. They may use other chemicals depending on what drug you’re talking about, but they all pass through that dopamine wiring. That includes not just chemicals, but also behaviors that are potentially addictive. Really, addiction is a problem where people discover that pleasurable chemicals or pleasurable behaviors can push back against the stress system.

Understanding what goes wrong at the level of stress processing in the brain, that would be the fourth level. All of this adds up to drive the quality of the processing in the higher areas of the brain like the frontal cortex, which is where we actually consciously make decisions and where we regulate our emotions and where we create things like meaning or have a spiritual life or have a social life. All of those faculties are dependent upon the processing that comes before it. That processing can be fixed, fortunately, but I got to be good to the other four levels.

David: Because our brain is really powerful. It’s really good at finding ways to cope.

Dr. McCauley: Exactly.

David: You said that you talk a lot with patients and families. That’s a big passion of yours, a big mission. How do you break this down and help them understand what’s going on in the brain?

Dr. McCauley: Sure. I think people are interested enough to deal with all five of those systems. I think it’s important for families to understand what’s going on in the frontal cortex because they really want to understand, “Where did my kid go? The person that I love or the friend that I value, where did they go? What’s behind this change in their personality, their behavior, whatever you want to call it?” I think what’s most important is not just talking about the problem, what goes wrong in the brain, but talking about the solution. What is it that we know repairs these areas of the brain?

David: Because there’s medical scientific evidence about how recovery works as well.

Dr. McCauley: That’s right. That’s right. I think what’s especially rewarding is when the patient can turn to their family and say, “See, this is what I’ve been going through.” If I’m doing a good job in the lecture, you start to see the families relax a little bit because they really have been traumatized living with the person with addiction. They have their own form of PTSD. This is the first point at which they can say, “All right. I see some hope. I see how this could be repaired. Therefore, the relationship that I have with my loved one could be repaired as well.”

David: Instead of just being this kind of vague, bad choices or, “Why is my loved one doing this?” It’s like, “Okay. Here’s validation.” Like you were saying, this is a medical disease.

Dr. McCauley: What immediately follows from that is, “Okay. I know I have a disease. Now, I have the responsibility to manage it.” I have a lot of success with the part about what goes wrong in the brain. When I turned to, “Okay. Would you like to know how we can fix this?” that’s not as well received. [chuckles] All the goodwill that I created with the first lecture, I usually undo a little bit.

David: Why do you think that is?

Dr. McCauley: Because it’s hard. It’s hard to do these things and that’s true for most treatments for chronic diseases. It’s a drag and no one really wants to do these things. They’ve thought of themselves as healthy and capable. Now that there are going to be limits placed on some of those things, at least temporarily, that’s harder to swallow. That’s the tricky part is to try to introduce that information and not have people just completely pull back.

The idea that addiction is a disorder of pleasure, which it is, in the dopamine system and that defect in the hedonic system, the pleasure system is caused by stress, especially chronic and early life stress. Those are important sentences. The idea that all of this ends in the frontal cortex and becomes a disorder, a disease of volition, that’s a very big idea. That volition can become part of the disease process. It strikes me as apt. That’s biologically plausible that people would react badly to the idea that they have a disease of volition.

The way they would react would be to try to take their broken will back and to try to use it and then to get in even more trouble. Same thing is true with a person who had a broken leg. What would occur to them is, “All right. Let me get up and walk on this. Let me walk it off.” That’s how it happens. You have to immobilize the leg so that it can heal. The same thing is true with the human will is that you have to immobilize your decision-making, really put it in the hands of someone that you trust like a sponsor and then slowly rebuild it over time.

David: Just to back up a little bit, can you define this “disease of volition” idea?

Dr. McCauley: We’re set up to observe things. The way we observe things is we make associations. I notice that when the clouds get dark, it’s more likely to rain, right? I might think, “Okay. Well, if I say a certain prayer or something like that, that will make the clouds darken. It will rain.” Because we’re set up to understand causation for the simple reason that we’re set up to affect the world.

That affecting the world, that acting on the world and having a result, that agency that I pour into the world and the outcome that I’m looking for, that’s a process that’s realized in the brain. Addiction is very much a disease of doing, which is why I think especially intravenous drug use is particularly powerful. I can’t think of any way of changing the world to such a degree as intravenous drug use, as injecting heroin.

With all of its cues, all of its ritualization that goes along with that, all of that has a point. The idea is to go from a state where I’m extremely uncomfortable to a state where I’m more than just comfortable, right? The faster that happens, the faster that comes on, that gives the person the sense that they can do, that they can act, that they can exert agency and it will have an effect.

David: It reinforces that I’m in control getting away with–

Dr. McCauley: Exactly right. These are the things that you have to think about if you’re contemplating a disease of volition. Typically, the arguments that exist out there against the idea of addiction as a disease really refuse to admit this. It’s what I call the hard libertarian argument against the idea of addiction as a disease. For that argument to hold, you have to give primacy to free will. Free will has to be an absolute. It cannot be part of the brain or a disease process.

It’s simply a God-given thing. You better use it or you’re bad. What we understand from the neuroscience of addiction is that creating an act of volition is a multi-step process in the brain dependent on past memories, dependent on reward coding from previous rewards. That I find quite fascinating because it gives us the ability to really understand what goes into a choice. How does the brain do that and how can that process be repaired if it breaks down?

David: Every person has their own complex profile when they’re presented with the same decision. Everybody’s coming in with their own history, they’re own style.

Dr. McCauley: Exactly right, exactly right, which is one reason why we tend to praise liberty, especially Americans. We almost turn choice into a fetish. We print words like liberty on our money. It seems particularly fitting that the United States in particular would have trouble with drug addiction. We don’t tend to see choices as made in a social context, as dependent on the people around us. We tend to take that Gary Cooper, rugged, individualist view of choice-making. I think that the neuroscience of addiction while it doesn’t defeat that, it has something to say about it.

David: Looking at the neuroscience of recovery then, how do you bring that hope to patients and families in a medical, scientific way?

Dr. McCauley: I think if you look at certain groups of professionals who have phenomenal success rates at getting into recovery, very often these people are truly impaired. They have very severe addiction. The research is there for doctors and nurses, lawyers and airplane pilots, which is important to me because I’ve always loved pilots as a group of patients. If you look at what it is that they do, what does a good state medical board professional health program require of its doctors or its nurses?

What does the FAA require, needs to be in place for a pilot to go back to flying? We can draw from that and hopefully apply it to other groups of people. One of the places that it’s been applied to are college students. The argument always was, “Well, the reason that these pilots and doctors are getting sober at such high rates like 95% is because they’re doctors and pilots.” They have something to lose and they have all this education.

What the college students show us is that they’re having the same success rates. The collegiate recovery community is a very, very exciting places around the country. Almost every college now is developing one. I think they teach us that it’s not just having accomplished something as the foundation of your cover. It’s having a future and being around other people who support that and you support them. That’s really the resilience factor, not necessarily being at the top of your college class.

David: It’s less about being this great, special person and more about what support do you have, what does your community look like, the structural points that guides you through?

Dr. McCauley: That’s right.

David: You deal a lot with the general public. You’re talking to the DAs. You’re talking to the families. What would be one thing that you wish the general public at large in America understood better about how addiction recovery works?

Dr. McCauley: There’s a general pessimism about patients’ chances of getting sober. I think that’s what’s most concerning to the parent who’s facing this problem. I think this is exactly what was going through my mother’s mind, which is, “Am I going to have to bury my child?” I want to go right for that and make the statement, which is true, is that people get sober all the time, that recovery is not a rare thing at all, that we’ve got a pretty good handle on what predicts it.

Most people who stick with this recovery thing do eventually get it. It may be a long process, longer than we’d prefer. If we just keep on going, then generally, the effects of that support, they start to take. The other thing I would say is that addiction is an interesting disease in that it can exploit whatever is unhealthy about a society. If that society is racist, addiction will find that and it will use it.

If that society is economically unequal, addiction will find that and it will exploit it. In many ways, the degree to which addiction has struck our country is proportional to the unfairness and the injustice and the unequalness of our society. If we really want to fix addiction, I think the thing that we have to do is want other people to have the things that we got.

Let’s take an active interest in making sure I don’t just say, “Well, I got sober. Now, I’m going to pull up the ladder,” but making sure that that’s a universal for all people who may take it or may not, but at least those opportunities are there. I’m very concerned quite frankly. I’ll just confess this to you. The reason that I’m sober today is not because I went to meetings and I met wonderful people and I worked a program and I worked hard.

I’m concerned that the main reason that I’m sober today is that I’m white and I’m male. I think that that’s something that’s on my mind a lot now. How do I know really what degree of privilege was behind my ability to get sober? The only answer that I can give back is I can’t know, but what I can do is make sure that that privilege is a common opportunity for everybody.

David: Just to even have that opportunity?

Dr. McCauley: That’s right.

David: For someone who wants to dive in even deeper about that, what would be one book or resource that you might recommend?

Dr. McCauley: Yes, this number. My favorite book is a technical book called Addiction Recovery Management. I think the publisher is Springer and the editors are John Kelly and Bill White, two very well-regarded names in addiction research. It really lays out what I tried to lay out in my second film. What constitutes good recovery management? What are the things that really predict success as a person leaves treatment?

David: Dr. McCauley, thank you so much for being with us.

Dr. McCauley: Thank you very much.

David: To wrap up, what would be one piece of advice that you’d like to leave listeners with, something that someone gave you that’s meant a lot?

Dr. McCauley: Let’s see. I know that the people that I’m speaking to at The Meadows are really any audience of people in treatment. These are hard days for them and that while they enjoy the lecture, they still have to deal with the fallout of their addiction. A lot of them have family members who are really angry with them. I did too. I know that they’ve got a couple of family members who probably never want to speak to them again. I really try to help them see that maybe all of this misery could be converted into something good.

I think that this is what epigenetics gives us is that it teaches us not just about the heritability of the disease, but also about the heritability of recovery itself and the resilience factor. I tell them, “You may have a family member who’s angry with you now, but I promise you–” and I feel pretty confident and being able to say this, “I promise you that the day will come, don’t know if it’s next year, don’t know if it’s 20 years from now, when that family member will call you and they will say to you, ‘Listen, I realized we’ve had our differences. We haven’t always gotten along, but I know that you went through this and I know that you got sober. We just got a call from our kid’s school. He’s been kicked off for drugs. Can I ask you some questions?'”

That’s the point at which that person’s recovery becomes a resilience factor, not just for them but for their family, that their family will seek them out because of the strength of their recovery. Not just their family, but their community. If it’s true for their community, it might even be true for their nation. That’s the thing that is so beautiful about recovery is none of us really know where the arc of our story will end. It could be that the things that we’re most ashamed of now end up being the things that people love us for and value us for the most in the future. That, I think, is the story of recovery.

David: Dr. Kevin McCauley is the senior fellow with The Meadows based in Sedona, Arizona. He’s also the writer and director of two films about addiction recovery titled Pleasure Unwovenand Memo to Self. You can find out more about those films and the rest of his work at www.drkevinmccauley.com.

To check out more episodes of this podcast and find all kinds of other resources and tools for Meadows Behavioral Healthcare, visit www.beyondtheorypodcast.com. Finally, thank you for listening to our inaugural season and I hope you’ll join us again next time for season two of Beyond Theory.