The Victim Meme In Addiction and Recovery

The popular press has created a victim meme in discussing addiction and the recovery process.  An example would be the popular quote from the NYTimes: "Only in death do drug users become victims. Until then, they are criminals".  I have problems with these quotes that have become memes in social media because the idea that people with substance use disorders are victims does not seem to originate in either the medical field and the physicians who treat them or the recovery literature written by the affected people themselves.  The other operative word in this quote is "users".  To me that means that nobody here is forced to initiate drug use or assaulted and forcibly given addictive drugs.

My first year as a psychiatry resident, I can recall a fellow resident presenting a patient to the senior attending.  He used the term unfortunate to describe the patient, a homeless middle aged man with a chronic psychosis and alcoholism.  The attending cut him off and said "What do you mean by unfortunate?"  In the next ten minutes or so, we learned that the patient was no more unfortunate than any of the other 20 men with severe psychiatric disorders on that unit. By extension the term was essentially meaningless, because it did not discriminate that person from any one else and it was irrelevant to the diagnosis and treatment planning. Years later, I learned it could also be an impediment to the treatment relationship.  A ban on smoking rapidly went into effect and the staff were split on what that meant. Many believed that it would result in more violence and aggression. Part of the ensuing rhetoric was "That is all that these unfortunate people have.  If we take smoking away from them - what's left?"  A very dim view of a person's life is required to see it as existence for the sake of smoking.  I would go so far to say it is blatantly dehumanizing.

The idea of patient as victims occurred again in psychiatry during the satanic ritualistic abuse phase and more recently during the patients are all victims of childhood abuse phase.  In the former case it lead to a proliferation of multiple personality disorder diagnoses and encouraging the proliferation of this myth with the associated unnecessary treatment.  In the case of treating everyone like a victim,  that program was correlated with an increase in aggression and staff assaults in state hospital settings and an eventual abandonment of the program.  Somewhere along the way, the application of a broad implementation of treatment based on whether or not a person is a victim is problematic from a programmatic standpoint, as well as the individual treatment relationship.

In terms of the individual evaluation, being victimized is a part of the clinical history.  Like grief, practically everyone has a history of some type of physical, emotional, verbal, or sexual abuse in the past.  The psychiatrists job is determining if it is relevant to the current problem and how it has impacted the patient's long term conscious state on an ongoing basis.  At a practical level it has resulted in an  ICD-11 diagnostic criteria set that identifies fewer patients as having PTSD compared with DSM-5.  From the linked reference it appears that there will be concern over identification of PTSD as well as under identification.  It is a more difficult task than just matching clinical criteria.  In many cases, PTSD symptoms recur in the context of depressive episodes and significant episodes of anxiety and resolve again when those episodes are treated.  In acute situations like intimate partner violence, advocates can provide a valuable function until a patient's living situation has been stabilized.  If victimization is a relevant clinical theme, it is addressed by addressing the associated syndromes and psychotherapy that is focused on maintaining safety, alleviating symptoms, and facilitating relevant lifestyle changes.           

Apart from victims the concept of the criminalization of the drug user is also a popular meme.  Simplified it is that drug users and alcoholics should be treated and not incarcerated.  It is based on the assumption that most of these folks are incarcerated on trivial drug or alcohol charges or probation violations from those trivial charges.  That can certainly happen.  Unfortunately real crimes involving loss of life, serious injury, and property crimes also happen.  I recently heard a District Attorney talk about the scope of the problem at the Minnesota Society of Addiction Medicine May 30 meeting.  He was keenly aware of the problem because law enforcement resources are currently flooded with opioid and methamphetamine users as well as people with severe mental illnesses.  He presented the problem to his prosecuting attorney and asked them to come up with a solution for people being prosecuted for drug crimes.   They ended up with a three step plan for sentencing offenders to maximize the likelihood of treatment and the ability to change felony crimes to misdemeanors after adjudication. The main message was that there is no interest on the part of prosecutors to incarcerate drug offenders, but there is clearly a limit with the associated crimes.

In the recovery literature, victim is rarely seen.  The Narcotics Anonymous book uses it in one place in the Eighth Step:  "Many of us have difficulty admitting that we caused harm for others, because we thought that we were victims of our addiction.  Avoiding this rationalization is crucial to the Eighth Step"  (p 38).  The AA 12 and 12 (2) contains the words victim in Steps 1, 3, 4, 10 and 12.  The term is used to make the general argument for powerlessness (Step 1), to discuss the effects of remorse and guilt (Step 3), to discuss the effects of erratic emotions (Step 4),  to illustrate the problem with resentments (Step 10), and how the program can free members from irrational fears (Step 12).  The bedrock of 12-step recovery is powerlessness and that is not the same thing as being a victim even though that word is used in Step 1. 

I don't think that I am going too far out on a limb in suggesting that the victim meme is not relevant in addiction, addiction psychiatry, or recovery. The importance of powerlessness as opposed to being a victim is captured from reference 2:

"Our admissions of personal powerlessness finally turn out to be the firm bedrock upon which happy and purposeful lives can be built."  (p. 21).


George Dawson, MD, DFAPA


Supplementary:

For other variations on the victim meme see these previous posts:


The Whitening of the Opioid Epidemic:

https://real-psychiatry.blogspot.com/2018/05/the-whitening-of-opioid-epidemic.html

Addiction Narratives Versus Reality:
https://real-psychiatry.blogspot.com/2018/05/addiction-narratives-versus-reality.html



References:

1.  Narcotics Anonymous (6th Edition).  World Service Office.  California, USA 2008, p 38.

2.  12 Steps and 12 Traditions.  AA World Services, Inc.  New York City 2007.

Schizoaffective Disorder and Surfing Music

I will disclose my biases on schizoaffective disorder from the outset.  My decades of acute care experience suggests that it is a lot less common than suggested by medical records.  Reflecting on the unique experience of seeing people hospitalized many times over the course of 20 years, the most frequent pattern I observed was clear cut bipolar disorder turning into a diagnosis of schizoaffective disorder or in some cases "bipolar disorder and schizophrenia".  Since I worked at this hospital long enough and had the memories of my enthusiastic young psychiatrist self and my compulsive documentation to count on, I can say that the most frequent pattern was patients presenting with manic episodes turning to the less specific diagnosis.  Most of these people were in their 20s or 30s when they experienced a clear cut manic episode.  There was no doubt about it because of the rapid onset and mood congruent psychotic symptoms.  They responded well to treatment and I discharged them from the hospital.  They would be rehospitalized from time to time, either on my inpatient service or another.  I would eventually see them in more detail after another 5 - 20 hospitalizations, look at the chart and notice that for some time, the diagnosis had become schizoaffective disorder.  Some would ask me about the diagnosis and some recalled the original diagnosis.  If they asked my opinion, I would always tell them what I considered to be the best answer: "As far as I am concerned, your diagnosis is still bipolar disorder.  I am basing that answer on your first hospitalization and your response to treatment.  You don't have any residual symptoms.  Having episodes of bipolar disorder for various reasons does not change the diagnosis."

One of the biases that exists about this diagnosis is that it tends to be more chronic and difficult to treat than bipolar disorder.  The reality is that bipolar disorder can be associated with a significant number of losses in terms of social network, net worth, and in some cases functional capacity.   There are frequently problems with alcohol and use of other intoxicants. Primary psychiatric disorders are always made more complicated by addictions. Like schizophrenia and depression, psychiatric research has not done a good job of defining the cognitive problems associated with bipolar disorder or coming up with successful treatment approaches. Although some rehabilitative approaches are in place for people in Assertive Community Treatment (ACT) programs, successful treatment is usually based on getting the mood symptoms in remission and the prevention of rehospitalization and suicide.  I have treated people on an outpatient basis with chronic mood disturbance and a diagnosis of schizoaffective disorder - bipolar type who work and function at an excellent level.  If they ask me what the diagnosis is - I tell them that it is probably bipolar disorder, even if they have episodic hallucinations.  I tell them "probably" because I know how the diagnosis of schizoaffective disorder is made.  And also because they are functioning well and I don't think that there is a lot of good information on the prognosis of that disorder.  At some level I am also probably biased by the idea that bipolar disorder has a better diagnosis.

My experience with the schizoaffective disorder diagnosis is a necessary backdrop for the following comments from the screenwriter Oren Moverman on whether composer Brian Wilson has a mental disorder:  "Yes, and it's public knowledge. It's called schizoaffective disorder, and it's really a combination of some schizophrenia symptoms, like hallucinations, and mood disorder, such as depression." (see transcript for reference 1).  Moverman is the screenwriter for the Brian Wilson biopic Love and Mercy.  For younger people reading this, Brian Wilson is the founder and composer for the rock and roll group The Beach Boys.  When I was in middle school in the 1960s, people of my generation started dancing to this group.  Their early genre was known as surfing music, based on that culture in southern California.  In these interviews Wilson talks about how he got started writing surfing music.   During the broadcast one of the early songs was Catch a Wave and that immediately brought me back to this time:





The Beach Boys were very successful in that type of music and made a significant comeback in the 1970s and 1980s with different types of music.  Behind all of that was Brian Wilson, a widely acknowledged musical genius who also performed live with the group in its early days.  Wilson is also known for his mental illness and substance use problems as well as his involvement with a highly controversial therapist.  The therapy methods included exerting total control over Wilson, by living with him 24/7 and having him under constant supervision by several case managers.  Wikipedia states that the cost of these services was about $20,000/month.  There was an initial 14 month episode of involvement followed by dismissal due to a dispute over fees and then another episode of involvement prior to permanent dismissal and placement of a restraining order.  Although that therapist seems to be credited in many ways with saving Wilson's life and getting him back to composing music, he was also reported to his California psychology licensing board for violations of professional conduct and according to Wikipedia resulted in a loss of license.  That same source points out that Wilson developed tardive dyskinesia and impaired functional capacity from prescriptions from this therapist's "staff".  I did not see any reference to prescribing psychiatrists or physicians.

This brings me to the inspiration for this post.  Once again it is Fresh Air's longtime interviewer for this program - Terry Gross.  In this series of interviews, Gross starts out with a story about the release of a new film about the life of Brian Wilson titled Love and Mercy.  She has two interviews that she conducted with Wilson from the past and a current interview with the screenwriter of the current film. One of the full length interviews is available on the Fresh Air web site from 2002, but I could not find the one from the 1990s.  There are also excerpts of earlier interviews played in the current interview.  The author starts out describing the focus on three discrete periods in Wilson's life and how that proved to be too much and how the focus had to be narrowed to two periods in the 1960s and 1980s.  Because of those time frames, Wilson is played by two different actors Paul Dano in the 1960s and John Cusack in the 1980s.  Moverman comments on the technical aspects of the film, like the reason for focusing on the musicians.  He also comments on the therapy controversy and states that Wilson was misdiagnosed and overmedicated.  At that point Terry Gross comments that the California Board of Medical Quality Assurance was investigating the therapist because medications were being prescribed and he was not licensed to prescribe them.

One of the most interesting aspects of Gross's work is the historical context.  She has commentary from Brian Wilson in an earlier interview commenting on the therapist controversy:

WILSON: "He's been performing a health operation on my head. He's done something that's impossible that nobody could do."

GROSS: "What do you think he's done that's really worked for you?"

WILSON: "Well, what he's done that worked for me was he's taken my body and transformed not only my physical shape, but he's transformed the chemistry within my blood, you know, from dirty to clean. And when you go through those transformation periods, you go through a little hell, you know what I mean? It's a little bit of hell to have to come through all that, all right?......."

Moverman thought that Wilson was referring to getting him off of intoxicants when he refers to blood chemistry.  Listen or read the complete transcript but in this section Wilson emphasizes the need for moving ahead rather than focusing on revenge for something that happened in the past.  I encourage anyone interested in this particular story or recovery from mental illness to listen to Brian Wilson's spoken words in these interviews with Terry Gross. 

Any acute care psychiatrist will probably be interested in this story.  For me it highlighted a number of issues.  Whenever I see a story like this, the usual way it is handled in the media is to get an expert and try to make diagnosis.  This is exactly the wrong thing to do at many levels.  One of the main concerns is the interplay between substance use and psychosis and mood symptoms.  In my experience, 95% of people seen in acute care and addiction settings are misdiagnosed with bipolar disorder, schizophrenia, depression, and even attention deficit hyperactivity disorder when they have a clear substance use problem that is responsible for those symptoms.  That does not mean that medical treatment is not necessary, but it probably means that it will be temporary.  I am not prepared to say that was an issue in this case, only that when you have seen that problem as often as I have that is one way to approach the issue.  The other dimension here is how difficult it is to effect changes and help people get back on path when they are clearly engaged in high risk and what is described in these transcripts as destructive behavior.  There are really very few options left for people with problems as severe as the ones that Brian Wilson was going through.  In most cases, it is a number of emergency department visits and brief admissions to psychiatric units.  I can say without a doubt that problems this severe are not reversible by those interventions or outpatient visits for twenty minutes to see a psychiatrist every one to three months or seeing a therapist every week for an hour.  Most people stop seeing the therapist after a visit or two.  They may have the thought that they are seeing the therapist because it is somebody else's idea.  

I certainly do not condone the therapy methods used Wilson's case, but fully acknowledge that our current systems of care are not likely to produce a positive result for persons with severe disabilities.  Above everything else this is a story of recovery.  Brian Wilson endured acute symptoms and significant disability and came out the other side.  He continues to write and produce music and that music inspires millions of people.  


George Dawson, MD, DFAPA


References:

1:  Fresh Air with Terry Gross.  'Love & Mercy' Brings The Life Of Brian Wilson To The Big Screen'.  June 18, 2015.

2:  Fresh Air with Terry Gross.  Producer And Arranger Brian Wilson, A Genius Of Rock.  August 27, 2002.

Supplementary:

I have not seen Love and Mercy yet but will probably add a few comments here when I have.

Attribution:

By Brocken Inaglory (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

How To Ruin Your Life Without Being Dangerous

Changes in Personality and Decision-Making

The above table is really all that you need to know. You don't need to know anything about psychiatric diagnoses. You don't need to know anything about medications. That is typically how the problem is approached these days. What could have gone wrong? What kind of mental illness could account for what happened to this person? Let's get a panel of experts together, put them all on TV and have them speculate about what type of mental illness the person might have. I have never observed this to be a useful exercise. How could it be? There are just too many conflicts of interest and too much entertainment bias for anything of value to occur. The diagram is meant to illustrate the basic transitions associated with many mental illnesses and how the problems occur. It appears to be very simple and it is even more simple than depicted.

The top two zones - both Dangerousness and Altered State of Consciousness can be combined because Dangerousness has no medical or psychiatric meaning.  It is a legal and/or managed care definition.  From the legal side of things it determines grounds for civil commitment, guardianships and conservatorships. More importantly it determines when courts can dismiss these cases and not spend money on the people brought to their attention.  In the case of managed care companies, they view dangerousness as the only reason that somebody needs to be in a psychiatric hospital.  The diagram illustrates why they are wrong.  Rather than considering this process to be tabular a Venn diagram might be a better way to view things.  I constructed this one looking at some relative contributions of these conscious states.  Keep in mind that the dangerous conscious state here is an artificial legal and insurance company construct and that all of the demarcations here are permeable to indicate that transitions between states commonly occur.  A porous line might be better but I am limited by my software.  The diagram also illustrates that in these transition zones the difference between an altered and even dangerous state may be practically indistinguishable from the baseline state.

The simple 3 row table also describes what families have observed happening since ancient times.  It has only recently been modified to include the role of physicians, medications, insurance companies and local governments.   What do I mean about family observations?  Within the timeline of any family, the generations observe their members starting out as a vigorous young people and going through the expected developmental stages of adulthood.  The trajectory is predictable with some notable exceptions.  Some family members will get sick and die unexpectedly.  Some may get sick or injured and become disabled.  That is as true today as it was a hundred years ago.  It is also the case that the disabilities can be mental problems as well as physical health problems.  They can be something that you are born with or something that you acquire along the way.  Most families have stories about members who experienced some kind of transitional event and they were never the same afterwards.  That transitional event could have been a serious illness, an accident,  an episode of psychological trauma, exposure to combat,  excessive exposure to street drugs or alcohol, changes in interpersonal relationships, or losses of significant people in their life.  There is a consensus in the family.  They all see the person as changed.  That change is sometimes positive, but typically the person seems less well and less capable of handling life's everyday stressors.  The diagram attempts to illustrate what families observe in terms of personality characteristics and decision-making.

In the diagram, the diagnosis is really not the most important consideration.  All diagnoses and all problems for that matter are mediated by a conscious state.  All human beings have a unique conscious state that starts in the morning when we wake up and our feet hit the floor.  We have a stream of ideas and thoughts that occur in familiar ways every day and our behavior patterns and personalities are fairly predictable to our friends and family.   There are very limited discussions of conscious state in any discussion about psychiatric diagnosis or the ways that diagnosis impacts on a person's ability to function.  A further complicating factor is that most of the considerations about problems functioning suggest that there is a linear relationship between the mental illness and the inability to function.  For example, in the case of schizophrenia the diagnostic criteria may be met, but at some point a determination of the person's insight and judgment is made.  Problematic behavior is often taken as proof of a lack of insight.  Anosognosia or a form of neglect has been cited as one of the reasons for impaired insight in schizophrenia.  The actual sequence of events looks something like this:

Baseline -> Symptoms of schizophrenia ->  Diagnosis of schizophrenia ->  Problematic behavior

The real sequence of what happens is far from that linear.  Problems are often noted over a number of years.  Drug use and other behavior problems are often theories that families have before there are more clear cut symptoms allowing the diagnosis.  The concepts of pre-clinical, sub-clinical, and latent syndromes are described by some researchers.  But the main point I am trying to make here is that the pathway is not linear and there are associated changes in the person's conscious state.  There is rarely a sequential pathway to a significant mental illness.  There are starts and stops and often misdiagnosis along the way.  People can pass back and forth between an altered state of consciousness and their baseline mental status for a long time before any psychiatric diagnosis is declared.  

Psychotic depression is often a difficult illness to diagnose and treat.  Consider another common scenario.  An elderly woman walks into her kitchen and discovers her husband pointing a shotgun at himself.   She convinces him to put the gun down and go to see their doctor.  She is completely shocked about the suicidal behavior and did not see it coming.  They have been married for 40 years.   Her husband had no prior history of suicidal behavior or depression.  As they talk with his primary care physician, she corroborates that he seemed to have been sleeping well, but seemed less spontaneous and "happy".  She was shocked to find out that he had lost about 15 pounds.  He is sent to a local hospital where he talks with a psychiatrist and at one point says: "I just could not go on living anymore."  Further questioning leads to a discussion of an event that occurred when he was in high school (over 65 years ago) that he was guilty and embarrassed about.  His worries about the event continued to build until he got to the point that he saw suicide as his only means of relief.  He was too embarrassed to discuss it with his wife.  He had the original suicidal thought over 6 months ago and he observed it "come and go" over time.   This is a good illustration of how delusional guilt can be associated with transitions between baseline and then within the altered states model to one that is potentially dangerous.  It also illustrates how the individual life experience of the person is relevant. 

Manic and hypomanic patients often have transitions in their mood state.  Families members will call and say that the person needs to be in the hospital because they are keeping the whole family up all night and there have been some dangerous confrontations as a result of the sleep deprivation.  The patient can present very calmly and declare that the only problem is their family.  They may not acknowledge that they are spending money excessively, driving recklessly and starting to drink a lot.  Since they do not believe that there are any problems they will refuse crisis care, sleep hygiene advice or medication changes.  They are incapable of recognizing a change in their conscious state that puts their marriage, finances, and health at risk.  With many people this can be a self limited change, but in others it can lead to mania and psychosis or severe depression.  At the critical point where the altered conscious state could be treated, they are unable to process that information and make a decision in their best interest.  They may come back later and tell the psychiatrist who was trying to make an acute assessment that they were really out of it at the time but during the acute episode they were not able to see this reality.

Altered conscious states also occur in outpatient settings.  It is not uncommon to talk with professionals who need a specific medication that is prohibited by their licensing or regulatory body.  These are typically professions that regulators decide can inflict a significant amount of damage if they are compromised in some way by prescription or illicit drugs.  In the case of a person concerned about losing that profession, not reporting the medication or not taking it can happen.  That can occur as both a direct attempt to mislead regulators or as a result of impaired decision making from a substance use or mental disorder.

From what I have seen about the way that mental illness and substance use can alter conscious states, figuring out how to recover baseline conscious state is far from clear.  The first issue is that there is no real focus on the problem.  Psychiatric hospitalizations depend on a handful of yes-no questions about suicide and in some cases homicide.  I was recently told that a psychiatric hospital said that their admission criteria was: "You have to be suicidal and we have to be able to discharge you in less than a week."  That statement is so far from the reality of how mental disorders need to be treated it is stunning.  That statement shows a lack of regard for quality assessment and treatment.   There is no apparent interest in restoring a person to their baseline or even finding out what that baseline was.  On the other hand, I have had active discussions with psychiatrists who were interested and actively talked about these things to their patients each day.  If you are such a psychiatrist, patients will often say that in retrospect their very interested and compulsive psychiatrist missed the fact that they had significant suicidal thinking or that their were probably psychotic in a previous interview.  

The life ruining events discussed in this post and the possible mechanism illustrate that our lives are a complicated web of social interaction.  We make decisions based on that web every day and all day long.  Going into a hospital and being discharged based on whether or not the suicide question is endorsed or whether or not you are aggressive is a very low standard of social behavior and ability to function.  It takes a lot more than that to stay married, stay on the job and perform it safely, stay in the role of spouse and parent, and stay in a stable living situation.  Those are the real goals of assessment and treatment when it comes to recovery rather than ruin. The necessary decision making is linked to a conscious state that may be in a state of flux during an acute episode mental illness.

It is important to recover and recover completely.  Being familiar with baseline conscious state rather than a list of symptoms as being a good measure for this seems like a reasonable approach.  


George Dawson, MD, DFAPA

Cravings

"Unlike most of our crowd, I did not get over my craving for liquor much during the first two and one-half years of abstinence.  It was almost always with me......"  Doctor Bob's Nightmare.  Alcoholics Anonymous, Fourth Edition, New York City, 2001, p 181.

Craving to use drugs and alcohol is a common problem.  As Doctor Bob points out in the above quote, craving is rare for alcoholics beyond the acute detoxification phase, but protracted for many other drugs depending on the class of addictive compound and the pharmacological properties of the specific drug.   Apart from the biological determined heterogeneity of response to addictive compounds there are also the subjective aspects.  In order strive for more objectivity, modern psychiatry has established diagnostic criteria for disorders of interest.  These disorders are grouped in categories to seem uniform.  Depending on the criteria of interest there is a broad range of subjective experience and description when describing common problem like anxiety and depression.  Some people don't know the difference between them.  Others have a mixture of both.  Some people are anxious all of the time independent of their surroundings.  Others get depressed or panic only in certain situations.  The interpretation of what a person considers to be a craving is as diverse.

Craving for an addictive drug or alcohol comes in many forms.  It can be a perception of a physical property of the actual compound itself such as the taste, odor, appearance or consistency.  It can be physical acts associated with its use and a common example there is a feeling that cigarette smokers get when they feel like they need to do something with their hands after they stop smoking.  It can be cue induced like being offered a drug or being in a place where previous drug transactions occurred.  It can be recall of the first intense and protracted euphoric experience of using the drug even though that has long passed related to tolerance.  The overwhelming affect associated with craving is anxiety and fear because of the sign on an impending withdrawal or relapse.  The negative reinforcement that keeps addictions going after the initial states of positive reinforcement due to the euphorigenic effects of the drug is avoiding withdrawal.  Craving may be a signal that acute withdrawal is imminent or that there is a state of chronic withdrawal.

Craving has had an uncertain place in the field of addiction and the diagnosis of addictive states, largely because of the broad range of experiences associated with craving.  This diagrammatic summary shows that various groups have considered the definition to be too vague.  In other cases there was no consensus that craving was a universal enough phenomenon to be considered a diagnostic criterion.  That changed this spring when the DSM-5 added craving and eliminated legal consequences of drug and alcohol use as a diagnostic criterion.  Medications used to eliminate cravings probably led to that consideration, but people with cravings are more likely to relapse and have significant distress during recovery.

The addition of cravings to the DSM-5 opens up a whole new area of focus during encounters with people who have addictions.  Prior to this change the two major texts on addiction devoted about 3-4 pages to craving phenomena.  Addiction psychiatrists and addictionologists may have already been focused on this area, but I think that overall it makes ongoing assessments more dynamic because it is an intervention point for physicians and there are a number of medical and non-medical interventions that are possible.  Omar Manejwala, MD reviews the options in his very readable book entitled Craving.  This book is interesting because it gives a number of practical tips on how to counter cravings based on the substance involved as well as the importance of psychosocial interventions like 12-step recovery and how that might work.  Addiction science has probably been at the cutting edge of neurobiology for at least the past decade and with this focus there is often the implicit understanding that we are searching for some medication that will be an immediate solution to craving.  In some cases we have that medication, but I always emphasize that cravings at some point disappear and that there are non medication approaches to addressing them.

George Dawson, MD, DFAPA

Manejwala O.  Craving: Why We Can't Seem To Get Enough.  Hazelden, Center City, MN, 2013.

Definitions:

Neuropsychopharmacology The Fifth Generation of Progress (2002):  Craving is a powerful, "must-have" pull that causes addicted people to risk and sometimes lose, their relationships, families, money, possessions, jobs and even their lives. (p.1575)