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The Medium is the Message

The Medium is the Message

Friday, October 16, 2009 Author: Dr. Kevin McCauley Categories: Neuroscience
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Once a month I set aside a day to read the latest research about addiction in the leading medical journals. For the last ten years I’ve watched this knowledge expand. What was once a trickle, then a stream, is now a flood, and the research is pouring out so fast that it is difficult to keep up.

Still, I try. And whenever I read this research, I never fail to notice two things.

First, how well it speaks to the experience of addiction; how it explains so many of the baffling and frustrating behaviors of pre-recovery addicted people. Why do addicts continue to use despite the threat of prison? There’s a reason for that. Why do addicts put drugs and alcohol above the people they love? There’s an explanation for that one, too. In fact it’s all there for the reading. Yes, there are many mysteries still to be untangled, but as brain disorders go, the pathophysiology of addiction is pretty well fleshed out.

The second thing that strikes me is that even though this research has been steadily accumulating over the last twenty years, there is still no good way to get it to the people who need it. To the people who wake up in detox, wondering how they got there, asking themselves why they act in ways they do not value. Or to the family,  secure in the belief that their child does not use drugs, who gets a call from the school announcing their child has been suspended because marijuana was found in his or her locker. This astounding neuroscience should not pile up on the dusty shelves of medical libraries. It should be delivered swiftly to the people who need it most, and to whom it most belongs, so that families can feel some hope, and patients can feel less ashamed.

Yet there have only been two major media projects in the last ten years on the subject of addiction: the PBS “Close to Home” series with Bill Moyers, and the HBO video and companion book “Addiction,” made in collaboration with the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Robert Wood Johnson foundation.

These are fine, well-made, incalculably beneficial programs. They have given millions of people a better understanding of addiction. But, “Close to Home” was made in 1997, and the HBO project filmed in 2006. Their total length combined is less than ten hours. They reflect certain perspectives about addiction. Neither addresses in detail what I maintain is the most important question about addiction, the one on which the entire credibility of addiction medicine hinges: is it really a disease?

These programs share one other problem: they are not fun to watch. They are grim. They are serious. That makes sense; addiction is a serious matter. But when I read the research on addiction, the message I come away with is that the news is pretty good. Addicts do terrible things, yes: they lie, they cheat, they steal. But this research indicates quite clearly that addicts are not intrinsically liars, cheats, and thieves. There are very good reasons for their behavior. And, people get sober all the time – more now than ever before. More people are entering treatment earlier; they’re keeping their jobs and families. More young people are getting sober and avoiding a host of health problems. There are now some good medications to help them get a foothold in sobriety, and more are on the way. The future looks bright for people seeking recovery.

Where’s that message?

Instead of programs building on the fine work of PBS and HBO, I see the proliferation of cable television shows about addiction that focus more on the symptoms of addiction than the reality of recovery. They depict the rights of addicts as patients routinely violated in the service of coerced treatment. They use self-serious cinematographic techniques such as high-grain film and slow shutter speeds that convey more bathos than pathos. And they take an almost prurient interest in showing intravenous drug use.

These programs worry me, because they show addicts at their worst, with very little explanation of the brain mechanisms behind these behaviors. Yes, the symptoms of addiction are graphic, but do the viewers really understand what they’re looking at? Do they know that the hyperprioritization of drugs because of their effect on the dopamine system explains why addicts keep on using despite terrible consequences? Is it explained that relapse is a largely unconscious process, or that addiction is a disorder of the brain’s pleasure system that damages its decision-making capacity? I’ll state it plainly: do these programs cash in on the suffering of addicts for entertainment value?

I confess that I don’t know if these programs are exploitive, or whether they increase or decrease stigma, or if they bring more or fewer people to treatment. All I know is that I have always wanted to see a different kind of media project about addiction. Something positive, even upbeat, that portrays recovery as much as it does addiction. I yearn for high-definition, broadcast-quality, beautifully filmed programs that convey the wondrous neuroscience of addiction, that lay out an argument for why it can be rightly considered a disease.  Programs that paint that bright future. I dream of a renaissance of expression – films, music, art, theater, poetry and prose that give voice to the experience of addiction and recovery.

Most of all I would like to see a simple, sixty-minute video that a family can pop in their DVD player, or a patient can watch at his or her treatment center, to get a solid understanding of the research behind addiction, to see that there’s more to addictive behavior than just bad people, making bad choices, behaving badly. It would show no people in gutters. No shots of intravenous drug use, and at the end of that video the dignity of the addict would remain intact.

For these last ten years, as I sit out practicing medicine waiting for my recovery to solidify, I have given lectures on addiction at a number of different treatment centers. I try to bring a positive message when I explain this exciting new picture of addiction as a brain disease to patients and their families. I focus on that bright future. I never fail to mention that the news about addiction is good, and that most people who stick with recovery eventually get it.

Not surprisingly, the lectures have been well received. And I’ve often been asked, “Do you have a DVD of that lecture?” So far the answer has been “no,” for several reasons.

One is that I don’t want to be the next doctor trying to get on T.V.  I’m not sure how that serves the mission of carrying the message of recovery.

Second, although I dream of that perfect, sixty-minute video on addiction, I’m not sure it can be done. Lecturing is easy. Filmmaking is hard – and I know nothing about it. It would be a very tough project to pull off well. It would require a level of creativity, talent and production quality that I’m not sure I have, or have access to. If the project worked, it might help a lot of people. But if it came off badly at best it would look stupid, at worst it would be little more than an exercise in narcissism. The project frightens me.

A film of a lecture would be mind-numbing, and even if it could cover all the neuroscience of addiction it would last hours. This video could be no more than 60 minutes. To counter the tendency toward melodrama, it would have to be visually spectacular – eye-candy even, filmed in high-definition, using animation, beautiful locations and clever visual images to propel the material. It should look good enough to captivate the viewer even with the sound off. Dialogue must be tight. There will be no time to explain complex neuroscientific concepts. The first rule of film is “show, don’t tell.”

But how to do it? How do you convey complex neuroscientific concepts of addiction quickly so they stick in the viewer’s mind?

There is also the problem of funding – I estimated a project like this would cost between seventy-five and one hundred thousand dollars. Any less and the production quality would suffer so much the whole project would fall flat. Currently, good animation costs $1,000 a second. Where would I get that kind of money?

And talent: Do we need a stage? Actors? How about music? Where am I going to find a good cinematographer – a high-definition cinematographer?

For five years, these problems floated around in my head with no solution. It looked like this DVD would never be more than a fantasy.

Then, quite unrelated, I went on a trip to one of my favorite places on Earth. The first time I drove through Utah I immediately fell in love with it, and I knew that someday I would make this state my home.

Nothing is like Utah. It is totally unique. Colorado is nice, but it can look like Idaho. Areas of Oregon resemble California. But nothing looks like Utah, except Utah.

One day I was hiking near Moab and I found myself ruminating on my addiction video problem, as I was apt to do in my quiet moments alone.

Something occurred to me: like Utah, nothing is quite like the brain either.

One of the first things you learn in medical school about the brain is its feature of localization. Different areas of the brain handle different functions. And I realized that I could come up with a different place in Utah that reminded me of each different part of the brain involved in addiction.

When I thought of the frontal cortex, proud and rational, I thought of the majestic white stone monuments of Zion National Park.

When I thought of the midbrain, deep and spooky, I thought of Bryce Canyon, or the slot canyons in the Vermillion Cliffs wilderness.

The fiercely strong neural pathways of addiction reminded me of the Colorado River carving out the Canyonlands.

Hypofrontality – Monument Valley.

Anhedonia – the Bonneville Salt Flats.

This was fun.  And then, suddenly, I knew how to portray addiction: I could take a driving tour around Utah and describe addiction using its different and varied landscapes.

Over the next two years this idea began to take shape. There were huge gaps in the storyline and problems so seemingly insurmountable I had to block them out of my mind to make any progress.

In June 2008, I drove from one end of the state to the other, scouting locations. I stayed in cheap motels in tiny towns with names like Kanab and Loa. Each night, I’d spread a National Geographic map of Utah out on the bed to plot the next day’s exploration.

It was during that week that it all came together. Over the next month, I banged out the screenplay – the first version was bound with brass brads just like they do in “the business” with a blue cardstock cover. There would eventually be seven revisions and seven colored covers: blue, yellow, red, green, gray, lime and fuchsia.

Proud though I was, the project was barely off the ground. So many problems loomed, chief among them the problem of finding a cinematographer. This project had to really pop off the screen. So I felt it had to be filmed in HD. I knew nothing about HD. Or SD, or VD, or any kind of D.

Then my coworker, Jim, who eventually became the producer of the DVD, approached me and said, “Hey, there’s this guy who lives a couple doors down from me who does a lot of video work. We should go over and visit him.”

I rolled my eyes. C’mon, I thought, I need a serious cinematographer – not the guy two doors down! We’re going to have to go to LA or someplace to find someone with that kind of talent, not Utah.

But to be polite, I agreed to go see Norm.

Norm, it just so happens, was an HD cinematographer for (guess who?) National Geographic. His basement was a theater with a full editing studio: two quad-core Macintosh computers, stacks of terabyte hard drives, and the latest version of the same timeline editing software they use at Universal and Paramount … and PBS and HBO. He played me some of his work, and there it was on the screen: the breathtaking, eye-popping, sharp-as-a-tack, 1080p eye-candy of high definition video. I found him – the cinematographer from heaven. Or rather Jim did, two doors down. That was the moment that this project went from a pipe dream to a distant but possible reality.

The next piece of the puzzle was, again, solved by Jim: funding.

He drove, he flew, he called, he shook hands and solicited the people he knew were in a position to support our project. They were polite, but most declined. Then a few more companies helped us. Not all of them wanted to be named, but they helped us just the same. We were off the ground.

Norm and I could now focus on the creative end of the project. We still faced huge conceptual hurdles. There are as many as five theories that are currently in use in neuroscience to describe addiction, and they each have a different explanation. Some say it’s dopamine. Others claim it’s genetics. Then there’s stress and memory to keep in mind, too. Don’t forget impaired judgment. To describe them all would never work – the video would be too heavy. At the same time, we couldn’t leave any one of them out.

One night, I was sitting at the sober living house we run in Sandy, watching a movie with the residents. One of them was eating Oreo cookies, addict-style: stacking two on top of each other. And then it hit me: the theories don’t conflict if you stack them on top of each other.

Addiction is a disorder of pleasure, yes, and of genes, and of memory, and stress, and finally, in the frontal cortex, choice. Each theory describes what’s going wrong at each level of brain processing as the brain tries to generate a pleasurable experience … and fails.

So pleasure is a construct – different areas of brain processing woven together into a unified perception. Except in addiction, that process breaks down, and pleasure becomes unwoven.

Okay, how to show that? One Sunday I saw a Russian Nesting Doll in a shop window in Park City and thought, I wonder if I can make a nesting doll of something pleasurable, like … a cookie?

My call to St. Petersburg was a bit strange. “You want picture of cookie? On doll?” the voice said in a thick Russian accent.

“Yes, please.”

It arrived three weeks later – perfect.

Dopamine pathways. Glutamate pathways. How to keep them straight? By throwing green and red garden hoses up to the cortex (Zion National Park) and down to the midbrain (the Paria River slot canyon). Green water flowing out of one hose stood for Dopamine (green for Go!). Red water for Glutamate (red for Stop!).

How to show the Dopamine Hypothesis – that what all addictive drugs and behaviors have in common is their ability to release dopamine, and they can, therefore, easily be substituted to produce cross-addiction? My mother, avid fly-fisherwoman that she is, sent me a Columbian T-shirt for my birthday. On the back was a spoof on the Periodic Table of the Elements from Chemistry class, only instead of the elements there were different flies and bait. Hey, wait a minute, I thought. How about a Periodic Table of the Intoxicants?

Five trips to Southern Utah.

Six thousand miles of driving.

Fourteen hours of tape.

Two weeks of solid, fourteen hour days of editing.

Sixty thousand dollars.

And now, as it reaches its final days of post-production, I can only wonder: Does it work? Is it hopelessly corny? Or worse, narcissistic?

I’ll leave it for you to decide.

The premiere is November 6th in Newport Beach.

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