People addicted to alcohol and other drugs see the world differently. They SEE the world differently as a result of neurocognitive changes in perception that accelerate in tandem with increased tissue tolerance, increased intensity of cellular hunger (craving), and the resulting obsession with maintaining the drug relationship at all costs. As drug seeking, drug procurement, and drug use rise to the top of one’s motivational priorities, one develops attentional bias toward words, symbols, and images linked to these substances. Perceptual preferences for drug-linked stimuli are an essential element within the neurobiology of addiction. In recovery, this perceptual preference is reframed, giving perceptual priority to words, symbols, and images that reinforce the recovery process.
The journey from addiction to recovery is marked by extreme ambivalence, particularly during the early stages of recovery, and exposure to these contrasting sets of cues can tip the scales toward either addiction recurrence or the transition from recovery initiation to long-term stable recovery. The issue raised in this blog is the ratio of addiction cues versus recovery cues within community environments. The concern is the relative paucity of community-level recovery cues compared to a near-constant bombardment of drug cues.
Recovery folklore is filled with cautions about stimuli (aka “people, places, and things”) that can send a seductive call back to one’s past life in addiction. Imagine the sensory cues a person experiences in their first days of “sobriety sampling” as he or she pursues daily life in the community. Imagine her exposure to alcohol and other drug cues in every communication medium—the product of billions of dollars in alcohol, tobacco, and drug advertising that glamorizes intoxication and links mood-altering products to physical beauty, social popularity, romance, sexual fulfillment, financial success, and freedom from emotional distress. Imagine that even the social and print media she reads that address drug problems are filled with endless images of drug use, drug products, needles, and all manner of other drug paraphernalia. Imagine constant visual encounters with people and places closely linked to her past rituals of drug use. Imagine the sheer volume of drug cues she experiences driving down any U.S. commercial street—encounters with these cues on billboards and in restaurants, gas stations, grocery stores, and recreational venues, as well as through popular movies, magazines, and music.
One of the shared goals of alcohol, tobacco, and drug (ATOD) industries is to increase the physical presence of their products (and their carefully crafted images) within American life. They have been enormously successful over two centuries in achieving that goal. The result is a literal visual assault of drug-inviting words, images, and slogans infused into the very fabric of American life. In contrast, the stigma attached to having experienced problems with these substances has, until quite recently, rendered invisible the people, places, and things associated with addiction recovery. While ATOD icons have been ever-present in American life, words, images, and slogan celebrating the recovery experience have for too long existed only within subterranean subcultures hidden from mainstream community life.
Returning to our topic of attentional bias, one can see the challenge of initiating recovery within a cultural stew saturated with positive drug cues and few if any recovery cues. This imbalance is a personal challenge faced by each person beginning a recovery journey, but it is also a problem at an environmental level. Just as the ATOD industry sought proliferation of their product images, recovery advocates must help forge recovery-friendly communities in which the glamorization of these products are offset by images portraying their risks and by images linked to successful cessation of drug use and the resulting personal and social benefits.
For recovery advocacy organizations, this means two things. First, it means that they must counteract efforts by the alcohol, tobacco, and pharmaceutical industries to glamorize and promote drug consumption, target vulnerable populations, introduce products of ever-heightened potency, create more pleasure-inducing methods of drug administration, and expand the times and places in which the sale or use of such products are acceptable. By serving as a force to inhibit such cues within the community, recovery advocacy organizations can play important roles in ATOD prevention and the promotion of public health, while also reducing the cues people in early recovery are exposed to that could tip the scales toward re-addiction. An example of this is clearly evident in the history of tobacco policy in the U.S. It is far easier for a person to quit smoking today than in the 1960s, in part, because the massive promotion of smoking and the ever-expanding space within which smoking was acceptable has been reversed as a matter of public health policy. Imagine the cues the smoker trying to quit smoking would be exposed to in 1960 compared to today. Our goal as advocates should be to similarly reduce the cues and community spaces within which addiction to other drugs flourishes.
A second strategy of recovery advocacy organizations is to expand the public visibility of people, places, and things (and words, symbols, and images) that cast a recovery beacon within local communities. An ecumenical culture of recovery is rising into the light of community life through new recovery support institutions, recovery education and celebration events, and the increased representation of the recovery experience through art, literature, music, and social media.
Imagine that same young woman in decades to come in her earliest days of recovery. Imagine her ambivalence about addiction and about recovery. Imagine the challenges of attentional bias, but also imagine a community in which drug cues calling her back are counterbalanced by recovery cues calling her forward into a new life. In that new world, she has a much better chance than the chance she has in far too many communities today in which the former are ever-present and the latter are invisible. We must help build a world in which her recovery will be warmly welcomed. Addiction now flourishes on Main Street America; it is time recovery stepped out of the shadows and announced itself on Main Street. Thanks to recovery advocates across the country, that process has now begun.
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Cox, W. M., Hogan, L. M., Kristian, M. R., & Race, J. H. (2002). Alcohol attentional bias as a predictor of alcohol abusers’ treatment outcome. Drug and Alcohol Dependence, 68, 237–243.
Field, M., & Cox, W. M. (2008). Attentional bias in addictive behaviors: A review of its development, causes, and consequences. Drug and Alcohol Dependence, 97, 1–20.
Stormark, K. M., Laberg, J. C., Nordby, H., & Hugdahl, K. (2000). Alcoholics’ selective attention to alcohol stimuli: Automated processing? Journal of Studies on Alcohol and Drugs, 61, 18–23.
William (“Bill”) White
Emeritus Senior Research Consultant at Chestnut Health System
Read all of Bill White's Blog Posts on his website here www.williamwhitepapers.com