How to Overcome Addiction to Substances or Behaviors | Dr. Keith Humphreys

When a person expresses a desire to quit an addictive behavior, a good clinician doesn't immediately affirm or direct them, but instead asks 'Why would you want to do that?' This approach, rooted in motivational interviewing, aims to help the individual articulate their own reasons for change. The therapist acts as a facilitator, guiding the person to elaborate on the benefits they envision from quitting (the 'carrots') and the negative consequences they want to avoid (the 'sticks'). For example, if someone wants to quit smoking, the therapist might ask about the positive feelings of having fresh-smelling clothes or what they would do with the money saved. This process helps build intrinsic motivation, which is crucial for sustaining effort through the difficult phases of withdrawal and long-term recovery. By focusing on the individual's values and desires, the therapist empowers them to own their recovery journey, making it more resilient against challenges.

Dr. Humphreys emphasizes the profound importance of social connection and accountability in any behavior change, not just addiction recovery. He suggests that whether one is trying to start jogging or quit drinking, joining a group of like-minded individuals is highly beneficial. These groups offer two key elements: support, which helps individuals feel understood and less alone in their struggles, and accountability, where peers notice and question absences, reinforcing commitment. This external pressure and shared experience can be a powerful motivator, especially during challenging moments when individual resolve might falter. He points to the success of 12-step fellowships as a prime example of this principle in action, where mutual support and accountability are foundational to recovery.

Dr. Humphreys explains that understanding and modifying one's environment is a critical component of addiction recovery. This involves identifying 'cues to use'—places, people, or objects that trigger cravings—and actively removing or avoiding them. For example, if alcohol is a problem, removing all alcohol from the home makes it harder to relapse, requiring a trip to a liquor store rather than easy access. Conversely, identifying 'cues to non-use'—environments where the addictive behavior never occurs, like a parent's house or during religious observances—can provide insights into effective coping strategies that can be applied elsewhere. This behavioral analysis helps individuals proactively manage their environment to support sobriety, acknowledging that the brain's reward circuitry can be rewired by repeated exposure to powerful drugs and their associated cues, leading to relapse even against conscious will.

Dr. Humphreys highlights contingency management as the most effective treatment for stimulant use disorder, a field that has seen little pharmacological progress in decades. He credits Steve Higgins with pioneering this approach, which challenges the notion that addicts have no control. In contingency management, individuals receive immediate, escalating rewards (e.g., increasing monetary vouchers) for objective evidence of sobriety, such as negative urine analyses. This system can also reward other recovery-oriented actions, like completing job applications. The rationale is that individuals with addiction often heavily discount future rewards in favor of immediate ones. By providing immediate, tangible incentives for abstinence and positive behaviors, contingency management directly addresses this preference, making desired actions more appealing than drug use. This behavioral technology has expanded significantly and is now often covered by insurance, offering a practical and effective tool for recovery.

Dr. Humphreys discusses TMS as a promising intervention for treatment-resistant depression and its potential application in substance use disorders. He specifically mentions the 'SAINT protocol' developed by his late colleague Nolan Williams, which involves an intensive, accelerated TMS regimen. The key advantage of TMS is its non-invasiveness and the ability to target specific brain regions, offering a more precise intervention than general medications. Unlike psychedelics, TMS can be administered with a sham control that effectively blinds participants, strengthening the scientific rigor of trials. Dr. Humphreys notes that TMS for depression is already FDA-approved and covered by Medicare, making it an accessible option. He highlights ongoing multi-site studies, including one he's involved in, exploring TMS to the dorsolateral prefrontal cortex for cannabis use disorder. The goal is to 'intervene far more directly to the brain than talk therapy,' aiming to rebalance reward circuitry and improve cognitive control, which are often impaired in addiction.

Dr. Humphreys explains that the alcohol industry recognized a market opportunity in the late 1990s and early 2000s, as women's economic power grew but their drinking habits lagged behind men's. The industry then engineered long-term campaigns, including seemingly organic online movements like 'mommy wine culture,' to increase women's alcohol consumption. This strategy proved effective, leading to a significant rise in drinking among women. This is particularly concerning because women generally experience more damage per drink than men, partly due to body size and potentially hormonal factors. Dr. Humphreys views this as an exploitation of women, driven solely by the industry's profit motive, as a small percentage of heavy drinkers account for a disproportionate amount of alcohol sales.

Dr. Humphreys discusses how the gambling industry has become increasingly sophisticated in exploiting human psychology, particularly through slot machines. He references a story about a casino employee who realized children playing video games were motivated by the novelty of the next screen, not just winning. This insight was applied to slot machines, which now offer an 'infinite amount of novelty through novel combinations.' Players are given 'losses disguised as wins' (LDWS), where they might put in a dollar, get 100 credits, and then 'win' 10, 20, or 40 credits with exciting sounds and visuals, even though they've objectively lost money. This creates the illusion of winning and keeps players engaged, not primarily for monetary gain, but for the continuous stimulation and novelty. This mechanism makes it incredibly difficult for individuals to stop, as their brain is constantly being rewarded with new stimuli, draining their bank accounts in the process.

Dr. Humphreys expresses significant excitement about the potential of GLP-1 agonists, such as semaglutide (found in Wegovy and Ozempic), for treating substance use disorders. He notes that these drugs are already FDA-approved for weight loss and have been used by millions for over 20 years, suggesting a relatively low risk of unknown long-term side effects. The core idea is that GLP-1 agonists reduce the 'desire to want,' a sentiment echoed by his addiction psychiatrist friend whose patients express a wish 'not to want.' He cites an anecdote of a friend who, on GLP-1s, no longer spent all day thinking about food, indicating a reduction in effortful craving suppression. Dr. Humphreys believes this satiety-inducing effect could translate to reducing cravings for substances like alcohol and cocaine, which share similar reward pathways. He highlights that alcohol consumption is particularly analogous to eating behavior, making it a prime target for GLP-1 intervention. Early animal studies, small trials, and opportunistic epidemiological data show promising patterns of reduced alcohol use in individuals taking GLP-1s. He also points out a 'twofer' benefit: many people with drinking problems are also overweight, so GLP-1s could address both issues simultaneously, potentially motivating individuals to seek treatment for addiction who might otherwise only be interested in weight loss.