The last episode was very long as these things go, so I only covered the medical ways we have to increase midbrain dopamine tone. That may have made it sound too simple a process. It's not. The causes of low dopamine tone are interactive and any medication can have unintended effects. Personalizing and individualizing care helps a great deal, but we are nowhere near a perfect solution yet. 

There are other things we can do however to set up a treatment system that feeds the midbrain tonically. Before going over some of those, I want to repeat why we care. 

This series is about how we have treated addiction with the parallel processes of nature and gotten the large amounts of rework and lost efficiency that is inherent in such a mode of operation. We discussed how sequential processes would work better, but noticed that current discussions of the nature of addiction didn't allow us to formulate any. We took a different tack. We looked at addiction, not from the point of view of the behavioral effects, but from the point of view of the biological causes. Taking that approach we were able to start sequencing addiction treatment so that we could create an iterative process to engineer a better treatment solution. 

We recognized that the midbrain, not the cortex was the key, and in the last episode discussed some medical ways to improve midbrain function. That brings us to today and the discussion of some non-medical ways to improve midbrain function in our treatment. To understand these you'll need a few facts we haven't considered yet.

Remember from last time that we said that dopamine tone depended on 3 factors and that two of those could be changed by medication. The third factor, dopamine receptors, we said didn't have a medical solution. But we didn't say there was nothing to do. It turns out that our dopamine receptor density is affected by the world around us. Specifically, two stressors act to lower the density, and therefore the function, of dopamine receptors: physical isolation and feeling less than others. That's worth pondering a bit.

Almost everyone can recall a moment in their lives when they were spoken to in such a demeaning way that if felt like the lights went out and they couldn't imagine every being happy again. That feeling was the dopamine receptors being sucked back into the cell and no longer being available to see the dopamine reward signal. Now, think about how we treat addiction.

Some people are put in cells because they have addiction, they are often physically isolated, and certainly are made to feel less than. We have a system in which people can't go to their regular doctor for help because their regular doctor doesn't know how. The problems is so shameful, we don't even teach it in medical school. So they have to go to special clinics where they can be seen to walk in the building with the rest of "the addicts." What's inside those buildings isn't helpful either. Because reimbursement for addiction treatment (for many and various reasons that are beyond the scope of this piece) are so low, most treatment occurs in urban substance abuse clinics. Walking in one typically sees, not the ambiance of a medical office, but a run down version of the DMV. The broken and mismatched plastic chairs and cattle call mentality basically let "the client" know that everyone there is doing him a favor just to show up to make him feel bad. 

So, a person with low dopamine tone enters treatment in a place that lowers his tone in a new way by lowering dopamine receptor density. Imagine the success rates. And this is our clue of what to change.

We realized that to do addiction treatment, one needs good dopamine tone. So dopamine tone is the constraint to engaging in successful treatment. We wish to focus on that constraint, making all other processes subservient to it. We want to elevate it where possible. When we find parts of our system that lower dopamine tone, we want to change those. It may cost a lot of money or time to create a new system that raises dopamine tone, but it costs nearly nothing to stop doing something that lowers it. So how do we lower it?

I've already alluded to physical plant, but there may not be money available to fix that. There's still a lot we can do. Does everyone who works in the center know that they are saving lives? Do they all understand, from the top doctor to the guy that empties the waste baskets, that they are affecting patients' dopamine tone, and therefore their ability to engage in treatment? Does the receptionist answer the phone like they're saving lives? Does every member of the team know that by picking up trash on the floor they are saving lives? I've seen the changes that can take place in clinical care when a leader can teach everyone the importance of what they're doing. It saves lives.

And it starts with understanding addiction as a disease and not as a social problem such as substance abuse. The words we use tell us what to do. We can chose to use words that lower dopamine tone or words that raise dopamine tone. If we want treatment to work, it's clear we want to chose words that raise dopamine tone. But we don't. “Substance abuse,” “dirty urine,” "are you clean?," are all examples of word choices we can make that will lower dopamine receptor density. How we understand something will come out in our speech, and the patient is greatly affected by it. 

How we treat the environment of treatment, how we treat the patients and others we interact with are just a couple of the ways we can increase dopamine tone and improve our outcomes. These are things we'd never think of using in the parallel processes of the past, but they become critical using the sequential processes of a TOC solution. 

Up to this point we've only gotten to where we have dopamine tone normalized. All this effort and we've gotten to the point where change can begin. Next time we'll talk about how to sequence that change.