Episode 161 -- October 28, 2021

Those of us who have taken the First Step have already admitted that we're powerless over our substances. And while we may need the help of a Higher Power to overcome addiction, we're not completely powerless when it comes to our cravings. Dr. Omar Manejwala cautions us to avoid letting our beliefs about what it takes to stay sober set us up for failure.

In his book Craving: Why We Can't Seem to Get Enough, Dr. Manejwala examines the "apparently irrelevant" decisions we make that can either set us up for failure or help us succeed in avoiding a relapse or return to use. Even things as simple as what road we take home or what we put in our grocery basket can make a difference in our recovery.

In the following excerpt, Manejwala describes how human brains are predictable, both negatively and positively. Many of us who have been duped by our brains when we were using substances might feel that this sounds too good to be true, but data and science prove that a combination of beliefs and behavior can reduce our cravings and help us maintain abstinence--the cornerstone of recovery.

This excerpt has been edited for brevity.

What you believe affects what you want. Even more so, what you do affects what you want. In a previous chapter we reviewed that, in certain cases—and contrary to popular belief—when what you want is out of reach, you actually want it less. In this chapter, we'll be exploring how simple actions you take, many of which seem irrelevant, can actually affect your cravings. Many of the recommendations I make will even seem counterintuitive, but they are backed by scientific evidence. Remember that your intuitive responses while in the throes of your cravings may actually be partially responsible for fueling your cravings, so it will sometimes be necessary to do things that run counter to your common sense if you are to successfully lick your cravings.

Apparently Irrelevant Decisions
The father of craving research, the late Dr. Alan Marlatt, used the term "apparently irrelevant decisions" (which he called AIDs) to describe the actions that people with addiction sometimes take that don't seem to them to be related to their cravings but that actually lead to their relapse. The technical name for this is "covert antecedents." The original example that Marlatt used was an alcoholic who was sober, but who purchased a bottle of alcohol "in case guests dropped by." Marlatt used apparently irrelevant decisions to describe the actions that lead to relapse, but what I'm proposing takes it several steps further. It turns out that many of the actions you can use to reduce your cravings will also be apparently irrelevant. Let's look at some of them.

Removing access to the object of craving is, of course, critical, especially early on in your process. If you hadn't read this book, you might have drawn the conclusion that removing access to the object of craving would usually make you want it more. Scientific evidence, however, suggests otherwise.

Although there are exceptions, if you are trying to lose weight, it's probably a bad idea to get a job at Krispy Kreme. If you are trying to stop drinking, being a bartender is probably not the best option. And if you are trying to quit gambling, you may want to find a job far from the Vegas strip. Creating the awareness that the self-destructive behavior is truly off limits can be very helpful in managing cravings. In fact, in what is now considered to be a classic study by Dr. Roger Meyer, only 50 percent of alcoholics craved alcohol when exposed to the sight, smell, or even touch of their favorite beverage if they knew that they would not be able to drink it. The mere fact that the alcohol was completely off limits reduced the craving. Behavioral economic research shows similar effects with alcohol price escalation, suggesting that the mere difficulty of obtaining the object of the craving can also reduce cravings. Of course, there are situations where removing access increases desire, but by and large it's likelier that "out of sight, out of mind" will be effective.

What you believe about your cravings can also predict whether you will act on them. In 2010, Australian researcher Nicole Lee and her colleagues assessed 214 methamphetamine users, focusing specifically on what they believed about their cravings. I recently asked Lee about her research, and she explained that when using a questionnaire called the Craving Beliefs Questionnaire, she found a relationship between the addicts' beliefs about their cravings and the probability of relapse. This suggests that addicts who believe that cravings themselves have a detrimental effect on them or their risk of relapse are more likely to return to drug use. In my experience, a simple awareness that cravings are serious but definitely manageable helps people commit to other strategies that ensure abstinence. It's my sincere hope that you, too, can gain such awareness, as that very belief (which has the added advantage of being true) may help you stay away from the object of your craving.

Again, although it may seem to you that staying away from what you crave will increase your craving, research suggests just the opposite: the longer you can maintain abstinence, no matter how you do it, the less you crave. A recent study of 865 methamphetamine addicts followed over a four-month period of abstinence showed a clear, dramatic reduction in cravings over time.

Of course, abstinence alone does not produce recovery; this explains why so many people with addiction released from long prison sentences return to drug use before they even arrive home. One study of former smokers who had been abstinent up to ten years showed ongoing cravings in about 10 percent of them, even many years later. People who continued to crave tended to have a more severe history of nicotine dependence and to have more mental health problems. Abstinence is very helpful but hardly enough. Other research has suggested that non-cue-induced cravings do diminish over time, but cue-induced cravings are slower to diminish. (That cigarette display in the gas station tends to "speak" to recovering nicotine addicts for quite a while.) This is why I always emphasize that if you are tempted to test yourself by being exposed to a cue or trigger, you should reconsider. Life contains enough tests—you don't need to add your own.

No one solution will work for all cravings; however, many actions that reduce cravings can be deceptively simple. It can really seem like there is no way that these could work, and yet they do. For example, simply imagining your favorite activity as vividly as you can, can dramatically reduce cravings for food and cigarettes. Several recent studies have shown that the scent of peppermint can reduce cravings for food and nicotine. Mindfulness exercises have also been shown to reduce cravings and substance use. Long-established research shows that stress induces cravings (and this is only partly related to hormonal effects), so any strategies that reduce stress are also very helpful.

I strongly believe that many people with addiction will not be able to completely suppress cravings through cognitive (that is, thinking) methods. Nevertheless, these techniques can be extremely helpful. In a recent study, people with cocaine cravings attempted to suppress their cravings using cognitive therapy strategies, which functional imaging studies showed reduced the activity in their nucleus accumbens and orbitoprefrontal cortex. That's a fancy way of saying that just using thinking-based methods to suppress cravings affects the parts of the brain involved in craving and reward.

About the Author:
Omar Manejwala, MD, is a psychiatrist and an internationally recognized expert on addiction and compulsive behavior. He is the former medical director of Hazelden, a treatment center in Center City, Minnesota (now the Hazelden Betty Ford Foundation), and currently the chief medical officer of Catasys, a health management services company specializing in substance use disorders. He has appeared on numerous national media programs including 20/20, CBS Evening News, and The Early Show.

© 2013 by Omar Manejwala
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