Neurobiology of Holiday Relapses

Why does your car stop at a red light? Sure, you press the brake, but do you really think about it? For experienced drivers, the answer is no — it just seems to happen on its own.

A vaguely appreciated or unsensed cue (e.g., stoplight) causes a driver to bring their vehicle to a stop. Photo: Ludovic Simon, et al.

This is the miracle of the brain: it can automate processes so you don’t need to consciously think about them. But this is also the challenge of addiction. Unhelpful mental scripts keep executing themselves, even when you sincerely want them to stop.*

What causes the scripts to execute? The Big Book contains various clues that have since been verified by modern science. The biggest drivers are

  • Negative affect
  • Stress
  • Cues

The Big Book famously describes those with addiction as “restless, irritable and discontented.” This is the best description of negative affect that I have ever seen.

Stress occurs when “environmental demands tax or exceed the adaptive capacity of an organism.”

Cues are environmental triggers — “people, places, things” — that have previously been paired with drug use. Sometimes you are consciously aware that cues are present, for example, you notice bottles of wine in a restaurant. But in many cases, they are unsensed. The brain registers the cues but there is no conscious appreciation that they are there.

The vignette in Chapter 3 of the Big Book brings this all together. Jim, the salesman, reported, “I felt irritated” after a dust-up with his boss. (Negative affect) He might have been stressed over a sales goal. He stopped at a roadhouse to grab a sandwich. The place “was familiar for I had been going to it for years.” (Cues) Despite “no intention of drinking” and “no thought of drinking,” Jim inexplicably “ordered a whiskey and poured it into [my] milk.”

What was responsible for this “plain insanity”?

Negative affect, stress and cues.

Why are alcohol and other drugs “cunning, baffling, powerful”?

Because “addictive behaviour appears to involve processes outside of the sufferer’s personal consciousness by which cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs.” Spooky functional imaging studies have shown this to be true.

The holidays often involve negative affect and stress. And there are often a lot of cues, both sensed and unsensed, in holiday environments. This “perfect storm” can initiate a behavior chain that often leads to unintended problem behaviors (alcohol or drug use).

I will be talking with my patients about countermeasures for the next month. ✸

* St. Paul lamented, “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Romans 7:15; NRSV). This gets into the realm of reversal learning, which is part of the neurobiology of addiction.


The Twins were eliminated by the Astros yesterday, however, it’s still baseball season! In that spirit, I’m “pitching” a split doubleheader today in two different ballparks through the wonders of Zoom.

The first presentation is for the Minnesota Sheriff’s Association at its Correction Care Division’s Annual Conference. The subject is identification and management of substance withdrawal syndromes (I’m the medical director for two county jails).

CentraCare Health; St. Cloud, Minn.

The second outing is for CentraCare Health at its Opioid and Controlled Substances Prescribing Training. I’m the middle reliever in a line-up that includes Drs. Michael Massey (pain medicine) and Lynn McFarling (medical informatics). The two-hour event is designed to fulfill Minnesota’s new(ish) legislative mandate for provider education. My contribution deals with unhealthy substance use with special attention to patients with chronic pain syndromes.

CentraCare Health; St. Cloud, Minn.

Just click on the above images or hyperlinked text to access my PowerPoints. ✸