Opioid Addiction as an Attachment Disorder

By Michael Roeske, PsyD

To an outside observer, the behavior of an opioid addict seems quite bizarre…returning time and again to something that causes so much pain and suffering.  Interestingly, the field of psychology has been wrestling with such things since its beginnings.  In fact, Freud found our tendency to repeat painful experiences extremely problematic as he believed we were essentially pleasure seeking creatures.  Then, in 1920, he finally accepted there was something else going on and suggested humans also have a drive toward self-destruction.

This, unfortunately, was not a wholly satisfying explanation and others sought more straightforward models.  And arguably the most important one was put forth by Bowlby.  Drawing on evolutionary theory and the field of ethology, he saw us as biologically designed to connect because of our extreme vulnerability in infancy.  Therefore having attention from and proximity to a caretaker was considered more basic than even the need for food.  It is from that connection, he reasoned, that all other needs can be met.

Today, few people would argue the basics of his attachment theory.  As well, it had the power to explain a range of strange behaviors, such as why abused children would choose to protect and remain with an abusing parent.  But if Bowlby’s evolutionary perspective is accurate, and natural selection led to a new system in the brain, how might it relate to addiction to opioids or tell us why they do what they do?  An answer appears to come from where this attachment system is believed to have developed in the brain.

While many therapists know about the “Rat Park” experiments of the 70s, the effort to repeat the studies produced mixed results.  At the same time, though, another group of researchers had an idea about our brain opioid system and attachment needs.  In 1978, Panksepp and colleagues separated rat pups from their mothers and gave them small doses of opioids.  And then they measured the cries of distress.  When done, they concluded: “Functionally, administration of morphine to young puppies simulates the presence of the mother.”

In the forty years since, a line of research has emerged that has supported what Panksepp and others later called the Brain Opioid Theory of Social Attachment (BOTSA).  And, in my estimation, it provides a clear, economical understanding for what I see clinically.  The literature became even more compelling when, in 2004, Eisenberger and Lieberman examined studies on animal lesion and human brain imaging and similarly concluded the attachment system likely evolved from and mapped itself onto the brain opioid system.

Particularly interesting was that Eisenberger and Lieberman demonstrated social pain appears to utilize the same neural circuity as physical pain.  Thus, mammals would activate the pain system in order to prevent social separation.  Then, in 2011, Machin and Dunbar reviewed the literature and, while arguing the limitations of rodent research, concluded opioids may play a larger role in human sociality than even other mammals…and that we need more studies as it relates to addiction.  And other studies have only strengthened the BOTSA theory.

So can we explain the behavior of an opioid addict from an attachment theory perspective?  Well, if a new system mapped itself onto the brain opioid region because of how slowly we mature, it powerfully illuminates the pain and distress we experience when those ties are absent or breakdown.  As well, if opioids function to not just lessen pain, but also help us feel connected we have a strong rationale for why opioid addicts return to using over and over again.  Indeed, it is not dissimilar to why we think people return to any abusive relationship.

This theory would also provide a framework for treatment.  That is, we would need to consider getting sober (or clean, depending on your allegiances) not as metaphors, but as literal experiences of loss.  In this manner a sufficient mourning and grieving process needs to occur.  As well, we could anticipate the existential anxieties, so common in this population, associated with losing a loved one.  It would also validate the idea that the opioid addict, however self-destructive, felt safe with the substance and was actually seeking health.

The idea, though, of connection (and community) as a therapeutic model opposes our tendency toward increasingly specialized approaches to care.  But it has been my experience that if we hold to it as a basic need, we can better understand treatment options, such as levels of care, 12-Step and mental health paradigms, medication assisted treatments, etc.  Of course, the origins of and treatments for opioid addiction are more complicated than this.  But if an opioid addict feels connected, I know they have a chance.  And without it…

Incidentally, I find it useful to view all addictions through an “attachment” lens (even further, I find it helpful for understanding nearly all psychopathology). But I also believe they are overdetermined and can be usefully seen as a coping deficit, a conditioned behavior, a genetic vulnerability, neurobiological alterations from prolonged exposure, an expression in a family system, a spiritual malady (which, to me, is analogous to the above), a reflection of drug availability and socio-historical pressures, etc.