Inverse tolerance, or awareness, represents a counterintuitive neurobiological phenomenon, in which the effectiveness (perceived effect) of a substance increase with repeated use, also to constant or decreasing dosages. Exactly the opposite of what happens in “classic” tolerance, one of the most distinctive criteria of pathological addiction.
Awareness is therefore manifested when, with the same dose, the physiological or behavioral response to a substance is more marked than the first hires.
It is a brain and systemic adaptation that can derive from modifications in the circuits of pleasure and motivation, organic damage (as in the case of the liver in chronic alcoholism), or psychological conditions and predisposing environmental.
A clinical example: the chronic alcoholic
A patient with long history of alcoholic consumption can get drunk with much lower quantities of alcohol compared to the past. This may be due to a chronic liver damagewhich slows down the alcohol metabolism, but also to one raising awareness of brain circuits who manage gratification.
It is precisely in these cases that reverse tolerance becomes an alarm bell For an advanced phase of addiction and for a possible risk of acute poisoning.
The paradox of awareness
Reverse tolerance has been observed in different psychoactive substances: cocaine, amphetamine, opiates, alcohol and cannabis.
The evidence show how intermittent use of a substance (together with other vulnerability factors that we will see later) can lead to a greater reactivity of the dopaminergic system, in particular of the Mesolimbic circuit.
This, in turn, leads to two relevant effects:
- a Increase in “Wanting” (compulsive desire);
- a greater salience stimuli associated with substance.
In practice, places, people, emotions and even specific times can activate Craving in an intense and uncontrolled way, in an even stronger mode than that which is already observed in the case of addictions characterized by “classic” tolerance.
Causes and risk factors
Literature identifies as possible risk factors for the development of addictions characterized by the phenomenon of reverse tolerance the following:
- Intermittent use at high doses (typical of the initial phase of abuse, but also prototyping of some consumer styles);
- Chronic stress (which alters the dopaminergic circuits);
- Presence of illnesses (such as hepatopathies, neurological or psychiatric pathologies);
- Accumulation in the body (for example, the THC of cannabis);
- Cross-sensitization between different drugs.
Clinical implications: what changes in practice?
Increased risk of intoxication and overdose
When a patient develops inverse tolerance, he can in fact affect serious effects even with doses previously considered safe. This first element therefore makes crucial:
- Monitor the dosage of the substances/drugs of use/abuse (e.g. benzodiazepine) with great attention;
- Educating patients and family members on possible alarm signals (tremors, agitation, confusion even with small quantities).
Empress prevention
Awareness is persistent over time. Even after months of abstinence, a minimum exposure to a trigger for:
- Violently reactivate the reward circuits;
- Induce intense craving;
- Precipitate a fall.
Multidimensional evaluation of the user
During the assessment phase, it is important:
- Do not presume a “classic” tolerance in chronic users;
- Evaluate the liver function, the neuro-cognitive state and the chronic level of stress;
- Consider epigenetic factors and the family history of addictions.
Specific implications for psychotherapy
Cving and relapse: a phenomenon of emotional memory
The intensification of the response to the stimuli associated with the substance makes the Craving a highly emotional and difficult to manage experience.
In therapeutic practice it is therefore essential to help the patient to recognize their internal and external triggers, deconstruct the expectations it has built around the substance and create new more functional emotional regulation strategies.
Working on these aspects means building a New “language of desire”where not everything that active must necessarily be followed by a compulsive action.
In fact, awareness enhances the Cving not so much in response to the substance, but to its symbolic and relational correlates. This requires a therapeutic work centered on:
- early identification of emotional and contextual triggers;
- exploration of implicit memories associated with use;
- promotion of a emotional re -usethrough replacement and regulatory experiences.
Illusion of control and vulnerability to the return of use
Often those who have developed reverse tolerance underestimates the risks connected to the intake, even minimal.
The therapist has the task of accompanying the patient in a path of awareness of one’s functioningfacilitating a critical reading of one’s beliefs and fantasies of invulnerability.
It is a matter of offering an alternative narrative that takes into account the in progress neurocompormal changes, trying to provide the neurobiological rational of this recursive pattern.
The patient who includes and internalizes these notions, in fact, acquires a greater degree of freedom than his “compulsiveness” in the use of the substance of abuse. They will therefore be essential elements:
- A careful psychoeducationthat explains how the amplified effect is not a sign of stability but of vulnerability;
- A job on cognitive discrepancy between desire and awareness of the consequences;
- An exploration of Fantasies of omnipotence typical of the pre-related phase.
Monitoring and therapeutic continuity
Reverse tolerance does not follow a predictable curve: it can remain silent for months and suddenly reactivate itself. For this reason it is important to plan a personalized follow-upto support self-monitoring practices (such as emotional diaries or body indicators) and promote the growth of metacognitive skills that allow the patient to anticipate and face any repercussions.
It is therefore crucial to integrate:
- long -term strategiesas distanced but regular follow-ups;
- development of Metacognitive skillsso that the patient recognizes the intensification of internal signals;
- use of emotional diary as an instrument of auto-monitoring.
Therapeutic relationship as a regulation tool
For many people, the substance has long carried out a regulatory, identity or even emotional function.
In this sense, the therapeutic setting must become a new place of containment and transformation. Not only an area of care, but a real “relational environment” capable of welcoming fragility, offering resonance and building new methods of response to disorganizing internal states.
There therapeutic relationship It becomes a space in which the patient can experience a new type of regulation through the intersubjective encounter.
The ritual repetitiveness of the sessions, the reliable presence of the therapist and the possibility of verifying also disturbing emotions offer a concrete alternative to the automatic response of consumption.
Mentalization
In clinical work with sensitized people, it is particularly useful to use interventions that enhance the reflective functionlike mentalization, the shared narrative of experience and the exploration of body emotions.
The therapeutic relationship takes on a “Co-regulatory” functionwhich helps the patient (but also the therapist) to integrate his somatic, emotional and cognitive responses in a cohesive and tolerable way and to choose his behavioral response in a less reactive way.
If this is true for all psychotherapeutic paths, and therefore also for the treatment of all forms of pathological dependence, it is even more for those forms of dependence which are characterized by reverse addiction, where compulsive reactivity to hiring has also increased compared to cases of classical tolerance.
Finally, it is essential that the therapist recognizes the role that the substance played in supporting the patient, avoiding a regulatory or judgmental approach.
The therapeutic task is to accompany, with respect and patience, the progressive replacement of the substance with new relationships, practices and meanings, that make the dependence obsolete not by prohibition, but by overcoming and discovery.
Conclusion
Reverse tolerance offers a precious look at the complexity of addictions. It is a phenomenon that intertwines neurobiology and psychological functioning.
Intercept it and understand it allows you to intervene more effectivelyprevent repercussions and return to the patient a more stable and lasting reflective and regulatory capacity.
Essential bibliography
- Robinson, Te, & Berridge, KC (1993). The Neural Basis of Drug Craving: an incentive-sensitization Theory of Addiction. Brain Research Reviews18 (3), 247-291.
- Vanderschuren, Ljmj, & Pierce, RC (2010). Sensitization Processes in Drug Addiction. Current Topics in Behavoral Neurosciences3, 179–195.
- Stewart, J., & Badiani, A. (1993). Tolerance and Sensitization to the Behavoral Effects of Drugs. Behavioral Pharmacology4 (3), 289–312.
- Christie, MJ (2008). Cellular Neurodapatitions to Chronic Opioids: Tolerance, Withdrawal and Addiction. British Journal of Pharmacology154 (2), 384–396.
- Becker, JB, et al. (2013). Neurodaptivative Changes that result from Chronic Drug Exposure. In Biological Research on Addiction (Vol. 2, pp. 543–552). Academic Press.
- Wikler, A. (1976). Aspects of Tolerance to and Dependence on cannabis. Annals of the New York Academy of Sciences282, 151–162.
