Heroin addicts are sweet people.

I sometimes make this shocking statement in my lectures. I think I do it to push back against what I learned in medical school: that addicts are sociopaths. I don’t believe this. When I talk to a person struggling with addiction, I don’t hear a person who doesn’t care about the feelings in those around them. Addicts — heroin addicts especially — are exquisitely sensitive to the feelings in those around them.

A lot of parents agree with me. They’ve always known their child to be uniquely sensitive — may be too sensitive. Addicts seem possessed of a uniquely acute capacity for empathy. They’re plugged into the pain of the world. For some, it is their undoing. (About one in five parents, though, say “Uh, no. He’s always been kind of a selfish jerk.”)
So which is it? Are addicts uniquely empathic? Or commonly sociopathic?

Where do addiction, empathy, and recovery meet?

Empathy has three components: shared affect — the ability to share the feelings of another, empathic concern — my motivation to comfort another’s pain, and perspective-taking — can I see the world through the eyes of another?

My theory about empathy and addiction is this: in addicts, the first two are too strong and the third is impaired.
Perhaps what we’re seeing isn’t so much an especially developed capacity for empathy as it is a collapse of the way the brain constructs empathy. This sets up a dangerous paradox: addicts see themselves as uniquely sensitive but are blind to the ways in which they hurt the people about whom they purport to care. This is the most destructive symptom of addiction. Fortunately, it is also the most repairable. The task of recovery is to re-calibrate the addict’s capacity for empathy.
Intoxicants, especially opioids, play havoc with empathy because they disrupt my ability to accurately feel pain. The areas of my brain that process the pain I feel are also active when I observe pain felt by others. Acutely, pain relievers dampen both felt pain and observed the pain. A recent study showed that taking a single Tylenol can decrease one’s capacity for empathy. So imagine what taking heroin can do.

With chronic use, opioids can actually make the pain worse. Everything hurts—the opioid addict is hypersensitive to physical pain but also to emotional pain. There’s even a word for this phenomenon: hyperkatifeia. It is the residual hypersensitivity to emotional distress that persists long into abstinence. There is simply too much-shared effect.

The second component of empathy — empathic concern — may not be a strengthened desire to ease another person’s pain but rather an attempt to avoid intensely felt pain where the ability to distinguish self from other is compromised. This is not so much compassion as codependency. My urge is not to comfort, but to control.

If the shared affect and empathic concern components of empathy are too strong in addicts, then perspective-taking is the component that isn’t strong enough.


Much of what we call “mood” starts out not in the brain, but as signals sent to the brain by a myriad of systems in the body. Interoception is my awareness of these signals coming from my body. Heartbeat, breathing, digestion, even blood glucose level — all this information goes the brain and usually falls outside conscious awareness, although I can train myself to become conscious — or mindful — of these signals. But when interoceptive awareness fails – a condition known as alexithymia – feelings become muddled and difficult to identify. Am I sad or angry? Is this craving or hunger? My emotions, decisions, and ability to relate others all suffer.
Two areas of the brain process interoceptive signals. The Insular Cortex (IC) attaches interoceptive awareness of consciousness. Naqvi described a group of smokers who suffered strokes in their insular cortex. This damage caused them to simply forget they were smokers (they didn’t even go through nicotine withdrawal). This area of the brain has been receiving a lot of attention lately since it is active during craving brain states. This area of the brain is believed to be the key to denial and inflexible thinking that characterize addiction. I cannot take into account the opinions of those around me.

The Anterior Cingulate Cortex (ACC) links interoception to self-awareness and is a key area of the cortex for pain perception. The ACC serves as an error and conflict detection system. One kind of error is picked up are social cues: this is where I see myself through the eyes of others. If my ACC fails, I may lose my ability to understand how my addiction hurts those around me. My perspective-taking is shot. This is a terrible impairment for a person who considers themselves sensitive to the feelings of others to have.
When confronted with these deficits some addicts have a sudden “moment of clarity” that opens the door to recovery. Others suffer a flood of shame that powers their addiction further. It takes a skilled therapist (and/or sponsor) to hold up the mirror to the patient at just the right moment. Perhaps this is why contemplative practices and mindfulness-based therapies such as Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT) improve empathy and facilitate recovery from addiction. Techniques such as Neurofeedback and Somatic Experiencing improve interoceptive awareness, thus improving emotional regulation and decision-making.
As an addiction, it may not be that I am more empathic, but I still remain acutely sensitive to the feelings of others. If I can learn to control this capacity, that sensitivity and accurate empathy could be of great value to others. Recovering addicts can be some of the most gifted therapists, nurses and doctors you would ever care to meet —once we understand where the pain of the world ends and our pain begins, and gain the wisdom to know the difference.

Dr. Kevin McCauley is a Senior Fellow at Meadows Behavioral Healthcare. He first became interested in the treatment of substance use disorders while serving as a Naval Flight Surgeon, where he observed the U.S. Navy’s policy of treating addiction as a safety (not moral) issue and returning treated pilots to flight status under careful monitoring.
Dr. McCauley wrote and directed two films: Memo to Self, about the concepts of recovery management, and Pleasure Unwoven, about the neuroscience of addiction, which won the 2010 Michael Q. Ford Award for Journalism from the National Association of Addiction Treatment Providers. Dr. McCauley lives in Sedona with his wife, Kristine, who teaches third grade at the Desert Star Waldorf School. www.themeadows.com
(Printed with permission: The Meadows)