The article about the nature of addiction incorrectly described Lee N. Robins as a University of Washington sociologist. Robins is a psychiatrist at the Washington University School of Medicine in St. Louis.
So, What Made Me an Addict?
Tuesday, August 28, 2007
Many people think they know what addiction is, but despite non-experts' willingness to opine on its treatment and whether Britney or Lindsay's rehab was tough enough, the term is still a battleground. Is addiction a disease? A moral weakness? A disorder caused by drug or alcohol use, or a compulsive behavior that can also occur in relation to sex, food and maybe even video games?
As a former cocaine and heroin addict, these questions have long fascinated me. I want to know why, in three years, I went from being an Ivy League student to a daily IV drug user who weighed 80 pounds. I want to know why I got hooked, when many of my fellow drug users did not.
A bill was introduced in Congress this spring to change the name of the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction, and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) to the National Institute on Alcohol Disorders and Health. In a press release introducing the legislation, Sen. Joseph R. Biden Jr. (D-Del.) said, "By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease."
But opinion polls find weak support for the concept of addiction as a disease, despite years of advocacy by such agencies as NIDA and NIAAA and by recovery groups. A 2002 Hart poll found that most people thought alcoholism was about half disease, half weakness; just 9 percent viewed it wholly as a disease.
So what does science have to say? Addiction research has advanced dramatically since my high school years in the early 1980s, when I began using marijuana and psychedelics, then cocaine, in the hope they would relieve my social isolation. My progression from psychedelics to coke was fed by a definition of addiction that still causes widespread misunderstanding. In 1982 -- around when I first tried cocaine -- Scientific American published an article claiming it was no more addictive than potato chips. This was based on the fact that cocaine users, unlike heroin users, do not become physically sick when they try to stop taking their drug.
Addiction, by this reasoning, is a purely physiological process, one that results from drug-induced chemical changes in the brain and body. Over time, with heroin and similar drugs, the article explained, the user develops tolerance (needs more of the drug to experience the same effect) and eventually becomes physically ill if he doesn't have access to an adequate dose. Addiction, by this theory, is primarily an attempt to avoid physical withdrawal.
I bought into this idea because it was confirmed by my experience: I never had a problem stopping marijuana, LSD or mushrooms, none of which cause significant physical dependence. I expected cocaine to be similar and, therefore, safer than heroin. With no physical withdrawal to avoid, stopping should be a snap. Or so I thought.
By the time I got suspended from college for my involvement with cocaine, I was smoking it, often daily. And because I believed that my suspension meant I'd already ruined my life, I felt I had no reason not to try heroin. I just didn't care.
Heroin became my drug of choice. It calmed me, gave me distance from my obsessions and anxieties. Over time, cocaine made me feel anxious, but heroin always soothed and smoothed. I continued taking both, injecting higher and higher doses.
Today's most widely accepted definition of addiction -- used in psychiatry's latest edition of its diagnostic manual, the DSM-IV-TR -- recognizes that compulsive use of a substance despite negative consequences is key. And that's exactly what I experienced: At least six times, I made it through the physical sickness of heroin withdrawal -- the shaking, diarrhea and vomiting -- only to use again because I wanted the drug. This compulsive aspect helps explain why we can now consider video games and, yes, even potato chips more addictive than we did in the past.
But the DSM retains a focus on physical aspects of addiction: It calls addiction "substance dependence," suggesting that physical need is critical. Tolerance and withdrawal are part of the criteria used to diagnose the condition, even though pain patients taking opioids as directed may experience both and not actually be addicted. Studies find that less than 1 percent of people who take pain medications and don't have a past history of drug problems become addicted. Many pain patients who stop opioids after the source of their pain has been removed even undergo withdrawal without realizing it: It's called "hospital flu." But the vast majority have no difficulty refusing further medication.
As a result, experts -- including NIDA director Nora Volkow -- have called for the official name of the disorder to be changed from "substance dependence" to "addiction" in the next edition of the DSM. They say the confusion between physical dependence and addiction leads to under-treatment of pain: Surveys find many patients, even those who are dying, don't receive enough medication for effective relief. Physicians are even criminally prosecuted for "over-prescribing" when patients with painful conditions become physically dependent on opioid drugs.