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.
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So, What Made Me an Addict?
Your Brain on Dope
But if physical symptoms don't define addiction, does it follow that addiction is a brain disorder? Matters are murky here as well.
While researchers have argued that addiction is a disease because drugs change the brain, the fact is, most users -- even of drugs such as heroin -- do not become addicted. While 50 percent of American soldiers in Vietnam tried heroin or opium, only 10 percent continued to use such drugs after returning home, and just 1 percent became long-term opioid addicts, according to a federally funded study by University of Washington sociologist Lee Robins.
Further, all brain changes are not indicative of disease. Learning itself changes the brain. FMRI brain scans of London taxi drivers and virtuoso violinists show changes that embody the effects of years of practice in relevant brain regions -- however, no one argues that this means they are ill.
As a result, scans alone cannot prove that addiction is a disease. "The idea that fMRIs can explain addiction is based on the same unscientific grounds as phrenology," says psychologist Stanton Peele, a longtime opponent of seeing addiction as a disease and author of the new book "Addiction-Proof Your Child."
In my own experience, I stopped using when addiction threatened my core values. On my last day taking heroin, I found myself considering seducing a man to get drugs. Because I despised this guy and had a serious boyfriend, I was shocked that I would consider it: I knew that that was addictive behavior. At that point, my personal definition of an addict was someone who violates her own principles to get drugs. I sought treatment the next day and never used cocaine or heroin again.
In Peele's view, addiction is a bad habit, a learned behavior that gets out of hand, an exaggeration of the human tendency to put off pain in favor of immediate pleasure. Even, in some instances, a rational choice when life presents little opportunity for connection, purpose or joy.
Volkow disagrees. She has pioneered brain-imaging research on addictions, looking for ways in which they differ from ordinary learning. "Drugs of abuse affect multiple systems, not just those involved with learning and memory," she says, adding that they interfere with regions that put the brakes on unwanted behavior.
"What happens in the brain of the addicted person is equivalent to a state of deprivation. It changes the brain from operating in a situation where someone has a choice and does something because he wants to do it to a situation where it feels like need," she says.
That, too, comports with my experience: Cocaine seemed to affect my motivation, leading me to take more even when I knew it would fuel a burst of paranoia, not euphoria. While at first it brightened and enhanced other joys, over time it sucked the pleasure and color out of my life. But although I could consciously see this, I felt I couldn't stop.
Another relevant factor seems to have been my youth: We now know that the frontal cortex, the seat of judgment, the region that should apply the brakes, is not fully developed until the early to mid-20s. I quit at 23; when I look back on my behavior now, the sheer stupidity of some of the risks I took shocks me. Genetic research also suggests that certain people are more prone to addiction, particularly those with other mental illnesses such as depression, a condition I also have.
So does that make it a disease? Some would argue that my response to treatment proves it. I underwent seven days of detox, 30 days of rehab, then three months in a halfway house and ongoing self-help support. Later, antidepressant medication helped reduce the distress that I'd previously self-medicated with heroin.
As Thomas McLellan, chief executive of the Treatment Research Institute in Philadelphia and professor of psychiatry at the University of Pennsylvania, notes, treatment for addiction is as effective as treatment for other chronic diseases that involve lifestyle change, such as diabetes and asthma.
Just calling it a disease, however, may not reduce the moral stigma tied to addiction -- as some hope. University of Nevada psychologist Steven Hayes is studying people's unconscious responses to words. "Disease" was as stigmatizing overall as clearly pejorative terms such as "drunk," and was more stigmatizing overall than such terms as "addict" and "intoxicated," he says.
Consider the historical treatment of people with epilepsy or "madness." Or the fact that we think "tough" rehabs are good, despite evidence suggesting otherwise -- though we wouldn't even contemplate "getting tough" with diabetics. Says McLellan: "Yes, people with epilepsy were sent to priests and shamans, too -- but that was the 18th century. Addicted people are still told to get religion."
The program I attended, for example, told me that I would not recover if I didn't surrender to a higher power, make amends and pray. This is not how most diseases are treated.
Further, labeling people with a brain disease characterized by lack of self-control can have negative consequences, particularly for adolescent users, most of whom are not addicts, suggest NIDA surveys and other research. In many teen rehabs, youths are told that they have "chronic, progressive" illness with a 90 percent chance of relapse. Forcing teens, whose identity is not fully formed, to accept an "addict" identity can be a self-fulfilling prophecy.
As Peele points out, "Self-efficacy and the image of the ability to control oneself are critical to recovery" -- as they are to maturation. For the same reason, it's a bad idea to tell people that without treatment, recovery is impossible. In fact, most addicts who recover do so without treatment. Among those who relapse, belief in the disease model is predictive of greater severity, research shows.
So is addiction disease or learned behavior? Given its complexity, some experts say, what probably matters most is which view best yields compassionate and effective treatment.
Maia Szalavitz is a senior fellow at Stats.org and the author, with Bruce D. Perry, of "The Boy Who Was Raised as a Dog and Other Stories From a Child Psychiatrist's Notebook" (Basic Books) and the author of "Help at Any Cost: How the Troubled Teen Industry Cons Parents and Hurts Kids" (Riverhead).