By Maia Szalavitz
Special to The Washington Post
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.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.Stigma-Proofing Addiction
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).