Why Addiction is Not a Disease
Addiction results…from the motivated repetition of the same thoughts and behaviours until they become habitual. Thus, addiction develops-it’s learned-but it’s learned more deeply and often more quickly than most other habits, due to a narrowing tunnel of attention and attraction.
One: Defining Addiction – A battleground of Opinions
The fact is that we in the West embrace the logic of pigeonholing problems, givin gthem unique names, and finding technical solutions-the more targeted the better-for alleviating them. That is, to a T, the logic of Western medicine.
Here are the specifics. According to the National Institute on Drug Abuse (NIDA-a component of NIH), “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
Most of the recovered addicts I’ve talked to would rather think of themselves as free-not cured, not in remission. Having overcome their addictions by dint of hard work, intense self-examination, and the courage and capaicty to regrow their perspectives (and their synapses), they’d rather see themselves as having developed through addiction and become stronger as a result. Neuroscientific findings actually support this intuition-once neuroscience stesp away from the funding priorities set by the medical mainstream (e.g., NIDA). And that’s another reason I’m writing this book: to give addicts what they need, and what they deserve, by interpreting the scientific data in a way that actually corresponds with their experience of what they’ve ben trhough and their sense of who they are. Science, meet subjective experience. Subjective experience, meet science. I’d like you two to try to get along.
Addicts seeking treatment, or those coerced into treatment by the justice system, are compelled to follow a recipe for recovery targeted to what is viewed as their disease, independent of their personal beliefs, which are foten dismissed as irrelevant. If they do not follow the recipe, they may be denied any treatment at all, a policy that is fundamentally at odds with offical twelve-step literature (though some twelve-step groups adopt the same punitive methods). For many addicts, this pressure tactic is a deal breaker, and that helps explain the acrimonious tone of the criticisms expressed by those who’ve quit or been excluded from twelve-step-based care.
There are other ways in which twelve-step practice has helped erect barriers while attempting to relieve suffering. First, the AA framework and the medical notion of disease share the core assumption that addiction is a lifelong disorder and total abstinence is necessary to arrest it. The graded (e.g., occasional, social) use of any substance is deemed self-destructive, inevitably leading to relapse. This position often strikes former addicts as exaggerated and untenable, and epidemiological research shows that many recovered alcoholics are capable of social drinking. … Second, the collaboration between the twelve-step movement and institutional thinking asserts the need for treatment through recognized programs. This policy discourages addicts from finding their own way to recovery, and it blocks their access to benefits that might help pay for alternative resources. Moreover, it ignores compelling data, collected by a variety of independent organizations, …showing that most addicts and alcoholics do recover, and that a majority of those-up to three-quarters, depending on where you get your statistics-recover without any treatment. Third, twelve-step literature maintains that the disease of addiction is built into one’s character. Experts including Stanton Peele have shown how destructive this attribution can be, especially for young people whose identities are still in question.
Finally, and most troubling, is the confusion that surrounds AA’s emphasis on recognizing one’s “powerlessness” as a condition for overcoming addiction. For those helped by twelve-step methods, powerlessness is usually viewed as a hinge point for surrendering unworkable strategies and admitting that one has to start over and revamp one’s design for quitting. However, others interpret the emphasis on powerlessness as suggesting ongoing helplessness, perhaps because their thinking has been distorted by sumissioin to a set of impersonal rules imposed by the courts, institutional policies, or overly severe group leaders. As I noted earlier, many experts highlight the value of empowerment for overcoming addiction. In fact, most former addcits claim that empowerment, not powerlessness, was essential to them, especially in the latter stages of their recovery. Sensitivity to the meaning of empowerment in recovery may be greatest for those who’ve been disempowered in their social world, including women, inorities, the poor, and those with devastating family histories.
Harvard researcher Gene Heyman reframed addiction as a “disorder of choice” in the 2009 book Addiction: A Disorder of ChoiceI. More recently Heyman traced a “natural” (i.e., developmental) time frame of recovery for each of four addictive drugs: pot, alcohol, cocaine, and tobacco. It’s hard to square that kind of schedule with the notion of a disease that requires treatment. According to some experts, the best evidence against the disease model comes from the study of heroin-addicted veterans of the Vietnam War, about 75 percent of whom kicked the habit once they returned home. A number of us view this heartening statistic as a human counterpart to what Bruce Alexander demonstrated in his classic “Rat Park” studies.
To repeat: proponents of the disease model argue that addiction changes the brain. And they’re right. It does. But the brain changes anyway, at every level: gene expression, cell density, the concentration and location of synapses and their fibres, even the size and shape of the cortex itself. Of course, neuroscientists who subscribe to the disease model must know that brains change with learning and development. So they must view the brain change that accompanies addiction as extreme or pathological. In fact, they would have to show exactly that in order to be convincing. They would have to show that the kind (or extent or location) of brain change characteristic of addiction is nothing like what we see in normal learning and development, or even in the more extreme transitions people go through when they fall in love or have children. But that’s where they step onto thin ice. The kind of brain changes seen in addiction also show up when people become absorbed in a sport, join a political movement, or become obsessed with their sweetheart or their kids. The brain contains only a few major traffic routes for goal seeking. Like the main streets of a busy city,the same routes get dug up and paved over time and time again, no matter who’s in charge.
Brain disease may be useful metaphor for how addiction seems, but it’s not a sensible explanation for how addiction works.
Two: A Brain Designed for Addiction
So reptile brains are almost entirely prefabricated. But human brains require extensive cellular changes, from before birth to the end of our lives, in order to function at all. Most of these changes take place in two broadly defined areas. The first is the cerebral cortex, that vast surface of braided greyish brown matter that covers the innards of the brain with networks of “programmable” cells. The second is the so-called limbic system, which includes the amygdala, hippocampus, and striatum-regions that play a major role in emotion, memory, and goal pursuit. Cells in these regions are also programmable for the most part.The more than twenty billion neurons in the cortex and limbic system aren’t told which other cells to connect with when we’re in the womb. Although the initial placement of neurons is similar for all human brains, the connections among them-the synapses, which number in the trillions-are designed to change radically. They do this throughout life, in response to our experiences. And each wave of synaptic change alters the way we experience things.
The brain is certainly built to make any action, repeated enough times, into a compulsion. But the emotional heart of addiction-in a word, desire-makes compulsion inevitable, because unslaked desire is the springboard to repetition, and repetition is the key to compulsion.
The emotional intensity of the experience, the degree of focus and concentration, and the recurrence of that experience over time are usually what make the difference between simple experience and learning. If your boss’s recent remark sent a flock of molecules from neuron X to neuron Y, enough to change its firing rate, then you are likly to perceive something: there he goes again. But if that remark was caustic, or upsetting, or heard once too often, then the connection between those two neurons is likely to be strengthened, so even more molecules will cross between them the next time around-the next time your boss says something even slightly unkind. That’s brain change.
Three: When Craving Comes to Power
Researchers used to talk about this machinery as the “pleasure circuit”-but it turns out that our intense pursuit of goals, like sex, heroin, and chocolate cheesecake, has a lot more to do with desire than with pleasure. Wanting something is not the same as liking something, and most of the accumbens is devoted to wanting. Pleasure is a pasty puff, a dessert, a flash in the pan. Desire is what gets us moving, whether that means calling your dealer, driving to the liquor store, or stealing twenty bucks from your aunt’s purse. Dopamine-at least where it’s absorbed in the striatum-is the fuel of desire, not fun.
Four: the Tunnel of Attention – Brian’s Romance with Meth
But the biggest change in Brian’s life was the way its fundamental patterning shifted to some sci-fi scenario-from a rising and falling line that moved through dark and light phases, sleep and wakefulness to some unearthly orbit where day and night were irrelevant, artificial constructions. Meth was like a sun that was always at the centre of his trajectory. It was never further away than the next thought. And living life in orbit changes the way you get from hour to hour and day to day. Wanting is one thing. Even needing it-yes, he needed it; he’d admit that. But this constant tugging at his thoughts, at the atoms of his attention…this went beyond wanting and needing. This was a cognitive mutation. And because he could get it whenever he wanted, the biggest problem was that he usually wanted it right now.
In fact, what we see is a brain that is in the throes of strong emotion, while making its way in a social world characterized by conflict and contradiction. (A fairly typical word, especially for addicts.) We are designed to connect the many components of cognition with feeling itself. The triumvirate of the amygdala, OFC, and accumbens-the motivational core of the brain-evolved precisely for the purpose of linking congition with emotion, thought with feeling, and then putting the best available plan into action.
The accumbense evolved to get the animal to go for low-hanging fruit, available sexual partners, whatever is most accessible-a habit it has kept to this day. Dopamine rises with anticipation, rushing in to rev up the accumbens, when rewards are just around the corner. So dopamine (in the striatum) is, once again, the villain here. Its hypnotic attraction to immediate goodies distorts the perspective we could have (otherwise) achieved using our more advanced cognitive abilities. We are so famliar with this built-in bias that we’d be surprised and disappointed if Hollywood lovers didn’t rush into each other’s arms with stunning velocity. We lunge for the immediate. Which makes life tricky for lovers and addicts both.
Perhaps Brian could now imagine a future self valuable enough to pursue-a future self valuable enough to pursue-a future self that was a continuation of the thoughtful, insightful self he was now becoming. A self that formed an unbroken path from his childhood to the rest of his life. And because he’d stopped using regularly, the disconnect between the dorsal regions of his prefrontal cortex and his striatum could reverse, reknit, regrow. Perspective could regain its foothold and get stronger with time.