There seems no end to our "dependencies," their bewildering intractability, the glib explanations for their causes and even more glib "solutions."
The news, however, is that brain, mind, and behavior specialists are re-thinking the whole notion of addiction. With help from neuroscience, molecular biology, pharmacology, psychology, and genetics, they're challenging their own hard-core assumptions and popular "certainties" and finding surprisingly common characteristics among addictions.
They're using new imaging techniques to see how addiction looks and feels and where cravings "live" in the brain and mind. They're concluding that things are far from hopeless and they are rapidly replacing conjecture with facts.
For example, scientists have learned that every animal, from the ancient hagfish to reptiles, rodents, and humans, share the same basic pleasure and "reward" circuits in the brain, circuits that all turn on when in contact with addictive substances or during pleasurable acts such as eating or orgasm. One conclusion from this evidence is that addictive behaviors are normal, a natural part of our "wiring." If they weren't, or if they were rare, nature would not have let the capacity to be addicted evolve, survive, and stick around in every living creature.
"Everyone engages in addictive behaviors to some extent because such things as eating, drinking, and sex are essential to survival and highly reinforcing," says G. Alan Marlatt, Ph.D., director of the Addictive Behaviors Research Center at the University of Washington. "We get immediate gratification from them and find them very hard to give up, indeed. That's a pretty good definition of addiction."
"The inescapable fact is that nature gave us the ability to become hooked because the brain has dearly evolved a reward system, just as it has a pain system," says physiologist and pharmacologist Steven Childers, Ph.D., of Bowman Gray School of Medicine in North Carolina. "The fact that some things may accidentally or inadvertently trigger that system is somewhat beside the point.
"Our brains didn't develop opiate receptors to tempt us with heroin addiction. The coca plant didn't develop cocaine to produce what we call crack addicts. This plant doesn't care two hoots about our brain. But heroin and cocaine addiction certainly tell us a great deal about how brains work. And how they work is that if you taste or experience something that you like, that feels good, you're reinforced to do that again. Basic drives, for food, sex, and pleasure, activate reward centers in the brain. They're part of human nature."
New Thinking, Old Problem
What we now call "addictions," in this sense, Childers says, are cases of a good and useful phenomenon taken hostage, with terrible social and medical consequences. Moreover, that insight is leading to the identification of specific areas of the brain that link feelings and behavior to reward circuits. "In the case of addictive drugs, we know that areas of the brain involved in memory and learning and with the most ancient part of our brain, the emotional brain, are the most interesting. I'm very optimistic that we will be able to develop new strategies for preventing and treating addictions."
The new concept of addiction is in sharp contrast to the conventional, frustrating, and some would say cynical view that everything causes addiction.
Ask 10 Americans what addiction is and what causes it and you might get at least 10 answers. Some will insist addiction is a failure of morality or a spiritual weakness, a sin and a crime by people who won't take responsibility for their behavior. If addicts want to self-destruct, let them. It's their fault; they choose to abuse.
For the teetotaler and politicians, it's a self-control problem; for sociologists, poverty; for educators, ignorance. Ask some psychiatrists or psychologists and you're told that personality traits, temperament, and "character" are at the root of addictive "personalities." Social-learning and cognitive-behavior theorists will tell you it's a case of conditioned response and intended or unintended reinforcement of inappropriate behaviors. The biologically oriented will say it's all in the genes and heredity; anthropologists that it's culturally determined. And Dan Quayle will blame it on the breakdown of family values.
The most popular "theory," however, is that addictive behaviors are diseases. In this view, an addict, like a cancer patient or a diabetic, either has it or does not have it. Popularized by Alcoholics Anonymous, the disease theory holds that addictions are irreversible, constitutional, and altogether abnormal and that the only appropriate treatment is total avoidance of the alcohol or other substance, lifelong abstinence, and constant vigilance.
Absolving The Diseased
The problem with all of these theories and models is that they lead to control measures doomed to failure by mixing up the process of addiction with its impact. Worse, from the scientific standpoint, they don't hold up to the tests of observation, time, and consistent utility. They don't explain much and they don't account for a lot. For example:
- Not all drugs of abuse create dependence. LSD and other hallucinogens, caffeine, and tranquilizers are examples. Rats, for example, which can be easily addicted to heroin and cocaine just like humans, "just can't appreciate a psychedelic experience," notes Childers. "The same is true of marijuana and caffeine; it's hard to get animals to take them. People take these drugs for different reasons, not to feel pleasure."
At the same time, rats and other animals can become physically dependent on alcohol, but won't seek out alcohol even when they are in convulsions of withdrawal. Says Jack Henningfield, Ph.D., an addiction researcher at the National Institute of Drug Abuse in Baltimore, "we can get rats physically dependent on alcohol and even get them to go through DTs by withdrawing them. But we can't get them to crave alcohol naturally." Apparently, they have to learn, to be taught to want it. "Only when we give them the rat equivalent of smoke-filled rooms, soft jazz, and other rewards will they seek out alcohol."
- Some substances with dearly addictive properties are almost universally used and socially acceptable. Giving up coffee and colas containing caffeine can yield rapid heart beats, sweating, irritability, and headaches—markers of withdrawal.
- People can experience withdrawal syndromes with drugs that don't addict them or make them physically or psychologically dependent. Postsurgical morphine is always withdrawn gradually in the hospital, but most people who get morphine still undergo so-called white flu—flu-like symptoms after they leave the hospital. They are actually undergoing withdrawal symptoms, but they have not become dependent on or addicted to the morphine. There is also no evidence that terminal cancer patients in severe pain get "high" on heavy doses of morphine, although they do become dependent.
- Some drugs of abuse produce tolerance and some don't. Heroin addicts need more and more of it to avoid withdrawal symptoms. Cocaine produces no tolerance, yet most would say cocaine is far more addictive because craving accelerates to sometimes lethal doses. If permitted, lab rats will continue to take cocaine until they die.
- Some people, notably celebrities, check in regularly at the Betty Ford Center to overcome addiction to painkillers, alcohol, and barbiturates. Yet one of the most famous studies on Vietnam veterans shows that very few of those who returned addicted to heroin stayed addicted. Lots of planning went on for intensive treatment for them. But on follow-up back home, their rate of continuing addiction dropped to levels no different than those of the general population, despite their exposure to lots of drugs, stress, high-risk environments, youth, and other risk factors that predicted a serious addiction epidemic. They had no trouble for the most part leaving their addictions behind in the jungles, while in the U.S., relapses are legendary and widespread.
For decades, we've sent heroin addicts to Lexington, Kentucky, for treatment in an isolated treatment facility; the idea was to remove them for long periods from their conducive environments. Almost all got "clean" and stayed that way, but when released, still sought out their old haunts and relapsed. Yet the majority of people living in drug-infested cultures never get addicted.
- The children of alcoholics have a much higher risk of alcohol abuse than children of nonalcoholics. Some studies show that alcoholics have an enzyme abnormality related to alcohol activity that doesn't seem to exist in people who've never had a drink. Yet some people who are classic alcoholics can and do learn to drink moderately and safely. Others quit even when they know they can drink moderately.
Debunking The Domino Theory
"I began to understand the bankruptcy of many addiction theories when a lot of my predictions about alcoholism and treatment for it were dead wrong," says William R. Miller, Ph.D. A professor of psychology and psychiatry and director of the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico, his controversial studies of "controlled drinking" in the early 1970s were among the first to dash with the "disease" theory of addictions.
"I developed a reasonably successful program that taught alcoholics how to drink moderately. Lots of them eventually totally quit and became abstainers. I would never have predicted that. The prevalent theories were that they would either eventually relapse and lose control of their drinking or that they would quit because moderation did not work. We knew from blood and urine tests that they were able to moderate but quit anyhow. The old domino theory that one drink equals a drunk proved, for some, to be baloney. We know with cigarette smoking and alcohol and other addictive behaviors that moderation, tapering, and 'warm turkey' can be very effective." Miller blames mostly the persistent strength of the addiction-as-disease concept on the peculiarly American experience with alcohol and Prohibition.
"During Prohibition, alcohol was marked as completely dangerous and the message was that no one could use it safely. At the end of Prohibition, we had a problem: a cognitive dissonance. Clearly many people could use it safely, so we needed a new model to make drinking permissible again. That led to the idea that only 'some' people can't handle it, those who have a disease called alcoholism."
Everyone likes this model, Miller says. People with alcohol problems like it because they get special status as victims of a disease and get treatment. Nonalcoholics like it because they can tell themselves they don't need to worry if they don't have the "disease." The treatment industry loves it because there's money to be made, and the liquor industry loves it because under this theory, it's not alcohol that's the problem but the alcoholic.
"What's really bizarre," says Miller, "is that the alcohol beverage industry spends a lot of money to help teach us about the disease model. It's the inverse of the temperance movement, which many now laugh at, but which saw alcohol more realistically as a dangerous drug. It is."
Today, Miller notes, heroin and cocaine are looked upon the way the temperance movement once looked on alcohol. "Ironically, too," he says, "we are treating nicotine and gluttony the way we once treated alcohol. It's easy to see how the disease model and all other single-cause theories of addiction can lead to blind alleys and bad treatments in which therapists adopt every fad and reach into a bulging bag of tricks for whatever is in hand or intuitively meets the immediate moment. But what we wind up with are three myths about alcoholism and other addictions: that nothing works, that one particular approach is superior to all others, and that everything works about equally well. That's nonsense."
No Easy Targets
"The most likely truth about addiction is that it's not a single, basic mechanism, but several problems we label 'addiction,'" says Michael F. Cataldo, Ph.D., chief of behavioral psychology at Johns Hopkins Medical Institutes. "No one thing explains addiction," echoes Miller. "There are things about individuals, about the environment in which they live, and about the substances involved that must be factored in." Experts today prefer the term "addictive behaviors," rather than addiction, to underscore their belief that while everyone has the capacity for addiction, it's what people do that should drive treatment.
So while all addictions display common properties, the proportions of those factors vary widely. And certainly not all addictions have the same effect on the quality of our lives or capacity to be dangerous. Everyday bad habits, compulsions, dependencies, and cravings dearly have something in common with heroin and cocaine addiction, in terms of their mechanisms and triggers. But what about people who are Type A personalities; who eat chocolate every day; who, like Microsoft's Bill Gates, focus almost pathologically on work; who feel compelled to expose themselves in public, seek thrills like racecar driving and fire fighting, or obsess constantly over hand washing, hair twirling, or playing video games. They have—from the standpoint of what their behavior actually means to themselves and others—very little in common with heroin and crack addicts.
Or consider two of the more fascinating candidates for addiction—sex and love. Anthropologist Helen Fisher, Ph.D., of the American Museum of Natural History, suggests that the initial rush of arousal and romantic, erotic love, the "chemistry" that hooks a couple to each other, produces effects in the brain parallel to what happens when a brain is exposed to morphine or amphetamines.
In the case of love, the reactions involve chemicals such as endorphins, the brain's own opiates, and oxytocin and vasopressin, naturally occurring hormones linked to male and female bonding. After a while, though, this effect diminishes as the brain's receptor sites for these chemicals become overloaded and thus desensitized. Tolerance occurs; attachment wanes and sets up the mind for separation, so that the "addicted" man or woman is ready to pursue the high elsewhere. In this scenario, divorce or adultery becomes the equivalent of drug-seeking behavior, addicts craving for the high. According to Fisher, the fact that most people stay married is "a triumph of culture over nature," much the way, perhaps, nonaddiction is.
Experts generally agree on the most common characteristics of addictions that trouble society:
- The substance or activity that triggers them must initially cause feelings of pleasure and changes in emotion or mood.
- The body develops a physical tolerance to the substance or activity so that addicts must take ever-larger amounts to get the same effects.
- Removal of the drug or activity causes painful withdrawal symptoms.
- Quite apart from physical tolerance, addiction involves physical and psychological dependence associated with craving that is independent of the need to avoid the pain of withdrawal.
- Addiction always causes changes in the brain and mind. These include physiological changes, chemical changes, anatomical changes, and behavioral changes.
- Addiction requires a prior experience with a substance or behavior. The first contact with the substance or activity is an initiation that may or may not lead to addiction, but must occur in order to set in motion the effects in the brain that are likely to encourage a person to try that experience again.
- Addictions cause repeated behavioral problems, take a lot of a person's time and energy, are openly sanctioned by the community, and are marked by a gradual obsession with the drug or behavior.
- Addictions develop their own motivations. For addicts, their tolerance and dependence in and of themselves become reinforcing and rewarding, independent of their actual use of the drug or the "high" they may get. "One way of understanding this," says Cataldo, "is to analyze what is happening behaviorally in withdrawal. Given that withdrawal is so punishing, why do addicts let themselves go through it more than once? One answer is that the withdrawal, when combined with relapse and returning to the use of the substance, itself may be 'rewarding.'"
Hair Of The Dog
The withdrawal and relapse cycle suggests that like any behavior, the addict "gets something out of" the pain of withdrawal—attention, perhaps, or help. But, in any case, enough so that he not only is willing to do it again, but also may seek out the cycle the way he once sought out the drug.
In gambling addictions and certain eating disorders, particularly, says Toni Farrenkopf, Ph.D., a Seattle psychologist, the "rush" for the addict often comes from pursuit of the activity after "getting clean and clear" for a while, along with eluding police, spouses, parents, bill collectors, and employers.
"We know this is the case with animals we can train to do something, even if they never get a positive reward out of it," Cataldo says. The "reward" is escape from or absence of an electric shock or punishment, even if it's only occasional escape or unpredictable escape. The cocaine addict may be addicted to the pursuit of cocaine and stealing to get money to buy the drug; using coke may be secondary to the reward of not getting caught and the "high" of pursuing the drug life-style.
If addictions have characteristics in common, so do addicts, the experts say.
They have particular vulnerabilities or susceptibilities, opportunity to have contact with the substance or activity that will addict them, and a risk of relapse no matter how successfully they are treated. They tend to be risk takers and thrill seekers and expect to have a positive reaction to their substance of abuse before they use it.
Addicts have distinct preferences for one substance over another and for how they use the substance of abuse. They have problems with self-regulation and impulse control, tend to use drugs as a substitute for coping strategies in dealing with both stress and their everyday lives in general, and don't seek "escape" so much as a way to manage their lives. Finally, addicts tend to have higher-than-normal capacity for such drugs. Alcoholics, for example, often can drink friends "under the table" and appear somewhat normal, even drive (not safely) on doses of alcohol that would put most people to sleep or kill them.
The biological, psychological, and social process by which addictions occur also have common pathways, but with complicated loops and detours. All addictions appear now to have roots in genetic susceptibilities and biological traits. But like all human and animal behaviors, including eating, sleeping, and learning, addictive behavior takes a lot of handling. The end product is a bit like Mozart's talent: If he'd never come in contact with a piano or with music, it's unlikely he would have expressed his musical gifts.
Floyd E. Bloom, M.D., chairman of neuropharmacology at the Scripps Clinical and Research Foundation in La Jolla, California, once gave a talk called "The Bane of Pain Is Mainly in the Brain." His point was that both pain and pain relief occur in the brain, triggered by the release, control, uptake, and quantity of assorted brain chemicals and other natural substances. The same might be said for addiction. Regardless of the source of addiction, the effects are "mainly in the brain," physically, chemically, and psychologically affecting emotions and energy levels.
The new view of addiction ties together biology, chemistry, behavior, and emotions in the brain. Among others, Edythe London, Ph.D., chief of neuroimaging and the drug-action section of NIDA, has conducted experiments demonstrating that such links are in fact formed and offering some clues as to how that happens.
In her work, the first of its kind funded by the Office of National Drug Control Policy, she is using positron emission tomographic (PET) scans to figure out how drugs and behaviors produce the rewards that create addicts and keep them addicted even when the euphoria ends, the tolerance builds, and the withdrawals occur. She is homing in on areas of the brain where craving lives both neurochemically and psychologically.
PET scans measure the brain's uptake of glucose, the principal source of energy used by the brain to function, and locate areas of the brain affected by various experiences. By tagging glucose molecules with radioactive and other "tracers," scientist like London can watch the brain react to stimuli such as and work.
In early studies, she and her colleagues gave addictive drugs under carefully controlled conditions to addicts and gauged their mood and feelings while monitoring the rate of glucose use. "The surprising thing we found is that all drugs of abuse—even those that differ radically in structure such as morphine and cocaine—do the same thing. They reduce use of glucose in the brain, so providing a way to observe which areas of the brain are involved in specific psychological effects. The amount of glucose used in certain parts of the brain's cortex, moreover, was closely related to how good people felt, regardless of where any drug binds.
London says this common pathway of reduced brain metabolism should not really have surprised her. "If you think about it, it makes sense," she says, "because glucose is an index of brain activity and brain activity in any given area is a function of not only what drugs are binding right there, but of nerve connections feeding into that area. The final picture of drug action usually looks quite different than the pattern of where a drug binds. That's because the brain is a highly interconnected organ. Clearly, if a drug acts on dopamine-neurotransmitter systems in part of the limbic brain initially, it's easy to see that there would be wider distribution through the brain's networks and that the impact of the drug could be very diffuse and varied."
So far, London and others have seen this reduction in glucose use with morphine, cocaine, nicotine, buprenorphine (a treatment for opiate addicts), amphetamine, benzodiazepine, barbiturates, and alcohol. "All drugs of abuse do this."
From these studies, London moved on to experiments designed to show that an addict's brain is permanently different from what it was before and after the initial exposure. "I wanted to know where craving lived in the brain," she says.
Her first idea was wrong. "I thought that drug addicts had the same kind of situation as people with obsessive-compulsive disorder (OCD) in terms of where the brain was affected," she says, "because all OCD victims, like drug abusers, had a lack of impulse control. Studies had shown that they had disorders of the orbital frontal cortex, the part of the brain near the temple, and that's where I went looking."
She conducted experiments in which she gave a lot of drug-related cues—but not drugs—to cocaine addicts. These cues included videotapes showing crack houses, mounds of white powder, $10 bills, and people "high." "We thought that would make them crave the drug and we'd be able to see glucose use diminish in the orbital frontal cortex."
The bad news was that the orbital frontal cortex showed nothing. The good news was that they got a "pretty dramatic effect" in two other areas of the brain, the amygdala and the hippocampus.
The hippocampus is a bundle of fibers linked to learning and short-term memory and carries signals in and around the limbic system, forming electrochemical junctions for the emotional seat of the brain. The amygdala, located in the lower arc of the limbic system, is the seat of "fight or flight" reactions, and impairment or injury can lead to profound behavior changes. There is also evidence that the amygdala has a role in recalling pleasant or painful consequences of experiences and damage to this may flatten or remove some of this recall.
London hasn't entirely abandoned her notion that the orbital frontal cortex also is involved in addicts' recall of their drug experience and the onset of craving. Research suggests this part of the brain may be the anatomical location of "source memory," the place that helps people remember when and where and how a memory was formed, or whether it is a "real" memory at all.
London says she is convinced that addiction takes place in stages and requires not only initiation to a substance or to an activity that brings great pleasure, physically and/or psychologically, but also creation of nondrug "incentives" to keep using the drug and craving it. The incentives include the creation of memories—via the creation of neural pathways—of the pleasure and good mood and the excitement of getting the drug, preparing it, or sharing it with others.
"What we're talking about is like conditioning," says London. "Over time, events that happen concurrently with the euphoria begin to contribute to the drug experience and are involved in a sensitization process. They too probably produce a biochemical effect in the brain and become very important in the addiction process."
If that happens, it goes a long way to explaining why relapse rates are so high, even for addicts who are "detoxified" and off drugs for long periods. Even when people clean up their act and stay clean for some time, they are still very vulnerable and this may have something to do not only with receptor sites and neurotransmitters, but also with biochemical processes that produce long-term, stored memories of the drug experience. Says London: "In my view, biochemical and psychological memories act in the same way. What we're talking about is learning at the molecular level—and the reason that addicts, long after they are free of a drug, can experience intense craving when presented with stimuli—even photographs or sounds—that remind them of the drug experience."
If there is a hitch in this picture of addiction it is that it is far from simple. It is also politically incorrect, unlikely to make the "Just Say No" and "law and order" crowd very happy. But it is putting solid foundations under prevention and treatment programs and promising entirely new strategies to combat drug abuse. The implications of this new view of addiction are in fact profound for treatment, prevention, and public policy.
L.H.R. Drew, an Australian addiction expert, notes that "if the idea prevails that drug use—and more particularly drug addiction—is a special type of behavior which is highly contagious, irreversible, inevitably leads to disease, and is due to the special seductive properties of certain drugs, then our approach to reducing drug problems is not going to change. If, however, the ideas prevail that drug use is more similar than different to other behaviors and that there is little that is special about drug addiction compared with other addictions that are universally experienced, then the drug hysteria may abate and a rational approach to policies to reduce drug problems may be possible. It must be known that people get into trouble with drugs in the same way that they do with many other things... particularly behaviors giving short-term rewards."
In the new view of addiction, says Childers, people vary in their ability to manage problems and pleasures, "but we must recognize that we all share the same circuits of pleasure, rewards, and pain. Anyone who takes cocaine will enjoy it; anyone who has sex will enjoy it. There is nothing abnormal about getting high on cocaine. Everyone will. There is a natural basis of addiction and we need to get away from the concept that only bad or weak or diseased people have problems with addiction. Telling someone to 'just say no' is like telling someone to just say no to eating and drinking and sex. We must begin to see how very human and very hard this is. But it is far from hopeless."