Our addiction theories and policies are woefully
outdated. Research shows that there are no demon drugs. Nor
are addicts innately defective. Nature has supplies us all
with the ability to become hooked--and we all engage in
addictive behaviors to some degree.
Millions of Americans are apparently "hooked," not only on heroin, morphine,
amphetamines, tranquilizers, and cocaine, but also nicotine, caffeine, sugar,
steroids, work, theft, gambling, exercise, and even love and sex. The War on
Drugs alone is older than the century. In the early 1990s, the United States
spent $45 billion waging it, with no end in sight, despite every kind of
addiction treatment from psychosurgery, psychoanalysis, psychedelics, and
self-help to acupuncture, group confrontation, family therapy, hypnosis,
meditation, education and tough love.
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
"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
"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:
o 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."
o 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
o 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.
o 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.
o 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.
o The children of alcoholics have a much higher risk of alcohol abuse than
children of non-alcoholics. 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
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.
Non-alcoholics 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
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
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 oxycotin 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, non-addiction is.
Experts generally agree on the most common characteristics of addictions that
o The substance or activity that triggers them must initially cause feelings
of pleasure and changes in emotion or mood.
o The body develops a physical tolerance to the substance or activity so that
addicts must take ever-larger amounts to get the same effects.
o Removal of the drug or activity causes painful withdrawal symptoms.
o 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.
o Addiction always causes changes in the brain and mind. These include
physiological changes, chemical changes, anatomical changes, and behavioral
o 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.
o 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.
o 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
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
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
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
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
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
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. Recent 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
"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
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 dean 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 new 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
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."
A TRIAL OF PRAYER
With a $30,000 grant from the National Institutes of Health's Office of
Alternative Medicine, Scott Walker, M.D., is embarking on a study of prayer
against substance abuse. It's not that alcoholics do the praying. Outsiders
totally unknown to them will pray on their behalf.
Walker says his interest in the potential healing effects of intercessory
prayer was triggered by his own strong spiritual beliefs.
There are more than 130 trials of "spiritual healing." Daniel J. Benor, M.D.,
reports in his 1993 book Healing Research, that 56 of the trials show "statistically significant results."
"Even if a therapist is atheistic, the majority of Americans have some
spiritual or religious belief. If your patients believe, you need to address
this faith factor if there is any chance it can help them," Walker says.
In the one-year study he is conducting, Walker will work with 40 adults about
to enter a treatment program with a clinically verified substance abuse problem.
At random, half the group will receive outside prayer, the other half will not.
All subjects will have urine drug screens and careful analysis of such
factors as their treatment expectations, religious behavior, membership in
support groups, and to what degree they are contemplating sobriety, are
relapsed, and so on.
Walker is recruiting the prayers from the Albuquerque Faith Initiative. The
group will include prayers of many religions.
They will get a specific suggestion about content: Thy Will Be Done. But they
can improvise and must keep time sheets about content, duration and location of
Walker will not reveal to any of the prayers or churches which or whose
prayers did anything, if in fact that happens.
"We must absolutely minimize the possibility of any group saying it has a
direct link to God."
By: Rodgers, Joann Ellison*
Originally published by Psychology Today: Sep/Oct 94
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