The Anatomy of Addiction (2 page)

S
everal years ago, I was a speaker at a conference about addiction medicine during which I called for change in how we think of addicts. If we accept the irrefutable science that drug addiction is a disease, then it follows that we must stop criminalizing addicts' behaviors. Imagine if we criminalized the behavior of other sufferers of leading chronic diseases? Our jails would be filled with people diagnosed with cancer, heart disease, diabetes, and asthma.

After my talk, a gentleman approached me and introduced himself as an agent with the federal Drug Enforcement Agency (DEA). He recounted the story of one of his arrests that continued to haunt him. A heroin pusher had plea-bargained his charge of possession by agreeing to finger accomplices. He identified a couple and, sure enough, a search warrant of their home turned up a couple dozen packages of heroin.

So what was the problem? Their arrest removed dangerous criminals from the streets of Los Angeles, right? In reality, the couple was anything but the stereotype of most people's idea of “heroin addicts.” According to the detective, you would have never guessed by looking at the perpetrators that they were abusing drugs. They appeared to be and, in fact, were a middle-class couple living in a nice three-bedroom middle-class home, both holding steady jobs, and neither having been previously arrested for a violent crime.

They were also parents to two young children—a four-year-old girl and seven-year-old boy.

After the man's arrest and conviction (he took the blame), he went to jail, essentially, forever. The woman, depressed and no longer able to get her regular opiate fix, committed suicide. Their kids ended up in foster care.

Even after many years, clearly the detective remained distraught at the havoc his by-the-book arrest had caused to this family. “If I could do it over again, I'd make sure this time that I never found any heroin,” he said with conviction. Welcome to the often heart-breaking world of addiction in America.

The Truth About Addiction

In another more just and humane world, the couple at the center of this real-life tragedy would have been diagnosed as having the chronic disease of addiction and provided medical help to end their substance abuse. After a successful evidence-based treatment program, they would have returned to normal, productive
lives but without the crutch of substance abuse and the constant fear and stress of being arrested.

Indeed, decades of basic laboratory science have revealed that addiction is a bona fide medical problem involving profound brain alterations. Alcohol, opiates, cocaine, and other substances increase levels of the chemical dopamine in the reward pathway of the brain. With the advent of MRI technology in the late 1970s, we could actually see with our own eyes how addiction depleted baseline dopamine levels, with the net result being a less pleasurable high, requiring ever-larger doses.

Scientifically controlled research studies have revealed that even when people are weaned from a drug, their brains don't return to normal. So such people remain vulnerable to the drug's draw and suffer mood swings and profound urges to use again.

Such findings have been published in science journals at a prodigious rate since the early 2000s, adding weight to the position taken by National Institute on Drug Abuse chief Nora Volkow that “addiction is a chronic disorder that will require multiple rounds of therapy to reduce the risk of relapse and to lengthen drug-free intervals.”

In the mid-1990s, a coalition of doctors, scientists, and leading government organizations, including the American Medical Association and the American Psychiatric Association, began pushing for broad recognition of addiction as a disease and advocating more medical approaches to therapy. Gil Kerlikowske, former director of the Office of National Drug Control Policy and President Barack Obama's former top adviser on drug policy, lent clarity to the effort by declaring that addiction “is not a moral
failing on the part of the individual. It's a chronic disease of the brain that can be treated.”

Despite all the progress in understanding addiction and how to treat it with evidence-based medicine, consider these sobering facts from an in-depth report released by Columbia University in 2013:

• About 21 million Americans have a substance abuse disorder for which they need, but are not receiving, evidence-based addiction treatment.

• Deaths from drug overdoses now exceed traffic fatalities.

• About 55 percent of all prisoners in federal prisons are there for drug-related offenses.

• Nine out of ten people addicted to drugs other than nicotine receive no treatment.

• Most of those who do get treatment are put through unproven programs run by people without medical training.

The Strange History of Addiction in the United States

What accounts for the discrepancy between the availability of modern-day treatment of addiction and its meager use? There are several interrelated reasons, but all have to do with the shame and ignorance surrounding addiction.

First and foremost, public opinion about addiction has not yet caught up with the science. Addicts are still stigmatized by society as moral failures who could cure themselves if they just
tried hard enough or, in a variation on this theme, addicts are born losers and there's nothing that can help them.

Let's take the last point first. Judy Garland, Robert Downey Jr., Oprah Winfrey, Bob Dylan, David Bowie, Ray Charles, Keith Urban, Brian Wilson, William F. Buckley Jr., Elizabeth Taylor, James Baldwin, and even Benjamin Franklin were all alcohol and drug addicts. Clearly, these talented and financially successful people were not losers in any conventional sense.

As for the stigma of being an addict, there's no doubt that it's still a powerful force that stops most people from admitting they have an addiction problem. We only have to look at the very high profile and tragic death of actor Philip Seymour Hoffman to confirm this. Here was a celebrated and admired artist, at the top of his career, who nevertheless refused to seek the kind of professional help he needed because of the stigma surrounding a relapse after more than twenty years of sobriety. Instead, he tried curing himself by attending AA meetings. Ten weeks after he relapsed, he was found dead in his apartment with a needle stuck in his arm and seventy-five packages of heroin strewn about.

These public attitudes toward addicts are in part created by America's unique Puritanical history, which underpins our nation's belief system on a wide range of social issues. Americans also tend to think that people who behave badly while drinking or drugging are bona fide addicts. In addition, the vestiges of the late-twentieth-century federal policy known as the “war on drugs” have indelibly etched into the public mind the idea that most drug and alcohol abusers exhibit criminal behavior (when, in fact, only a small minority do).

What history tells us about addiction in America is almost the stuff of fiction. In 1914, the federal government made the fateful decision to criminalize drugs in the United States with the passage of the Harrison Act, designed to limit the distribution of opiate narcotics and to appease the great temperance movement that was sweeping the nation at the time. In 1919, the passage of the Eighteenth Amendment prohibited the sale of alcohol, and by the mid-1920s, the sale and distribution of cannabis were also regulated by federal statue, with criminal penalties attached for those who violated the new rules.

That will be the last time alcohol, narcotics, and cannabis will all be on roughly equal footing in the eyes of the law because, by wildly popular demand, the ban on alcohol became the first and only amendment to the U.S. Constitution that was ever repealed. Alcohol again became readily available, and even glamorized as a lifestyle choice. Meanwhile, marijuana, which was further criminalized, and narcotic opioids diverged onto parallel pathways and were perceived as dangerous, illicit street drugs, along with prescribed painkillers that were considered “safe when used properly.” Note though that cannabis is seeing a reversal and has been legalized in some states.

From a medical viewpoint, that made no sense. Alcohol then, and now, by far continues to be the most dangerous drug in terms of the loss of human life and property—more than all other drugs combined. Six people die each day from alcohol poisoning; no one has ever died from a marijuana overdose. And while the country is currently in the midst of a heroin epidemic, it's reflective of the Alice-in-Wonderland world of drug
criminalization in the United States that the reason for its resurgence is because the legal version of opiates—prescription painkillers like OxyContin, Percocet, and Demerol—became too scarce on the black market as a result of new federal regulations. Pill addicts turned to heroin, because it became cheaper than prescription painkillers.

If you're looking for any rhyme or reason to how drugs (and alcohol) have been regulated in the United States, you won't find it in history. To add but one more chapter in the surreal saga, the Narcotics Addict Rehabilitation Act of 1966, in a refreshing burst of enlightened thinking, gave judges the discretion to divert a defendant into treatment rather than jail. It was a chink in the armor of the war on drugs begun in 1914.

What the drafters of this act didn't anticipate were the unintended consequences. Suddenly, local communities were encouraged, even expected, to open their own treatment facilities. Local officials, who had virtually no experience in dealing with addicts other than putting them in jail, turned to the only group they knew in the field, Alcoholics Anonymous (AA). But here was the conundrum: co-founder Bill Wilson intended AA to be voluntary. The new law demanded that treatment be regimented with defined time frames and discipline, just like a jail. The rehab industry took off like gangbusters and never looked back.

The Science of Addiction

Here's what science tell us: Addiction is not synonymous with recreational or social use of mood-altering agents, including alcohol. On one level, we all know this intuitively. After all, not everyone who takes a prescription pill, smokes a joint, swigs a cocktail, or even shoots heroin will become an addict. Once we clear up this misunderstanding, then we can begin to realize that addiction is a true medical illness and understand why it is classified as a disease by every medical organization in the world, including the World Health Organization (WHO). Obviously, if addiction were not a medical condition meeting the clear definition of
disease
, my board-certified area of specialization—addiction medicine—wouldn't exist.

Much of the disconnect between addiction and treatment is rooted in the recovery movement's history. Addicts, shunned by society and the medical establishment alike, received their help from those outside of it, a trend that continues to this day. Indeed, AA and other 12-step counseling programs, developed in the 1930s, have a near monopoly on addiction treatment in the United States, with only about 10 percent of rehab clinics offering any evidence-based treatment.

For decades now, the pseudo-religious AA's 12-step approach, emphasizing abstinence and submission to a “creator,” has dominated the recovery industry. Historically, then, the treatment of substance or drug-use disorder developed outside mainstream medicine, and today we're still suffering from that.

To be fair to Bill Wilson, he never intended his organization
to be twisted into a profitable industry, nor did he ever intend it to be antimedicine.
Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism
(generally known as the Big Book) warns against AA members playing doctor to the detriment of other members. Wilson himself advocated for research into the medical treatment of alcoholism, going as far as beseeching the doctors who created methadone for drug addicts in the 1960s to find a comparable treatment for alcoholics.

Furthermore, until the advent of evidence-based treatment, AA was the only viable alternative for addicts in a society that certainly stigmatized and often criminalized them. AA meetings at least offered safe sanctuary to kindred spirits in a world that truly did not understand them.

The problem with AA originates in its loose structure—it keeps no records and its members are anonymous—and its oblique, often contradictory statements. AA's philosophy could be interpreted and co-opted by anyone. For example, AA's doctrinal Big Book tells us that alcoholism is a disease, yet the treatment it recommends has nothing to do with medicine or science. At best, AA is a kind of spiritually tinged psychological counseling that we call “group therapy” today.

AA also contributed to the stigmatization of the addict and alcoholic thanks to the notion that if its 12-step program doesn't work, it's the fault of the follower, not the program itself. To wit, here's an excerpt from the Big Book: “Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give
themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. They are such unfortunates. They are not at fault; they seem to have been born that way.”

In one sense, AA was spot on when it said that addicts “seem to have been born that way.” But by mixing that simple statement of fact with pseudo-science, AA planted the roots of today's for-profit rehab industry. AA has become the cover for the highly lucrative nontreatment of addiction in the United States.

The Big Business of Rehab

Make no mistake. Recovery is an industry—a huge business with more than $34 billion in revenue in 2013—and one in which 90 percent of the treatment centers blithely follow and promote the fact their treatment is based on AA's 12-step philosophy. Never mind that even by AA's own admission, only 5 to 8 percent of those who ever attend a single meeting stay sober for more than a year. Indeed, a comprehensive study of treatment programs in the early 2000s, later published as
The Handbook of Alcoholism Treatment Approaches
, ranks AA thirtieth out of forty-eight methods. Just like in
Alice's Adventures in Wonderland
, things happen that do not make any sense and are the opposite of what you would expect.