The Anatomy of Addiction (4 page)

The probability of becoming an addict is less than the probability of becoming dependent. Your probability of becoming dependent is estimated to be 32 percent for tobacco; 23 percent for heroin; 17 percent for cocaine; 15 percent for alcohol; 11 percent for stimulants other than cocaine; 9 percent for cannabis; 9 percent for anxiolytic, sedative, and hypnotic drugs; 8 percent for analgesics; 5 percent for psychedelics; and 4 percent for inhalants.

A series of studies on the rate of addiction/behavioral dependence in chronic users of nicotine, alcohol, and opioids elegantly demonstrated that only a subpopulation of chronic substance users becomes dependent.

A majority of substance users do not develop addiction. I would venture to say that the majority of people who attend AA meetings and other 12-step programs aren't addicts, either. They
may have indulged in heavy drinking or drugging and perhaps at the risk of life and limb to themselves and others (a driving under the influence, DUI, citation is a wake-up call that sends droves of individuals to seek help from AA). And perhaps this is where an AA program excels—that is, facilitating a drinker at risk to examine her bad behavior.

Addicts are different. They suffer from a chronic disease characterized by an inability to abstain from substances they know are harmful. The heavy drinker might down a bottle of vodka while partying into the night. The addict-alcoholic drinks two bottles of vodka or more until he passes out. Addicts can't stop drinking or drugging because their behavioral control—including the ability to stop craving—is impaired.

Those who develop addiction do so primarily because of genetics. The genetic model of addiction predicts that addiction is more likely to develop after initial substance use in individuals with a genetic susceptibility. The more we know about genetics and genetic testing, the more we know about predicting and treating addiction. The addiction is not in the drug; it is in the genes of the individual.

Unfortunately, AA and their allies—most of the rehab industry—don't make those kinds of distinctions. AA true believers actually deny the medical evidence that contradicts their outdated concept of addiction, including that all-or-nothing abstinence is the only hope for recovery. The rehab industry is much more cynical, taking the easy money and using AA's philosophy to rationalize and justify its dismal success rates.

The social stigma of addiction is more destructive in many
cases than the disease itself, and the irresponsible continuation of false diagnoses of addiction by people with no medical credentials, combined with coerced treatment of people for a disease they may not have in the first place, especially when such treatment is devoid of comprehensive medical diagnosis, is an insult to both the patient and the entire medical profession.

Extreme Prejudice

In the all-important, life-saving profession of medicine, we must be clear and precise when discussing addictions. If the general public is wallowing in ignorance, their decisions and actions based on ancient errors and disproved assumptions, illness, and unhappiness will not only continue but increase. No person of good will and integrity would willingly promulgate ignorance.

Superstition is the child of ignorance. In a world of superstition, people believe in magical thinking, distrust new information, and cling tenaciously to outworn and even dangerous practices. A recent guest on a TV talk show insisted, with a perfectly straight face, that there was “real danger” in the practice of yoga because “Hindu demons could take up residence in your spine.” Our world is full of people who believe in demons but not in germs, despite overwhelming evidence of germs and none of demons. In this Information Age, the proliferation of misinformation is unparalleled, and erroneous beliefs regarding addiction and treatment are numerous.

One fact is certain: Americans have an extreme prejudice against people suffering from the disease of addiction. This same
prejudice is not shown against people with asthma, heart disease, or diabetes, despite these diseases sharing remarkable medical similarities. The reason we fear and distrust addicts is because of their behavior.

Writer and social activist Susan Sontag said it right when she observed about addiction: “Any important malady caused by something obscure and that has an inefficient treatment has the tendency to be full of meaning. At first, the objects of deepest fear (corruption, decadence, pollution, anomie, weakness) are identified with the disease. The disease itself becomes a metaphor. Then, in its name (that is, using it as a metaphor), that horror is imposed on other things. The disease begins to describe things.”

Diabetics don't write bad checks to buy Snickers bars, and people with clogged arteries don't break into McDonald's to steal hamburgers. But alcoholics write bad checks to buy more alcohol. The object of addiction takes priority in the damaged decision making of someone with addiction.

Addiction Is Treatable

This is an exciting time in medicine. Astonishing technology allows us to study the actual workings of the human brain, and there are continual breakthroughs in the treatment of chronic illness, including addiction. Researchers are on the cusp of identifying the eleven genes that look to be the hereditary component of addiction.

While scientific treatment of addiction continues to be hobbled by misconceptions and prejudice, there are many glimmers of
lights at the end of the tunnel. Remember how Hazelden's CEO touted the virtues of its 12-step program when it merged with the Betty Ford Center in 2014? Well, quietly behind the scenes at the same time, Hazelden's chief medical officer Marvin Seppala was introducing evidence-based medications like Suboxone into its treatment protocols. The results were dramatic. The drop-out rate at Hazelden for opiate addicts in the new medically assisted treatment decreased to just 7 percent compared to 22 percent of those patients not in the new program. In the program's first year, not one addict died from an overdose.

If the two biggest brands in the rehab industry can see the light, change engrained ways, and adopt medically assisted treatment, there's hope for the entire industry.

We must keep in mind, too, that like the privately run healthcare system of the United States, its addiction treatment industry is an anomaly in the world. In every other industrialized nation, addiction is treated like the chronic disease it is. France established evidence-based treatment of addicts in 1995 and saw the country's overdose deaths drop by 79 percent. Similar results have been reported in other Western countries, including Finland, Portugal, Switzerland, and Australia—all places where the grip of the AA philosophy never really took hold like it did in the United States.

Here in America the effectiveness of evidence-based medicine was witnessed in Baltimore with the publicly funded Baltimore Buprenorphine Initiative, which spurred a 50 percent reduction in the city overdose deaths over a fifteen-year period beginning in 1995.

The biggest change in addiction treatment will come when we stop seeing addiction as more of a crime than a disease. Until that time, the treatment of this chronic medical condition will be dominated by misguided amateurs and profiteering rehab providers—who put power and profit over patient well-being.

For the sake of saving lives, we must unite to eliminate prejudice against those born with this genetic predisposition, ensure honest and accurate public education on the subject of addiction, and protect people from fraudulent
treatment.

A
fter billions of dollars spent on the disinformation campaign known as the war on drugs, no wonder the American public is confused about alcohol and drug addiction. It's a crime. It's a moral failing. It's the parents' fault. It's the kids' fault.

So, why does it matter? It's important because public perception of alcohol and drugs, their use and abuse, influences public policy. From the length of sentences given to those arrested for possession of various kinds of illicit drugs to the billions of taxpayer dollars spent on addiction treatment, the truth about alcohol and drug addiction has a huge impact on society.

It's also a matter of life and death. Countless addicts are sent by courts—or seek help on their own—at treatment programs where there is no hope for recovery. It's not that real treatment doesn't exist, but rather that most Americans, doctors, judges, and addiction counselors have missed the memo.

The only thing standing between effective treatment of alcohol and drug addiction, based on real medicine, is misinformation and ignorance.

In this chapter I tell it straight—no spin, no hidden agenda, no ulterior motives. Only by telling and absorbing the real facts about alcohol and drug addiction will the American public and its elected leaders be able to come to terms with a rational strategy for dealing effectively with addiction. The truth shall, indeed, set us free.

So, take a walk with me now down the Hall of Shame of the ten biggest myths about alcohol and drug addiction.

1. Addiction Is a Problem of Willpower and Abstinence, Which Is Why Medications Don't Work

The biggest myth of all is that addiction is a problem of willpower and abstinence. The foundation for the sorry state of addiction treatment in this country was inadvertently started in the 1930s by an out-of-work investment banker named Bill Wilson. At the time Wilson had his revelation of what would become Alcoholics Anonymous, he was being treated in a hospital for alcoholism with an experimental drug whose active ingredient was belladonna, a plant known for its hallucinogenic effects (or death, if you ingest too large of a dose). Ironic, isn't it? The man who would set the standard treatment for addiction in the United States in the twenty-first century was being medicated with a psychoactive substance when he came up with it during the Great Depression.

Here's the fact of the matter: There isn't now nor was there
ever any evidence that AA's 12-step group talk therapy could treat addiction effectively. Indeed, AA itself never claimed to be the end-all answer to addiction and qualified the idea by emphasizing that its particular pseudo-spiritual philosophy isn't for everyone.

That's not to say that AA 12-step programs cannot be helpful as part of an overall treatment program for addiction that includes medications, psychological counseling, and lifestyle modifications. And by the way, that formula for treatment sounds a lot like the treatment protocol for other chronic brain diseases like bipolar disorder. However, AA is part of the problem of addiction treatment in America because it's remained intransigent on the point that its philosophy of abstinence alone can work miracles.

Fortunately, modern science tells us something different. Through diagnostic tools like MRI, we can see how the brain circuitry of addicts is wired differently from nonaddicts. The advent and use of pharmaceutical drugs since the mid-1990s to stop the craving that is characteristic of substance addiction clearly show us that medications can and do work. Thanks to evidence-based treatment, thousands of addicts formerly debilitated by their disease are living happy and normal lives: holding jobs, paying taxes, and surrounding themselves with friends and family.

2. Addicts Should Be Punished for Using Drugs and Drinking Too Much Because in the End, They Know Better

It is not a crime in the United States to have the physical illness of addiction. But if the object of your addiction, such as illicit
drugs, is illegal, you could be arrested and prosecuted for the mere act of possessing it. However, this places the person suffering from addiction in a situation of continually interacting with the criminal underworld rather than with medical professionals.

Imagine if we criminalized insulin or inhalers? Our jails would be filled with diabetics and asthma patients.

U.S. Supreme Court Justice Potter Stewart clearly and eloquently defined the problem in 1962 when he wrote in the case of
Robinson v. California
that “drug addiction is an illness and not a crime” and that “punishing someone for an illness violates the 8th Amendment of the U.S. Constitution.”

Let's take it from another perspective. Numerous studies have shown it's much less expensive to treat people with drug problems than to toss them into prison.

Adding to the Alice in Wonderland nature of addiction and criminal law in the United States is the fact that alcohol—
the most
destructive of all addictive drugs in terms of the consequences to the individual and society—is legal, heavily marketed and commercialized, and even glamorized in popular culture.

3. Alcohol Is Different from Other Drugs Because It's Easier to Control and You're Less Likely to Become Addicted to It

Because of our particular culture, we are less harsh on alcoholics than we are on people addicted to other drugs. When we think of heroin addicts, for example, our mental image is
not
one of a charming and upstanding citizen. We think of them as evil,
scandalous thieves and criminals. Most people don't know that heroin was once considered a “wonder drug”; it was 100 percent legal and available over the counter.

When heroin was first introduced by Bayer (the same company that gave us aspirin), tuberculosis and pneumonia were the leading causes of death, and even routine coughs and colds could be severely incapacitating. Heroin, which both depresses respiration and gives a restorative night's sleep as a sedative, seemed a godsend. It was used in the treatment of asthma, bronchitis, and tuberculosis and even in the treatment of alcoholism.

According to an article in the
Boston Medical and Surgical Journal
in 1900, “It [heroin] possesses many advantages over morphine. It's not hypnotic, and there's no danger of acquiring a habit.” Heroin was widely used in America, and most medicines used by women for relief of menstrual pain contained heroin. Cocaine, a stimulant and anesthetic, was also legal; it was often used in combination with heroin in various medications, often in an alcohol base.

Both heroin and cocaine were inexpensive until they became illegal. Suddenly, the price went sky high, and those already addicted had no choice but to get the money by any means necessary and give that money to criminals.

Alcohol, of course, has long been associated with compulsive, uncontrolled behavior among a certain percentage of the population. The term
alcoholism
was first used in Sweden in 1849, but the first chronicles of uncontrollable urges to drink appear in the early 1800s under the term
dipsomania
. That word actually means compulsive thirst, but it soon became used specifically to mean the compulsive, uncontrolled intake of alcohol.

The classic description of dipsomania was written by Valentin Magnan in 1893, and you will see that he did a very good job of describing what today we call alcoholism:

Preceded by a vague feeling of malaise . . . dipsomania is a sudden need to drink that is irresistible, despite a short and intense struggle. The crisis lasts from one day to two weeks and consists of a rapid and massive ingestion of alcohol or whatever other strong, excitatory liquid happens to be at hand, whether or not it is fit for consumption. It involves solitary alcohol abuse, with loss of all other interests. These crises recur at indeterminate intervals, separated by periods when the subject is generally sober and may even manifest repugnance for alcohol and intense remorse over his or her conduct. These recurring attacks may be associated with wandering tendencies (dromomania) or suicidal impulses.

Sigmund Freud saw the fevered consumption of alcohol as a complex substitute for sexual obsession and the drunken stupor as a sort of twisted victory in that it successfully desensitized the pain caused by the avoided obsession and featured an alluring mastery of total passivity. Freud considered that motor acts, with or without wandering, were central to sexual obsession, and repetitive drinking was one of those motor skills.

Whether or not Freud's analysis was psychologically accurate, he offered profound insights into the alcoholic's crises. “He never rested until he had lost everything,” Freud wrote. “The
irresistible nature of the temptation, the solemn resolutions, which are nevertheless invariably broken, never to do it again, the stupefying pleasure and the bad conscience which tells the subject that he is ruining himself (committing suicide)—all these elements remain unaltered in the process.”

Freud postulated a hereditary component and delineated similarities between compulsive drinking and compulsive gambling. He also suggested that these compulsions have an association with an organic, toxic brain disease. Decades worth of subsequent research studies have proven him spot-on correct in that regard.

There were early attempts to link alcoholism with manic-depression, now called bipolar disorder, or with a “false manic-depressive” condition. As there were no addiction medicine specialists in those days, there were no empirical medical studies of these conditions beyond noting their characteristics.

Today we know that alcohol is the most prevalent drug abused, causes more deaths than all other drugs combined, and is the most difficult to treat because of its ability to simultaneously affect multiple brain receptors (while other drugs tend to affect only one or two).

4. Virtually Everyone Who Uses Meth or Crack Will Become Addicts and the Meth and Crack Addiction Are Increasing

Most users of meth and crack—like all drugs—never become addicts. Your probability of becoming dependent is estimated to be 32 percent for tobacco; 23 percent for heroin; 17 percent for
cocaine and crack; 15 percent for alcohol; 11 percent for stimulants other than cocaine (like meth); 9 percent for cannabis; 9 percent for anxiolytic, sedative, and hypnotic drugs; 8 percent for analgesics; 5 percent for psychedelics; and 4 percent for inhalants. Bottom line: Most people simply stop using their drug of choice before it becomes a real problem.

The misinformation about crack and meth is legion. The very names of these street drugs cause politicians to foam at the mouth. Are they dangerous? Without a doubt. Do they deserve the kind of hysteria they generate? Nope.

It's worth saying again: Most people who try crack don't like it and don't use it again. Over 75 percent of people who tried crack between 2004 and 2006 were not using it at all two years later; 15 percent still smoked it occasionally, but not in a way associated with addiction.

Even though they're the same drug, but in a different form, crack and cocaine are perceived wildly differently both by the criminal justice system and the public alike.

During their lifetime, 7,840,000 (3.3 percent) of Americans have smoked crack cocaine, according to the National Survey on Drug Use and Health. However, only 467,000 (0.2 percent) of Americans reported smoking crack cocaine in the last thirty days. If crack were instantaneously addictive, the number of recent users would be much larger.

According to the same survey of Americans aged twelve and older, 5.9 percent of individuals who had tried cocaine went on to be “current users” (reported use within the past thirty days). The same statistic for crack use was also 5.9 percent. These numbers
show no statistical difference in the tendency toward the future use of cocaine and crack.

Again, there is no pharmacological difference between crack cocaine and powder cocaine. Crack cocaine is simply powder cocaine that has been converted into a solid “rock” form that may be smoked. The effects of smoking crack cocaine may be more intense, but this is a result of the mode of ingestion rather than the drug's purity. Regardless, it is difficult to rationalize the extreme sentencing disparity between crack and cocaine.

Similarly, crack is perceived not only to be more addictive but more deadly. The misuse of any drug (legal or illegal) can be detrimental to your health. However, it is simply not true to claim that crack cocaine is a major cause of death. The percentage of deaths attributed to
all
illegal drugs combined is less than 1 percent. By comparison, over 18 percent is caused by tobacco. More people die every year from legal drugs, legally prescribed, than all illegal drugs combined.

Fact: While often characterized as a drug of the black community, 60 percent of individuals who have used crack in the last month are white. White crack users also account for 66 percent of individuals who have ever used crack in their lifetime. Simply stated, the majority of crack users are white.

Despite this reality, 80 percent of people arrested for crack offenses are black. Consequently, a disproportionate number of black crack offenders face the harsh mandatory minimums associated with crack convictions.

Finally, crack is perceived as instigating violent behavior while cocaine gets a pass. Yet, research has shown that crack use
does not result in violent behavior. The violence one associates with crack is not from the effects of the drug, but rather the violence between rival criminal organizations and/or law enforcement.

Like crack and cocaine, meth is perceived as a drug with no redeeming value. That's true. About a hundred years ago the same argument was used to ban and criminalize the use of alcohol. What is
not
true is that meth is on the rise and meth users are harder to treat than, say, alcoholics.

Meth use in the United States peaked at least two decades ago and has slightly declined or stayed about the same. Addiction to methamphetamine is not much different from that of any other drug addiction except tobacco, which is the most addicting and the most difficult to quit. When it comes to successful treatment, it doesn't matter if you're talking about meth or heroin or alcohol.