MORE ABOUT THIS BOOK
There is often a struggle, and sometimes, even more interestingly, a collusion between the powers of pathology and creation.
I AM LYING ON MY BACK inside the thin metal tube of the brain scanner at the Semel Institute for Neuroscience and Human Behavior at UCLA, trying not to think about coffins and earthquakes. On my thigh is a rubber ball to squeeze in case of panic, which can immediately liberate me from the giant white donut-shaped machine; my head is now centered deep in the hole. Earlier, as I was propelled inside on sliding rails, I couldn’t help but be reminded of the drawers in which corpses are kept in morgues. Although I’m wearing earplugs, the machine’s metallic roar—complete with occasional shaking and shrill beeping—seems deafening. Since I am claustrophobic and abhor loud noise, I try to focus on my breathing. One task I will perform here is supposed to measure impulse control, but it is taking nearly all of mine not to immediately crush the squeeze ball and escape.
I’m not being scanned because a doctor has ordered it. I’ve actually chosen to put myself into this tight spot as part of an experiment. I want to understand more about addiction: my own history of it and what it means more generally. How did I go from being a “gifted” child and Ivy League scholarship student to injecting cocaine and heroin up to 40 times a day? Why did I recover at 23, when many others take much longer or succumb? More important, what determines who gets hooked, who recovers, and who does not? And how can we as a society do better at addressing addiction? As I wait in the scanner, I recall the last days of my drug use, a distressing period in 1988 when I spent my time either shooting up, selling drugs, or trying to buy. I consider what has changed—and what hasn’t.
Sadly, had I nodded off in the ’80s and somehow been revived in 2015, I wouldn’t find much different about how we frame and deal with addiction. Sure, at least four states and Washington, D.C., have legalized recreational marijuana sales. That would be shocking to anyone whose last memories were of the “Just Say No” years. And yes, addictive behavior is back in the media spotlight, though these days it’s not crack but Internet addiction, sex addiction, food addiction, gaming addiction, and the tragic drumbeat of prescription overdose deaths (celebrity and otherwise) that get the most attention. Overdoses are now, in fact, the number one cause of accidental death, surpassing even auto fatalities.
Indeed, today, more people than ever before see themselves as addicted or recovering from substance addiction: 1 in 10 American adults—more than 23 million people—said they’d kicked some type of drug or alcohol addiction in their lifetime, in a large national survey conducted in 2012. At least another 23 million currently suffer from some type of substance use disorder. That doesn’t even count the millions who consider themselves addicted to or recovering from behaviors like sex, gambling, or online activities—nor does it include food-related disorders. With the 2013 declaration by the American Medical Association that obesity, like addiction, is a disease, up to one in three Americans may now qualify due to their body weight.
At the same time, Big Pharma, Big Food, Big Tobacco, Big Alcohol, and Big Business in general all seem to intimately understand addiction and how to manipulate it. However, most of the American public—including most people with drug problems and their families—do not. Trapped in outdated ideas—many unchanged since the flapper days of Prohibition—we continue to recycle the same tired debates and enforce counterproductive criminalization strategies. But it doesn’t have to be this way.
I propose here a new perspective, one that could help end this stagnation and suggest a way forward in treating, preventing, and otherwise managing addictive behavior. As this book will demonstrate, addiction is not a sin or a choice. But it’s not a chronic, progressive brain disease like Alzheimer’s, either. Instead, addiction is a developmental disorder—a problem involving timing and learning, more similar to autism, attention deficit hyperactivity disorder (ADHD), and dyslexia than it is to mumps or cancer. This is clear both from abundant data and from the lived experience of people with addictions.
Like autism, addiction involves difficulties in connecting with others; like ADHD, it can also be outgrown in a surprisingly large number of cases. Moreover, like other developmental disorders, addiction can be associated with talents and benefits—not just deficits. For example, people with ADHD often thrive as entrepreneurs or explorers, while autistic people can excel at detail-oriented tasks and many are highly talented musicians, artists, mathematicians, and programmers. Dyslexia can improve visual processing and pattern finding, which is also helpful in science and math careers. Addiction is frequently linked with intense drive and obsessiveness, which can fuel all types of success if channeled appropriately—and some believe that the “outsider” perspective of people with illegal drug addictions is linked with creativity. In all of these conditions, the boundaries between normal and problem behavior are fuzzy.
Of course, in some ways addiction appears extremely unlike other developmental disorders, most prominently because it involves apparently deliberate and repeated choices, some of which, like taking illegal drugs, are considered inherently immoral. Early-life trauma also can play an important role in addiction, whereas it plays no role in autism. These differences mask important similarities, however. In both autism and addictions, for example, repetitive coping behaviors are frequently misinterpreted as the source of the problem, rather than being seen as attempts at solutions. In fact, severely neglected children often develop autistic-like behavior such as constantly rocking as a way to soothe or stimulate themselves—and maltreated children often appear to have ADHD because they are hypervigilant to “distractions” like the sound of a door slamming.
In all of these conditions—including autism itself—repetitive, vigilant, or destructive behaviors are not usually the primary problem. Instead, they are typically a coping mechanism, a way to try to manage an environment that frequently feels threatening and overwhelming. Similarly, addictive behavior is often a search for safety rather than an attempt to rebel or a selfish turn inward (a charge previously made against autistic children as well). We’ll see throughout this book how misinterpreting understandable attempts at self-protection as hedonistic, selfish, or “crazy” has needlessly stigmatized people with developmental disorders including addiction—and, as a result, has increased associated disability rather than helping.
Critically, addiction is not created simply by exposure to drugs, nor is it the inevitable outcome of having a certain personality type or genetic background, though these factors play a role. Instead, addiction is a learned relationship between the timing and pattern of the exposure to substances or other potentially addictive experiences and a person’s predispositions, cultural and physical environment, and social and emotional needs. Brain maturation stage is also important: Addiction is far less common in people who use drugs for the first time after age 25, and it often remits with or without treatment among people in their mid-20s, just as the brain becomes fully adult. In fact, 90% of all substance addictions start in adolescence, and most illegal drug addictions end by age 30.
The implications of the developmental perspective are far-reaching. For one, if addiction is a learning disorder, fighting a “war on drugs” is useless. Surprisingly, only 10–20% of those who try even the most stigmatized drugs like heroin, crack, and methamphetamine become addicted. And that group, which tends to have a significant history of childhood trauma and/or preexisting mental illness, will usually find some way of compulsively self-medicating, no matter how much we crack down on one substance or another. In this context, trying to end addiction by attempting to eliminate particular drugs is like trying to cure compulsive hand washing by banning one soap after another. Although you might get people to use more or less harmful substances while in the grips of their compulsions, you aren’t addressing the real problem.
Second, given that addiction is a learning disorder, it isn’t necessarily a lifelong problem that demands chronic treatment and the acceptance of a stigmatized identity: studies find that the majority of cocaine, alcohol, prescription drug, and cannabis addictions end before people are in their mid-30s and most do so without treatment. Similarly, between one third and one half of children diagnosed with ADHD no longer meet criteria for it as adults, and treatment doesn’t seem to affect whether they outgrow the disorder or not, although it certainly can affect their ability to thrive. Finally, the learning perspective offers insight into other conditions—from anxiety disorders to schizophrenia, bipolar disorder to depression—that often precede addiction and could benefit from similar approaches.
Challenging both the idea of the addict’s “broken brain” and the notion of a simple “addictive personality,”Unbroken Brain offers a new way of thinking about drugs, craving, and compulsions, whether seen in behavior as extreme as shooting drugs or as ordinary as dieting.
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AS I WAIT for the scanner to measure the soft structures under my skull, I can’t help but think about the organ that scientists consider to be the most complex object in the known universe. I know that all of our experiences are somehow written into our brains. Somewhere in the sinuous curves and pulsing surfaces of my own must be the echoes of everything I’ve ever learned, whether I can now recollect it or not, and every choice I’ve ever made, consciously or otherwise.
And somewhere in my gray and white matter are the neural structures that put me at high risk for addiction even before I’d taken drugs; here, too, is any lingering residue of chemical changes made by the substances themselves. Everything I am and everything I’ve ever been has at some point been represented here chemically, structurally, or electrically: not just addiction but now over 25 years of recovery and decades of other life experiences.
I hope that my scans can help me illustrate why learning matters in this disorder. After decades of reading, reporting, and writing on addiction, hundreds of interviews with experts, and even more with drug users and former users—many of whom have experienced addiction—I have come to believe that learning is the key to better treatment, prevention, and policy. While scientists have long recognized that learning is critical to addiction, most of the public does not—or is not aware of the implications of seeing it this way. However, trying to understand addiction without recognizing the role of learning is like trying to analyze songs and symphonies without knowing music theory: you can intuitively identify discord and beauty, but you miss the deep structure that shapes and predicts harmony.
Failing to recognize the true nature of addiction has also come at a catastrophic price. It prevents us from effectively tackling all types of drug problems, whether in terms of prevention, treatment, or policy. It buries the need for individualized approaches. It also keeps debates on these issues stalled in sterile arguments over whether addiction should be seen as a crime or a disease. Further, misunderstanding addiction allows drug policy to continue to be used as a political and racial football, since our ongoing use of ineffective tactics has produced widespread despair about affected people and families. In fact, however, research shows that, overall, addiction is the psychiatric disorder with the highest odds of recovery, not the worst prognosis—as many have been led to believe.
Addiction doesn’t just happen to people because they come across a particular chemical and begin taking it regularly. It is learned and has a history rooted in their individual, social, and cultural development. We think it’s a simple brain disease or a matter of criminal behavior because we don’t understand its developmental history and how that plays out in wildly varied ways to create a suite of problems that only look the same superficially. Understanding the role of learning illuminates what’s really going on and what to do about it.
Properly understood, the addicted brain isn’t broken—it’s simply undergone a different course of development. Like ADHD or autism, addiction is what you might call a wiring difference, not necessarily a destruction of tissue, although some doses of some drugs can indeed injure brain cells. While, like anything else that is learned, addiction may get more engrained with time, people actually have increased odds of recovery as they age, not reduced chances. This apparent paradox makes much more sense if seen as part of a developmental disorder that can change with life stages.
Moreover, as parents and teachers everywhere know well, it’s almost impossible to force or coerce learning—especially to alter behavior that has already become habitual. As B. F. Skinner himself observed, “A person who has been punished is not less inclined to behave in a given way; at best, he learns how to avoid punishment.” Fear and threat also literally shunt energy away from the areas of the brain involved in self-control and abstract reasoning—the exact opposite of what you want when you are trying to teach someone new ways of thinking and acting. Changing behavior is far easier if you use social support, empathy, and positive incentives, as a great deal of psychology research—though often ignored in addiction treatment and policy—demonstrates. This has obvious implications for the prospects of altering addiction via the criminal justice system.
Finally, the role of learning and development in addiction means that unlike in most physical diseases, cultural, social, and psychological factors are inextricably woven into its biological fabric. Pull any thread alone and the entire idea unravels into an incomprehensible tangle. Label addiction as merely biological, psychological, social, or cultural and it cannot be understood. Incorporate the importance of learning, context, and development, however, and it all becomes much more explicable and tractable.
Seeing addiction as a learning disorder allows us to answer many previously perplexing questions, such as why addicted people can make apparently free choices like hiding their drug use and planning to ensure an ongoing supply while failing to change their habits when they result in more harm than good. Learning helps explain why cultural trends and genetics can both have big influences and why addictive behavior is so varied. Further, learning and development elucidate why factors like employment and social support affect recovery in a far greater way than they do with physical illness. Sadly, cancer rarely disappears when someone falls in love and marries—but alcoholism and other addictions can and often do remit.
In the rest of this book, we’ll see just how intimately learning is involved in every aspect of addiction: from the molecular brain changes that result from certain patterns of drug use and experience to the associations between drugs and particular cues and memories that are mediated by individual, familial, cultural, and historical circumstances. Using my own experience as a case study, I’ll show how one addiction played out through one pathway and why others take different routes. Though my specific story is undoubtedly unusual, its particulars illustrate the universality of learning in the addiction process and why its singular nature in all cases is critical to understanding the larger problem.
Here, we’ll see how addiction affects a very specific type of learning, involving ancient brain pathways that evolved to promote survival and reproduction. Since those are the fundamental tasks of any biological organism, they produce highly motivated behavior. When starving, when in love, and when parenting, being able to persist despite negative consequences—the essence of addictive behavior—is not a bug, but a feature, as programmers say. It can be the difference between life and death, between success and failure. However, when brain pathways intended to promote eating, social connection, reproduction, and parenting are diverted into addiction, their blessings can become curses. Love and addiction are alterations of the same brain circuits, which is why caring and connection are essential to recovery, too.
The world is finally recognizing that the punitive American approach to addiction, which has dominated drug policy for the last century, is failing. In order to move beyond it, a new understanding of the disorder and its relationship to drugs and other behaviors is needed. Only by learning what addiction is—and is not—can we begin to find better ways of overcoming it. And only by understanding addicted people as individuals and treating them with compassion can we learn better and far more effective ways to reduce the harm associated with drugs.
As I lie in the scanner, a snippet of a Talking Heads song pops into my head. It goes, “Well, how did I get here?” That’s the mystery of every addiction—and to solve it, we need to look at it from an addict’s perspective, elucidating general principles by examining the specific and particular.
Copyright © 2016 by Maia Szalavitz