Pubdate: Sun, 25 Jun 2006
Source: New York Times Magazine (NY)
Contact:  2006 The New York Times Company
Author: Benoit Denizet-Lewis
Note: Benoit Denizet-Lewis is a contributing writer for the magazine. 
He is working on a book about addiction in America.
Bookmark: (Chronic Pain)
Bookmark: (Cocaine)
Bookmark: (Heroin)
Bookmark: (Methadone)
Bookmark: (Methamphetamine)
Bookmark: (Treatment)


Last month, the Picower Institute for Learning and Memory at the 
Massachusetts Institute of Technology was host to a conference about 
addiction for a small, invitation-only crowd of neuroscientists, 
clinicians and public policy makers.

It was an unusual gathering. Addiction conferences are usually sober 
affairs, but M.I.T. offered a lavish cocktail reception (with an open 
bar, no less). More important, the conference was a celebration of 
the new ways scientists and addiction researchers are 
conceptualizing, and seeking to treat, addiction.

While many in the treatment field have long called addiction a 
"disease," they've used the word in vague and metaphorical ways, 
meaning everything from a disease of the mind to a disease of the spirit.

Many assumed that an addict suffers from a brain-chemistry problem, 
but scientists had not been able to peer into our heads to begin to prove it.

Now they can, using advances in brain-imaging technology. And they 
tend to agree on what they see, although not necessarily on how to 
fix it: addiction -- whether to alcohol, to drugs or even to 
behaviors like gambling -- appears to be a complicated disorder 
affecting brain processes responsible for motivation, decision 
making, pleasure seeking, inhibitory control and the way we learn and 
consolidate information and experiences. This new research, in turn, 
is fueling a vast effort by scientists and pharmaceutical companies 
to develop medications and vaccines to treat addiction.

The National Institute on Drug Abuse and the National Institute on 
Alcohol Abuse and Alcoholism are studying, or financing studies on, 
more than 200 addiction medications.

The search for pharmacology to treat addiction is not new. The 
history of addiction treatment in America is rife with supposed 
miracle medications and "cures," most of which turned out to be 
useless. But there are a handful of drugs -- some developed in the 
mid-1900's, others in the last decade or so -- that are being used to 
help addicts quit. For heroin addiction, there's methadone and 
buprenorphine, both of which bind to and activate opioid receptors in 
the brain.

Each essentially substitutes for heroin by activating the same brain 
receptors as the drug, but many addiction doctors prefer 
buprenorphine, which the Food and Drug Administration approved in 
2002, because it causes less of a high and less dependence.

For alcohol, Antabuse, which makes people physically ill if they 
drink, has been on the market since 1948, although it isn't widely 
used. Addiction scientists are more hopeful about another 
anti-alcoholism drug, naltrexone, which was originally developed to 
treat opioid addiction but was approved for the treatment of 
alcoholism in 1994. Studies have found it can help some alcoholics 
abstain from or cut down on their drinking, and two pharmaceutical 
companies recently teamed up to produce Vivitrol, a long-acting, 
injectable form of naltrexone, which the F.D.A. approved in April. 
Some hope Vivitrol will sidestep a huge challenge facing those 
seeking pharmacological solutions for addiction: unless they're 
getting high from it, most addicts aren't model medicine takers. 
(Vivitrol requires a monthly shot from a doctor.)

None of the medications currently approved to treat addiction are 
perfect, and in many ways they are the products of some of our 
earlier advances in neuroscience. In the last few years, though, 
scientists say they've learned a staggering amount about how 
addiction affects the brain, and neuroscientists and other addiction 
researchers are eagerly testing and developing a new generation of 
anti-addiction medications.

"In 5 or 10 years, we will be treating addiction very differently," 
predicts Nora Volkow, a psychiatrist and the director of the 
institute on drug abuse, who attended the M.I.T. conference and 
presented a lecture, "Addiction: The Neurobiology of Free Will Gone 
Awry," in an intense and rapid-fire speaking style. (Besides being a 
leading American thinker about addiction, Volkow is the 
great-granddaughter of Leon Trotsky.) What Volkow means is that in a 
decade or so, we may actually start treating addiction effectively. 
Addiction is one of the nation's biggest public health problems, 
costing $524 billion (including lost wages and costs to the public 
health care and criminal justice systems) each year. The majority of 
the estimated 20 million alcoholics and drug addicts in America (and 
millions more compulsive gamblers, overeaters and sex addicts, if you 
accept an expanded understanding of addiction) never get help. Those 
who do often relapse repeatedly, sometimes returning to treatment 
centers 5, 10 or 15 times (if they don't die first). And many of 
those who "recover" simply trade one addiction for another -- addicts 
call this dance "switching seats on the Titanic."

The Dopamine Connection

For much of the past two decades, Volkow and other neuroscientists 
exploring the physiological basis of addiction have tried to explain 
it by studying the brain chemical dopamine, which functions as a 
neurotransmitter, sending signals between cells in the brain. 
Dopamine affects a variety of critical functions, including learning, 
memory, movement, emotional response and feelings of pleasure and pain.

Dopamine was originally thought to serve as a kind of pleasure signal 
in the brain, telling us when something feels good or rewarding.

But scientists now believe that dopamine is more a predictor of 
salience -- that is, it tells us, and then helps us to remember, what 
we should focus on. When you see a person you are strongly attracted 
to, scientists can now see a spike of dopamine in your brain.

If you are hungry and smell a food you like, dopamine also increases.

But even unpleasant experiences -- like physical pain or the fear of 
an intruder in the house -- can cause a dopamine spike. (Some 
hypothesize that different dopamine receptor cells are responsible 
for firing during rewarding or aversive situations.)

Drugs, particularly cocaine and methamphetamines, cause a large 
increase in the amount of dopamine secreted and pooling between brain 
cells, leading to feelings of euphoria.

With regular, repeated "addictive" drug use, though, the brain 
eventually responds by reducing its normal release of dopamine.

Studies also show a simultaneous decrease in the number of dopamine 
receptors created. That, in turn, makes the brain's reward system 
less likely to respond to behaviors (romance, a good meal, the 
company of friends) that produce a normal dopamine surge.

The addicted brain essentially becomes pathologically selective, 
dependent on bigger and bigger blasts of, say, cocaine to feel rewarded.

Perhaps most fascinating to addiction researchers is how an increase 
in dopamine creates a craving -- and an expectation of a reward.

In a study published earlier this month in The Journal of 
Neuroscience, Volkow used a brain scan to look at the dopamine 
releases in 18 cocaine addicts while they watched two videos: one of 
nature scenes, the other of people using cocaine.

Volkow found that dopamine increased while the addicts watched the 
cocaine video and that the severity of the increase matched their 
self-reported level of craving for the drug. "For these people, their 
lives and experience had taught them that when they see others using 
cocaine, they're probably about to get rewarded with drugs, too," 
Volkow told me. "So even though they consciously knew that they 
weren't going to get cocaine after watching the video, their brains 
had learned to expect the reward." Scientists posit that cue-induced 
dopamine spikes and craving essentially overpower the brain's 
well-meaning frontal cortex, which is responsible for planning and 
decision making.

The institute on drug abuse is currently financing studies of 
medications that could potentially blunt that process, interfering 
with the release of dopamine when an addict sees a conditioned cue.

Dopamine also travels to the parts of the brain responsible for 
solidifying memory, like the amygdala, which learns and stores 
emotional memories (including the high of drugs). Some researchers 
hypothesize that through a combination of medicine and behavioral 
therapy, addicts could "unlearn" these powerful memories and 
associations, making them less likely to relapse when they see a cue. 
"Potentially, you could put an addict in a virtual-reality situation 
where you show them videotapes of friends they used to use drugs 
with, or whatever their strongest triggers are," Eric Nestler, a 
neuroscientist and addiction specialist at the University of Texas 
Southwestern Medical Center, told me earlier this month. "But now, 
the cue isn't associated with any kind of rewarding response.

So then you can give a medication, which we're making progress on 
developing, that enhances memory formation.

Essentially, you'd be teaching them something new -- that a line of 
white powder means nothing special."

Dopamine may also make some people more vulnerable to addiction. 
Recent studies in both animals and humans have indicated that those 
with low levels of dopamine D2 receptors, which regulate the release 
of dopamine in the brain, are more likely to find the experience of 
taking drugs pleasurable. Some researchers, like Volkow, suggest that 
people with fewer D2 receptors experience a less intense reward 
signal, causing them to overindulge in order to feel satisfied.

In one experiment, Volkow increased the level of dopamine D2 
receptors in rats that had low levels.

After the increase, the rats significantly curtailed their intake of 
alcohol, which they had eagerly gulped down before.

Unfortunately, we don't yet know how to safely increase the number of 
dopamine D2 receptors in humans.

In fact, we don't yet know how to do much when it comes to dopamine 
and addiction.

Understanding how the neurotransmitter works may help us to 
understand addiction better, but it hasn't led to any effective 
medications, the ultimate goal of many researchers. Because addiction 
seems to disrupt so many different brain regions, neuroscientists are 
now casting a wider net in their pursuit of effective medications. 
For some, the new frontier involves the brain's two major "workhorse" 
neurotransmitters: GABA and glutamate.

Getting the Brain's Brakes to Work

Walter Ling, a neurologist and the director of the Integrated 
Substance Abuse Programs at U.C.L.A., likes to explain complex brain 
processes using simple metaphors.

GABA, he says, is to a brain what a braking system is to a car. "The 
brain works by inhibition," he told me recently. "At some point you 
realize that your car is a great car not because of its engine but 
because it has a great braking system. GABA is the brakes.

If your brakes don't work well, you crash."

GABA (gamma-aminobutyric acid) is the brain's major inhibitory 
transmitter, and its role, in essence, is to keep glutamate, the main 
excitatory transmitter, from overwhelming us. In the extreme, too 
much glutamate can cause a seizure and too much GABA can put us in a 
coma. Researchers are particularly interested in the brain's critical 
balance of GABA and glutamate -- some hypothesize that addictive 
craving is the result of too much glutamate or too little GABA. 
"We've been able to measure GABA in living brains for some time, but 
measuring glutamate in living human brains has just become feasible 
in the last few months," says Frank Vocci, the director of the 
division on pharmacotherapies and medical consequences at the 
institute on drug abuse. "What's been shown is that people with 
alcohol and cocaine problems have less GABA in their brains, and we 
do know that medications that increase GABA have shown some efficacy 
in treating addiction." (Vocci says that it isn't yet clear whether 
the absence of GABA is a cause of addiction or a result.) The seizure 
medication topiramate, for example, works on both GABA and glutamate 
and has helped some alcoholics in initial trials quit or cut back on 
their drinking.

The muscle relaxant baclofen, which essentially mimics the effects of 
GABA, may also help some cocaine addicts quit. Both are being tested 
further by the institute.

Hythiam, a Los Angeles-based health care services management company 
that made national news in the spring when it plastered Chris 
Farley's face -- with the words "It Wasn't All His Fault" -- on a 
series of Los Angeles billboards, is particularly interested in 
GABA's role in addiction.

The company is aggressively marketing its Prometa protocol for 
cocaine, alcohol and methamphetamine addiction, which involves 
therapy and medications, both oral and intravenously injected, not 
usually used to treat addiction: flumazenil, approved by the F.D.A. 
to treat overdoses of Valium and Xanax, and gabapentin, approved to 
relieve neuropathic pain. While no double-blind placebo studies have 
tested Prometa's effectiveness (two are under way), 
addiction-medicine doctors around the country who have administered 
the protocol report encouraging results.

Prometa appears to reduce anxiety and craving by enhancing the 
brain's GABA receptors, says David Smith, the former president of the 
American Society of Addiction Medicine and now the director for 
medical affairs at Hythiam and the head of a Prometa treatment center 
in Los Angeles. Sanjay Sabnani, Hythiam's senior vice president for 
strategic development, says: "It's all hypothesis at this point, 
because we haven't sliced open anyone's brain yet, but it seems that 
normalizing the GABA receptor takes away the craving and anxiety that 
one would typically experience in the absence of the drug. And it 
doesn't appear to be happening because of will power, love, God, 
discipline, family support or anything else. It seems to be happening 
because the protocol resets a faulty mechanism in the brain." Yet, 
several addiction scientists told me they were skeptical that Prometa 
works, and some criticized Hythiam for promoting it before it has 
been rigorously tested.

The Prescription Model

Hythiam was among a handful of companies publicizing their 
anti-addiction medications last month at the American Society of 
Addiction Medicine conference in San Diego. Several were armed with 
charts, graphs and clinical-study results (particularly the ones that 
found their medications most effective), and their eager young 
marketing and sales teams talked about doing for addiction what the 
pharmaceutical industry did for depression: medicalizing it, and 
destigmatizing it in the process.

They know it won't be easy. A series of recent surveys sponsored by 
the National Council on Alcoholism and Drug Dependence and by Faces 
and Voices of Recovery, a recovery advocacy group, found that half 
the public called addiction a personal weakness.

Among those who did see addiction as a disease, most put it in a 
special category of diseases that people get by making poor choices.

In a 2004 poll of the general public, two-thirds said they believed 
that a stigma -- usually defined as a thing that disgraces a person 
or injures one's reputation -- exists for people in recovery from addiction.

The pharmaceutical companies came to San Diego to argue that 
addiction is a chronic and recurring disease like diabetes or 
hypertension -- and no one, they say, tells a diabetic to try to 
tough it out without insulin.

They don't discount the importance of environment in inducing 
addictive behavior or psychosocial interventions as part of the 
recovery process; in fact, most stress therapy as an essential 
adjunct to their products.

But they insist that medications will stabilize addicts and make the 
deeper therapeutic and spiritual work more effective.

In the exhibition hall, the prime booth location near the entrance 
belonged to Alkermes and Cephalon, the two pharmaceutical companies 
producing and marketing Vivitrol, the recently approved, injectable 
form of naltrexone, prescribed for alcoholics. Alkermes and Cephalon 
are initially focusing on doctors who specialize in addiction, but 
they plan eventually to market the drug directly to primary care 
physicians, most of whom are used to sending their addicted patients 
to treatment centers and groups like Alcoholics Anonymous. "It would 
require a complete paradigm shift," Doug Neale, a product director at 
Cephalon, told me, "but we'd like to see the day when a patient who 
is struggling with alcoholism can walk into their primary care 
doctor's office, say, 'Doc, I'm drinking too much and can't seem to 
stop,' and the doctor will have a handful of options for medications 
that he could prescribe."

But Ling, the U.C.L.A. researcher, cautions that we still have a way 
to go before we can effectively treat most addicts medically. "In 
general, we have a pretty good handle on dealing with opioid 
addiction," he says. But "if you look at the various studies of 
alcohol-abuse drugs, the results are mixed at best," he continues, 
adding: "These kinds of mixed findings mean that the drug maybe works 
for some people, but it's not working all that great.

And we're still far off from having a handle on treating people 
addicted to stimulants like cocaine and methamphetamine."

A Higher Power Versus Medicine

John Schwarzlose, the president of the Betty Ford Center, says he 
isn't convinced that treating alcoholics and drug addicts with more 
drugs -- particularly if they aren't proved effective -- is a good 
idea. He points out that millions of addicts around the world have 
recovered without the help of medication. "We're open to medications 
that will actually work, but the fact is that today 12-step treatment 
is still the best treatment there is," he told me. "Nothing even comes close.

And until something does, we like to try to keep most of our patients 
as drug-free as possible."

Many addiction treatment centers share that view, which made for a 
strange scene in the exhibition hall at the society of addiction 
medicine conference. The treatment centers, most of which advocate a 
behavioral and spiritual solution to addiction, promoted their 
centers right next to pharmaceutical companies boasting novel medical 
solutions. "Why can't these two camps come together?" Smith, the 
medical director of Hythiam, said as he sat in front of the company's 
booth. "They need to come together.

In medicine, if something isn't working, you try something new. In 
addiction, if someone goes to treatment and fails, for years we've 
just sent them back again and again and expected different results.

That's insanity.

And we're starting to realize that. The field of addiction treatment 
is changing right before our eyes, and it's only going to continue to 
change. Advances in neuroscience and pharmacology will change everything."

Those changes could lead to addiction vaccines.

Several are already in development. The British company Xenova Group 
Plc has created what it says are effective vaccines for cocaine and 
nicotine addiction (NABI Biopharmaceuticals in Florida has also 
developed a nicotine vaccine). The vaccines, which the institute on 
drug abuse and others are testing, work by producing antibodies to a 
specific drug, binding to the drug when it enters the bloodstream and 
keeping it from entering the brain.

An effective vaccine won't stop craving or treat any underlying 
pathology (making it an inadequate solution, some say), but it will 
make it nearly impossible for an addict to get high on that 
particular substance.

And if it is combined with medications that could blunt craving, some 
addiction specialists believe that we'll stop using the word "treat" 
and start using the word "cure." Matthew Torrington, an 
addiction-medicine doctor in Los Angeles who works with Smith at his 
Prometa center, attended the society's conference and told me that he 
believes we can essentially eliminate addiction in America.

"With the scientific advances we're making in understanding how the 
human brain works," he says, "there's no reason we can't eradicate 
addiction in the next 20 or 30 years.

We can do it by fixing the part of the brain that turns on you during 
drug addiction and encourages you to kill yourself against your will. 
I think addiction is the most beatable of all the major problems we 
face. And I think we will."

The Stress Culture

It's not the first time a doctor has predicted the end of addiction. 
In his book "Slaying the Dragon: The History of Addiction Treatment 
and Recovery in America," William L. White recounts how in the 
1800's, countless "medications" like Knights' Tonics for Inebriates 
promised to remove "the craving for a stimulant that those who have 
been addicted to the use of ardent spirits know so well." In the 1905 
Sears, Roebuck & Company catalog, a person struggling with opium or 
morphine addiction could buy a bottled "cure" for 69 cents.

Most of these miracle potions were promoted as a result of important 
scientific and medical breakthroughs. Science, it seems, has always 
been just about to save us from addiction. "But it has never lived up 
to its promise," says Bruce Alexander, emeritus professor of 
psychology at Simon Fraser University in British Columbia, "and I 
don't believe the science will live up to its promise now, either. 
Addiction doesn't demand a scientific solution."

Alexander is among a vocal group of addiction researchers who argue 
that focusing on a pill to treat addicts fails to address the primary 
cause of becoming and staying hooked: our unhappy, disconnected 
lives. Beginning in the late 1970's, Alexander and his team of 
researchers at Simon Fraser set out to study the role of our 
environment on addictive behavior.

Until that point, most scientists studying addiction put rats in 
small, individual cages and watched as they eagerly guzzled 
drug-laced solutions and ignored water and food, sometimes dying in 
the process.

This phenomenon was noted -- first by researchers, then drug czars, 
then parents trying to keep their children off drugs -- as proof of 
the inherently addictive quality of drugs and of the inevitable 
addiction of any human who used them. This was false, of course.

Most people who use drugs don't become addicted.

So what made all those lab rats lose their minds?

Bruce Alexander and his research team had a rather simple hypothesis: 
The rats had awful lives. They were stressed, lonely, bored and 
looking to self-medicate. To prove it, Alexander created a lab-rat 
heaven he called Rat Park. The 200-square-foot residence featured 
bright balls and tin cans to play with, painted creeks and trees to 
look at and plenty of room for mating and socializing.

Alexander took 16 lucky rats and plopped them into Rat Park, where 
they were offered water or a sweet, morphine-based cocktail (rats 
love sweets). Alexander offered the same two drinks to the control 
group of rats he left isolated in cages.

The results?

The rat-parkers were apparently having too much fun to bother with 
artificial highs, because they hardly touched the morphine solution, 
no matter how sweet Alexander and his colleagues made it. The 
isolated and arguably depressed rats, on the other hand, eagerly got 
high, drinking more than a dozen times the amount of the morphine 
solution as the rats in paradise.

When I spoke with Alexander recently, he predicted that unless we 
undergo a "cultural renaissance" and all start living in a human 
version of his rat park (which he conceded isn't likely), we won't be 
eradicating addiction anytime soon. While Volkow of the institute on 
drug abuse doesn't agree with Alexander that developing addiction 
medications is a fruitless enterprise, she does say that a positive 
and nurturing environment, particularly during childhood and 
adolescence, is a strong protector against addiction.

Volkow says that addicts are more likely to have been unnecessarily 
stressed during childhood (from neglect; emotional, physical or 
sexual abuse; or poverty) and that they're less able to deal with 
stress as adults.

Studies show that animals who are stressed during early development 
are more likely to self-administer drugs later in life and that 
living in an enriched environment -- one with a minimal amount of 
strain and anxiety, like Rat Park -- appears to protect animals from 
developing addictive behavior.

And remember the dopamine D2 receptors that some hypothesize may 
protect us from abusing drugs?

There is evidence that our environment can affect those, too. In 
2003, researchers at the Wake Forest School of Medicine measured the 
levels of dopamine D2 receptors of 20 macaque monkeys while they were 
housed in isolation.

They then assigned the monkeys to social groups of four monkeys each, 
letting natural social hierarchies develop.

Three months later, they tested the levels of D2 receptors again.

The dominant monkeys -- who, the theory goes, were much less stressed 
and anxious than the subordinate ones -- had 20 percent higher D2 
receptor function, while the submissive ones were unchanged.

The monkeys were then taught how to self-administer cocaine by 
pressing a lever, with researchers finding that the dominant monkeys 
took significantly less cocaine than the subordinate ones.

Interestingly, though, when the animals that seemed to be protected 
from addiction were given cocaine repeatedly, the number of their D2 
receptors eventually went down, and they then became addicted.

The moral of the monkey story, Volkow says, is that environment -- if 
good or bad enough -- can sometimes trump genetics and biology.

"Some people may be naturally better protected against addiction than 
others," Volkow says, "but that's not enough to keep someone from 
becoming addicted.

The same thing is true for those who are genetically predisposed. We 
know from twin and family studies that about 50 percent of a person's 
vulnerability to addiction is genetic. But if you're never exposed to 
illegal drugs, or if you grow up and live in an environment without 
trauma and too many stressors, you probably won't become addicted."

If It's Not One Addiction, It's Another

What Volkow and other researchers can't yet explain is why we choose 
one particular manifestation of addiction over another.

Why do some of us become addicted to cocaine, while others are hooked 
on alcohol or cigarettes? Researchers hypothesize that environmental 
availability and genetic predisposition both play a part, but they 
don't know for sure.

Further complicating the question is that many people are addicted to 
more than one thing.

Howard Shaffer, director of the division on addictions at the 
Cambridge Health Alliance, an affiliate of Harvard Medical School, 
suggests a "syndrome model" of addiction: each outwardly unique 
manifestation of addiction is actually part of the same underlying disorder.

Shaffer's syndrome model argues that behavioral addictions (like 
gambling, sex and eating) can be just as powerful as an addiction to 
heroin or crystal meth, and his belief is gaining acceptance among 
neuroscientists and addiction researchers, many of whom used to 
dismiss this idea as a product of an American culture that's addicted 
to calling everything an addiction.

But by studying the brain's reward and pleasure systems, researchers 
are discovering that drugs and powerfully rewarding behaviors like 
gambling and sex affect it in similar ways. Neurologists at the 
University Medical Center Hamburg-Eppendorf in Germany, for example, 
found that pathological gamblers, like drug addicts, have a sluggish 
reward system that doesn't react normally to pleasing stimuli.

The scientists used an M.R.I. scanner to compare the brain responses 
of 12 gambling addicts and 12 nonaddicted people to a card-guessing 
game. Subjects were told to pick a playing card, and if the card 
turned out to be red, they won a euro.

The game activated the ventral striatum, an important part of the 
brain's reward system.

Those nonaddicts who picked a winning card had increased blood flow 
to the striatum, but the gambling addicts who picked the right card 
had much less of it (their reward system was less active). It was as 
if their brains, which were accustomed to powerful rewards, were 
saying, "You call this silly prize a reward?" The same kind of 
indifference to basic rewards has been seen in the ventral striatum 
of cocaine addicts.

"People addicted to gambling and drugs look a lot alike," Shaffer 
told me when I visited him in his office in March. "Gamblers have to 
increase their bets to get the same level of excitement, just like 
someone addicted to drugs who has to keep using more to get an 
effect. When addicted gamblers cut back, they experience withdrawal 
symptoms that look like stimulant withdrawal. They get depressed, 
they're irritable and they have trouble sleeping.

And if they gamble again, they can make the symptoms go away for the 
short run."

While Shaffer focuses much of his recent behavioral addiction 
research on gamblers, Volkow studies overeaters and also finds many 
similarities to drug addicts and alcoholics -- including the fact 
that obese subjects have lower levels of dopamine D2 receptors than 
those who eat normally. "Because we know that many people are 
addicted to more than one thing and that many people switch 
addictions," she told me at the M.I.T. conference, "in my own 
research I'm mostly interested in developing medications that could 
work across a variety of addictions."

An Addict's Perspective

What do addicts think about all this focus on their brains?

William C. Moyers, a recovery advocate (and the son of the journalist 
Bill Moyers) who for 12 years has been free of crack and alcohol, was 
invited to speak at the M.I.T. conference. In a room full of 
scientists and addiction researchers obsessed with the intricacies of 
the human brain, Moyers read a lecture that reminded them that 
treating addiction might be even more complicated than they thought.

"I have an illness with origins in the brain. . .but I also suffered 
with the other component of this illness," he told the gathered 
researchers and scientists, some of whom dutifully took notes. "I was 
born with what I like to call a hole in my soul.. . .A pain that came 
from the reality that I just wasn't good enough.

That I wasn't deserving enough.

That you weren't paying attention to me all the time. That maybe you 
didn't like me enough."

The conference room was as quiet as it had been all day. "For us 
addicts," he continued, "recovery is more than just taking a pill or 
maybe getting a shot.. . .Recovery is also about the spirit, about 
dealing with that hole in the soul."
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