Pubdate: Tue, 28 Aug 2007
Source: Washington Post (DC)
Page: HE01
Copyright: 2007 The Washington Post Company
Contact:  http://www.washingtonpost.com/
Details: http://www.mapinc.org/media/491
Author: Maia Szalavitz
Note: Maia Szalavitz is a senior fellow at Stats.org and the author, 
with Bruce D. Perry, of "The Boy Who Was Raised as a Dog and Other 
Stories From a Child Psychiatrist's Notebook" (Basic Books) and the 
author of "Help at Any Cost: How the Troubled Teen Industry Cons 
Parents and Hurts Kids" (Riverhead).

SO, WHAT MADE ME AN ADDICT?

Experts Debate Whether Disease or Defect Is to Blame

Many people think they know what addiction is, but despite 
non-experts' willingness to opine on its treatment and whether 
Britney or Lindsay's rehab was tough enough, the term is still a 
battleground. Is addiction a disease? A moral weakness? A disorder 
caused by drug or alcohol use, or a compulsive behavior that can also 
occur in relation to sex, food and maybe even video games?

As a former cocaine and heroin addict, these questions have long 
fascinated me. I want to know why, in three years, I went from being 
an Ivy League student to a daily IV drug user who weighed 80 pounds. 
I want to know why I got hooked, when many of my fellow drug users did not.

A bill was introduced in Congress this spring to change the name of 
the National Institute on Drug Abuse (NIDA) to the National Institute 
on Diseases of Addiction, and the National Institute on Alcoholism 
and Alcohol Abuse (NIAAA) to the National Institute on Alcohol 
Disorders and Health. In a press release introducing the legislation, 
Sen. Joseph R. Biden Jr. (D-Del.) said, "By changing the way we talk 
about addiction, we change the way people think about addiction, both 
of which are critical steps in getting past the social stigma too 
often associated with the disease."

But opinion polls find weak support for the concept of addiction as a 
disease, despite years of advocacy by such agencies as NIDA and NIAAA 
and by recovery groups. A 2002 Hart poll found that most people 
thought alcoholism was about half disease, half weakness; just 9 
percent viewed it wholly as a disease.

So what does science have to say? Addiction research has advanced 
dramatically since my high school years in the early 1980s, when I 
began using marijuana and psychedelics, then cocaine, in the hope 
they would relieve my social isolation. My progression from 
psychedelics to coke was fed by a definition of addiction that still 
causes widespread misunderstanding. In 1982 -- around when I first 
tried cocaine -- Scientific American published an article claiming it 
was no more addictive than potato chips. This was based on the fact 
that cocaine users, unlike heroin users, do not become physically 
sick when they try to stop taking their drug.

Addiction, by this reasoning, is a purely physiological process, one 
that results from drug-induced chemical changes in the brain and 
body. Over time, with heroin and similar drugs, the article 
explained, the user develops tolerance (needs more of the drug to 
experience the same effect) and eventually becomes physically ill if 
he doesn't have access to an adequate dose. Addiction, by this 
theory, is primarily an attempt to avoid physical withdrawal.

I bought into this idea because it was confirmed by my experience: I 
never had a problem stopping marijuana, LSD or mushrooms, none of 
which cause significant physical dependence. I expected cocaine to be 
similar and, therefore, safer than heroin. With no physical 
withdrawal to avoid, stopping should be a snap. Or so I thought.

By the time I got suspended from college for my involvement with 
cocaine, I was smoking it, often daily. And because I believed that 
my suspension meant I'd already ruined my life, I felt I had no 
reason not to try heroin. I just didn't care.

Heroin became my drug of choice. It calmed me, gave me distance from 
my obsessions and anxieties. Over time, cocaine made me feel anxious, 
but heroin always soothed and smoothed. I continued taking both, 
injecting higher and higher doses.

Today's most widely accepted definition of addiction -- used in 
psychiatry's latest edition of its diagnostic manual, the DSM-IV-TR 
- -- recognizes that compulsive use of a substance despite negative 
consequences is key. And that's exactly what I experienced: At least 
six times, I made it through the physical sickness of heroin 
withdrawal -- the shaking, diarrhea and vomiting -- only to use again 
because I wanted the drug. This compulsive aspect helps explain why 
we can now consider video games and, yes, even potato chips more 
addictive than we did in the past.

But the DSM retains a focus on physical aspects of addiction: It 
calls addiction "substance dependence," suggesting that physical need 
is critical. Tolerance and withdrawal are part of the criteria used 
to diagnose the condition, even though pain patients taking opioids 
as directed may experience both and not actually be addicted. Studies 
find that less than 1 percent of people who take pain medications and 
don't have a past history of drug problems become addicted. Many pain 
patients who stop opioids after the source of their pain has been 
removed even undergo withdrawal without realizing it: It's called 
"hospital flu." But the vast majority have no difficulty refusing 
further medication.

As a result, experts -- including NIDA director Nora Volkow -- have 
called for the official name of the disorder to be changed from 
"substance dependence" to "addiction" in the next edition of the DSM. 
They say the confusion between physical dependence and addiction 
leads to under-treatment of pain: Surveys find many patients, even 
those who are dying, don't receive enough medication for effective 
relief. Physicians are even criminally prosecuted for 
"over-prescribing" when patients with painful conditions become 
physically dependent on opioid drugs.

Your Brain on Dope

But if physical symptoms don't define addiction, does it follow that 
addiction is a brain disorder? Matters are murky here as well.

While researchers have argued that addiction is a disease because 
drugs change the brain, the fact is, most users -- even of drugs such 
as heroin -- do not become addicted. While 50 percent of American 
soldiers in Vietnam tried heroin or opium, only 10 percent continued 
to use such drugs after returning home, and just 1 percent became 
long-term opioid addicts, according to a federally funded study by 
University of Washington sociologist Lee Robins.

Further, all brain changes are not indicative of disease. Learning 
itself changes the brain. FMRI brain scans of London taxi drivers and 
virtuoso violinists show changes that embody the effects of years of 
practice in relevant brain regions -- however, no one argues that 
this means they are ill.

As a result, scans alone cannot prove that addiction is a disease. 
"The idea that fMRIs can explain addiction is based on the same 
unscientific grounds as phrenology," says psychologist Stanton Peele, 
a longtime opponent of seeing addiction as a disease and author of 
the new book "Addiction-Proof Your Child."

In my own experience, I stopped using when addiction threatened my 
core values. On my last day taking heroin, I found myself considering 
seducing a man to get drugs. Because I despised this guy and had a 
serious boyfriend, I was shocked that I would consider it: I knew 
that that was addictive behavior. At that point, my personal 
definition of an addict was someone who violates her own principles 
to get drugs. I sought treatment the next day and never used cocaine 
or heroin again.

In Peele's view, addiction is a bad habit, a learned behavior that 
gets out of hand, an exaggeration of the human tendency to put off 
pain in favor of immediate pleasure. Even, in some instances, a 
rational choice when life presents little opportunity for connection, 
purpose or joy.

Volkow disagrees. She has pioneered brain-imaging research on 
addictions, looking for ways in which they differ from ordinary 
learning. "Drugs of abuse affect multiple systems, not just those 
involved with learning and memory," she says, adding that they 
interfere with regions that put the brakes on unwanted behavior.

"What happens in the brain of the addicted person is equivalent to a 
state of deprivation. It changes the brain from operating in a 
situation where someone has a choice and does something because he 
wants to do it to a situation where it feels like need," she says.

That, too, comports with my experience: Cocaine seemed to affect my 
motivation, leading me to take more even when I knew it would fuel a 
burst of paranoia, not euphoria. While at first it brightened and 
enhanced other joys, over time it sucked the pleasure and color out 
of my life. But although I could consciously see this, I felt I couldn't stop.

Another relevant factor seems to have been my youth: We now know that 
the frontal cortex, the seat of judgment, the region that should 
apply the brakes, is not fully developed until the early to mid-20s. 
I quit at 23; when I look back on my behavior now, the sheer 
stupidity of some of the risks I took shocks me. Genetic research 
also suggests that certain people are more prone to addiction, 
particularly those with other mental illnesses such as depression, a 
condition I also have.

So does that make it a disease? Some would argue that my response to 
treatment proves it. I underwent seven days of detox, 30 days of 
rehab, then three months in a halfway house and ongoing self-help 
support. Later, antidepressant medication helped reduce the distress 
that I'd previously self-medicated with heroin.

As Thomas McLellan, chief executive of the Treatment Research 
Institute in Philadelphia and professor of psychiatry at the 
University of Pennsylvania, notes, treatment for addiction is as 
effective as treatment for other chronic diseases that involve 
lifestyle change, such as diabetes and asthma.

Stigma-Proofing Addiction

Just calling it a disease, however, may not reduce the moral stigma 
tied to addiction -- as some hope. University of Nevada psychologist 
Steven Hayes is studying people's unconscious responses to words. 
"Disease" was as stigmatizing overall as clearly pejorative terms 
such as "drunk," and was more stigmatizing overall than such terms as 
"addict" and "intoxicated," he says.

Consider the historical treatment of people with epilepsy or 
"madness." Or the fact that we think "tough" rehabs are good, despite 
evidence suggesting otherwise -- though we wouldn't even contemplate 
"getting tough" with diabetics. Says McLellan: "Yes, people with 
epilepsy were sent to priests and shamans, too -- but that was the 
18th century. Addicted people are still told to get religion."

The program I attended, for example, told me that I would not recover 
if I didn't surrender to a higher power, make amends and pray. This 
is not how most diseases are treated.

Further, labeling people with a brain disease characterized by lack 
of self-control can have negative consequences, particularly for 
adolescent users, most of whom are not addicts, suggest NIDA surveys 
and other research. In many teen rehabs, youths are told that they 
have "chronic, progressive" illness with a 90 percent chance of 
relapse. Forcing teens, whose identity is not fully formed, to accept 
an "addict" identity can be a self-fulfilling prophecy.

As Peele points out, "Self-efficacy and the image of the ability to 
control oneself are critical to recovery" -- as they are to 
maturation. For the same reason, it's a bad idea to tell people that 
without treatment, recovery is impossible. In fact, most addicts who 
recover do so without treatment. Among those who relapse, belief in 
the disease model is predictive of greater severity, research shows.

So is addiction disease or learned behavior? Given its complexity, 
some experts say, what probably matters most is which view best 
yields compassionate and effective treatment.
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MAP posted-by: Richard Lake