Pubdate: Sun, 26 Jun 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: Maia Szalavitz
Note: Maia Szalavitz is the author of "Unbroken Brain: A 
Revolutionary New Way of Understanding Addiction."


I SHOT heroin and cocaine while attending Columbia in the 1980s, 
sometimes injecting many times a day and leaving scars that are still 
visible. I kept using, even after I was suspended from school, after 
I overdosed and even after I was arrested for dealing, despite 
knowing that this could reduce my chances of staying out of prison.

My parents were devastated: They couldn't understand what had 
happened to their "gifted" child who had always excelled 
academically. They kept hoping I would just somehow stop, even though 
every time I tried to quit, I relapsed within months.

There are, speaking broadly, two schools of thought on addiction: The 
first was that my brain had been chemically "hijacked" by drugs, 
leaving me no control over a chronic, progressive disease. The second 
was simply that I was a selfish criminal, with little regard for 
others, as much of the public still seems to believe. (When it's our 
own loved ones who become addicted, we tend to favor the first 
explanation; when it's someone else's, we favor the second.)

We are long overdue for a new perspective - both because our 
understanding of the neuroscience underlying addiction has changed 
and because so many existing treatments simply don't work.

Addiction is indeed a brain problem, but it's not a degenerative 
pathology like Alzheimer's disease or cancer, nor is it evidence of a 
criminal mind. Instead, it's a learning disorder, a difference in the 
wiring of the brain that affects the way we process information about 
motivation, reward and punishment. And, as with many learning 
disorders, addictive behavior is shaped by genetic and environmental 
influences over the course of development.

Scientists have documented the connection between learning processes 
and addiction for decades. Now, through both animal research and 
imaging studies, neuroscientists are starting to recognize which 
brain regions are involved in addiction and how.

The studies show that addiction alters the interactions between 
midbrain regions like the ventral tegmentum and the nucleus 
accumbens, which are involved with motivation and pleasure, and parts 
of the prefrontal cortex that mediate decisions and help set 
priorities. Acting in concert, these networks determine what we value 
in order to ensure that we attain critical biological goals: namely, 
survival and reproduction.

In essence, addiction occurs when these brain systems are focused on 
the wrong objects: a drug or self-destructive behavior like excessive 
gambling instead of a new sexual partner or a baby. Once that 
happens, it can cause serious trouble.

If, like me, you grew up with a hyper-reactive nervous system that 
constantly made you feel overwhelmed, alienated and unlovable, 
finding a substance that eases social stress becomes a blessed 
escape. For me, heroin provided a sense of comfort, safety and love 
that I couldn't get from other people (the key agent of addiction in 
these regions is the same for many pleasurable experiences: 
dopamine). Once I'd experienced the relief heroin gave me, I felt as 
though I couldn't survive without it.

Understanding addiction from this neurodevelopmental perspective 
offers a great deal of hope. First, like other learning disorders, 
for example, attention-deficit hyperactivity disorder or dyslexia, 
addiction doesn't affect overall intelligence. Second, this view 
suggests that addiction skews choice - but doesn't completely 
eliminate free will: after all, no one injects drugs in front of the 
police. This means that addicts can learn to take actions to improve 
our health, like using clean syringes, as I did. Research 
overwhelmingly shows such programs not only reduce H.I.V., but also 
aid recovery.

The learning perspective also explains why the compulsion for alcohol 
or drugs can be so strong and why people with addiction continue even 
when the damage far outweighs the pleasure they receive and why they 
can appear to be acting irrationally: If you believe that something 
is essential to your survival, your priorities won't make sense to others.

Learning that drives urges like love and reproduction is quite 
different from learning dry facts. Unlike memorizing your sevens and 
nines, deep, emotional learning completely alters the way you 
determine what matters most, which is why you remember your high 
school crush better than high school math.

Recognizing addiction as a learning disorder can also help end the 
argument over whether addiction should be treated as a progressive 
illness, as experts contend, or as a moral problem, a belief that is 
reflected in our continuing criminalization of certain drugs. You've 
just learned a maladaptive way of coping.

Moreover, if addiction resides in the parts of the brain involved in 
love, then recovery is more like getting over a breakup than it is 
like facing a lifelong illness. Healing a broken heart is difficult 
and often involves relapses into obsessive behavior, but it's not brain damage.

The implications for treatment here are profound. If addiction is 
like misguided love, then compassion is a far better approach than 
punishment. Indeed, a 2007 meta-analysis of dozens of studies over 
four decades found that empowering, empathetic treatments like 
cognitive behavioral therapy and motivational enhancement therapy, 
which nurture an internal willingness to change, work far better than 
the more traditional rehab approach of confronting denial and telling 
patients that they are powerless over their addiction.

This makes sense because the circuitry that normally connects us to 
one another socially has been channeled instead into drug seeking. To 
return our brains to normal then, we need more love, not more pain.

In fact, studies have not found evidence in favor of harsh, punitive 
approaches, like jail terms, humiliating forms of treatment and 
traditional "interventions" where families threaten to abandon 
addicted members. People with addictions are already driven to push 
through negative experiences by their brain circuitry; more 
punishment won't change this.

In line with the idea that development matters, research also shows 
that half of all addictions - with the exception of tobacco - end by 
age 30, and the majority of people with alcohol and drug addictions 
overcome it, mostly without treatment. I stopped taking drugs when I 
was 23. I always thought that I had quit because I finally realized 
that my addiction was harming me.

But it's equally possible that I kicked then because I had become 
biologically capable of doing so. During adolescence, the engine that 
drives desire and motivation grows stronger. But unfortunately, only 
in the mid-to-late 20s are we able to exert more control. This is why 
adolescence is the highest risk period for developing addiction - and 
simple maturation may be what helped me get better.

At the time, nearly all treatment was based on 12-step groups like 
Alcoholics Anonymous, which help only a minority of addicted people. 
Even today, most treatment available in rehab facilities involves 
instruction in the prayer, surrender to a higher power, confession 
and restitution prescribed by the steps.

We treat no other medical condition with such moralizing - people 
with other learning disorders aren't pushed to apologize for their 
past behavior, nor are those affected by schizophrenia or depression.

Once we understand that addiction is neither a sin nor a progressive 
disease, just different brain wiring, we can stop persisting in 
policies that don't work, and start teaching recovery.

Indeed, if the compulsive drive that sustains addiction is directed 
into healthier channels, this type of wiring can be a benefit, not 
just a disability. After all, persisting despite rejection didn't 
only lead to addiction for me - it has also been indispensable to my 
survival as a writer. The ability to persevere is an asset: People 
with addiction just need to learn how to redirect it.
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MAP posted-by: Jay Bergstrom