A recent special report on an Indiana TV station (WSBT @KristinBienWSBT) explores addiction as a disease not a choice. I wrote a story about exactly this while attending the University of British Columbia’s School of Journalism for my masters’ degree. Here is the article:
Addiction: A Disease not a Choice
Rodrigo was such a gifted athlete that at 13 he joined the professional soccer circuit. By the time he was 19 he was one of the country’s best players, and married with one child. He was also addicted to Percoset that was originally prescribed for pain resulting from a sports injury. “My pills were more important than my beautiful wife and daughter. How sick is that?”
Cindy grew up in an upper class family where feelings were to be hidden. She became a stunning fashion icon married to a high profile politician who had high profile extra-marital affairs. She suffered five miscarriages and two of the three children she did have survived cancer. She drank vodka to numb her feelings. “I thought that is what you were supposed to do. But I continually embarrassed my family by making a fool of myself in public. It would be reported in the press time and time again. How sick is that?”
I was the youngest of four children with a raging alcoholic father. I enjoyed recreational drug use and drinking until I was 42 years old. My husband had died of cancer, leaving me with two small children and no parenting skills. My brother had died of AIDS. I turned to drugs and alcohol to cope. Then they took over. I drove my kids drunk and on pills. How sick is that?
Kate was sexually abused from ages 10 to 13 by a family “friend.” At 18 she left home with zero self-esteem and a problem with alcohol and marijuana. She soon became a heroin addict prostituting herself to finance her habit. How sick is that?
“Alcohol and drug addiction is the single most complex health problem facing North Americans.”
This statement by Paul Welsh, director of Rideauwood Addiction and Family Services in
Ottawa, is the belief of professionals who work in the field of alcohol and drug addiction.* Their research proves that addiction impacts the lives of one in every five people. It knows no demographic boundaries. Rodrigo, Cindy and Kate and I are no different than bums on skid row. We were all in the same drug and alcohol treatment facility six years ago.
Many addicts were once law abiding, decent family members who turned into liars, cheaters and manipulators who valued their substance of choice over their loved ones. Their shocking behaviour is explained away with reasons such as bad genes, poor parenting, misguided social groups and serious character flaws. But there are other reasons, brain chemistry reasons, that explain why addicts do the things they do.
“For the first time in the history of medicine, doctors have some hard and fast facts about what happens to the human brain when it becomes addicted to drugs and alcohol. There is a new neuroscientific understanding of addiction that will revolutionize its treatment,” says Dr. Kevin McCauley, an addiction doctor with The Institute for Addiction Study in Park City, Utah. He and his colleagues state uncategorically that, “Addiction is a disease, not a choice.”
Dr. McCauley refers to the fact that 100 years ago people with mental illness were considered criminals and incarcerated. As science advanced so did the understanding of how the mind and body interact. Along with this new understanding came a compassion for people with mental illnesses. They are now considered to a have a disease and hospitalized.
“How do we know we are not making the same mistake with addicts?” Our jails are overflowing with drug addicts and Dr. McCauley predicts that one day they will be regarded as patients instead of criminals.
There is one point The Centre for Addiction Study stresses adamantly, “We do not believe that any of this new research excuses bad behaviour, or absolves the addict of the
(* Addicts and alcoholics are being referred to in the same breath in this scientific exposition because alcohol affects the human brain in the same way as other addictive drugs. It is a mind-altering substance that can cause problems as severe as those caused by heroin and cocaine.)
responsibility to account for the pain they may have caused those around them. We believe that both the following statements are true: Addiction is a disease and addicts must take responsibility for managing it.”
The challenge to neuroscientists is: How can we call addiction a disease when addicts, after all, choose to use drugs. Real diseases do not involve choice. Diabetics cannot choose to have low blood sugar, but addicts can choose to stop using drugs. If you offer drugs to an addict, but put a gun to their head and tell them that if they use they will be shot, the addict will choose not to use. This is not a possibility for the diabetic. A gun to the head of a diabetic will not make them choose to lower their blood sugar. The crux of this particular argument is this: Diabetes is a real disease. Addiction is a choice.
Dr. McCauley argues that this explanation misses a fundamental point about addiction. This threat of death with a gun to the head of the addict does not alter their control over their craving for the drug. McCauley defines craving as, “an intense, emotional, obsessive thought process that occurs in addicts. It does not occur in non-addicts, or even in bad abusers. It is a form of neural activity that is visible on sophisticated brain scans.”
Craving for an addict causes severe suffering, is all-consuming, completely involuntary, annihilates good judgment and distorts the ability to exercise choice.
Dr. Graeme Cunningham, director of the addiction division at Homewood Health Centre in Guelph, Ontario elaborates, “Telling an alcoholic they can learn to control their drinking is like suggesting to a heroin addict they can learn to shoot up only socially. The science clearly shows they are addicted to a chemical, that the brain changes to develop the phenomenon of a craving and that the change is permanent.”
Rodrigo had made a decision to not pop those pills before his wedding. Cindy had made a decision not to get drunk at husband’s victory party. I had made a decision to never snort that powder before picking the girls up from school. Kate made a decision not to trust that ugly man. All of our good intentions were of no value because we had crossed the line. We had crossed the line into the disease of alcoholism and addiction and there is no going back. Once the disease is active the individual has no control whatsoever over the craving. This is not an excuse for our inexcusable actions. This is the reason.
The Disease Model that has been the standard for modern medicine for a century states that a disease is a physical, cellular defect that occurs in an organ in the body and leads to symptoms.
Organ > Defect > Symptoms of disease
Pancreas > No insulin > Elevated blood glucose, blurred vision, coma etc.
Doctors treat patients’ symptoms by knowing the defect in the organ and fixing it. This is straightforward for diseases like diabetes. The pancreas is malfunctioning so doctors can replace the insulin.
However, the organ involved in addiction is the brain, which is difficult to study. The part of the brain involved is actually the midbrain, the survival brain. The midbrain simply acts to save the organism’s life. It is the automatic, here-and-now, eat-kill-copulate, do-whatever-it-takes-to-survive part of the brain. It acts unconsciously and instantaneously, with no future planning or evaluation of long-term consequences.
The job of keeping the midbrain in check falls to the frontal cortex. It gives meaning to concepts and objects. It regulates love, morality, decency, responsibility, spirituality and conscious choice. In a healthy, non-addict brain the frontal cortex exerts a kind of top-down control over the midbrain. It is always stronger than the midbrain.
In an addict this is not the case. This has been proven through a study conducted all the way up the ladder of evolution from mice to monkeys and chimpanzees. In this study, cocaine was injected into the frontal cortex, and it had no effect on any of the animals’ behaviours. When given the option, they did not choose to self administer the drug. When cocaine was injected into the midbrain, on the other hand, the subjects self-administered the drug until it killed them, flying in the face of all survival instincts.
The erroneous perception of the drug as crucial to survival actually travels from the midbrain to the frontal cortex. It is no longer top-down. The drug takes on unreasonable personal meaning and the addict derives their sense of self from their drug of choice. This is why addicts seem to lose their morals when they are using. When Rodrigo said he loved his pills, when Cindy said she loved her vodka, when I said I loved my cocaine, and when Kate said she loved her heroin, we were not lying.
Genes can predispose a person to addiction but they are not necessarily the cause of addiction. For addiction to develop, something in the environment needs to act on the genes to trigger the addiction. That something is stress. Addiction is a stress-induced defect deep in the midbrain.
This has to be severe stress that can be caused by a number of conditions such as trauma, an undiagnosed mental illness, and consistent or long range suffering. Paul Welsh of Rideauwood explains that, “addiction is a disease whose causes are often rooted in childhood trauma – abuse, neglect or violence – and are reinforced as addicts get older.” Even the drug itself can be the source of severe stress.
Rodrigo’s stress came from a truncated childhood and the pressure endured by a professional athlete on an emotionally unfit boy. Cindy’s stress came from extreme pressure endured from personal tragedy under the public glare. Mine came from tragic events that I was ill equipped to handle. The original source of Kate’s stress was, of course, the sexual abuse. Then the consistent self abuse committed by all of us reinforced the stress cycle.
According to McCauley:
“These stressors, if severe enough, persist long enough, and are not resolved, can cause chronically elevated levels of stress hormones, the most important of which is called corticotropin-releasing factor, or CRF. This CRF sensitizes the stress system in the midbrain. Eventually the midbrain interprets this stress not as just unpleasant but as an actual threat to survival. Severe stress changes the midbrain. Chronic severe stress breaks the midbrain. And specifically what breaks in the midbrain is the dopamine system.”
Dopamine is the chemical the brain releases to give us the feeling of pleasure. Our brain uses pleasure to identify things in the environment that have survival value. If a person is starving, chocolate cake is more likely to save their life than broccoli. Chocolate cake releases more dopamine than broccoli and that is why it tastes better. That dopamine, in turn, relieves the survival stressor of hunger. The brain’s ability to identify whatever helps the body to survive is in effect our pleasure sense. Neuroscientists call this the brain’s hedonic capacity.
High levels of stress, thus high levels of the CRF hormone, cause the dopamine system to fail. The pleasure sense malfunctions. Normal stress produces normal levels of dopamine which are not enough for the stressed person to feel pleasure. There is no relief of stress. Chronic severe stress causes the person’s midbrain to become anhedonic. Their midbrain can no longer derive normal pleasure from normally pleasurable activities.
So what does register? What can produce big surges of dopamine?
Drugs and alcohol.
Addiction is a stress induced defect in the midbrain’s dopamine system – it’s hedonic (pleasure sense) system. The resulting symptoms are decreased functioning such as loss of control, cravings and Persistent Use of Drugs Despite Negative Consequences (PUDNC).
Organ > Defect > Symptoms
Midbrain > Stress-Induced Hedonic Dysregulation > Loss of Control, Craving, P.U.D.N.C.
Addiction, therefore, is a disease. There is no cure. The addict can manage their addiction, just as a diabetic manages their blood sugar levels. The task of treatment is to give the addict these “managing” tools – tools to deal with stress and emotions in a functional manner. That means realigning the healthy top-down (frontal cortex to mid-brain) directive in the addict’s brain functioning. These are skills of recovery and are essential for the addict to remain clean, to keep their disease in remission.
An addict usually has to hit a bottom in order to accept help. They need a moment of complete surrender which allows, if for however briefly, for the frontal cortex to peek its head out, and allow the addict to see just where the disease has taken them.
Rodrigo’s bottom was when he and his teammates took turns having sex with an overweight waitress for Hooters. For Cindy it was when she broke her shoulder falling on the side of the road and having her adult children put her in their conservatorship. For me it was when I woke up realizing I had blacked out the night before while driving the kids drunk and on pills. For Kate the final blow was waking with a dead body beside her.
Most treatment centres use the twelve steps of Alcoholics Anonymous which operate somewhat like an instruction manual for healthier ways to deal with fear, anxiety, strong emotions and stress. This requires brutal self honesty. One has to uncover reasons why one plummeted to such unmanageable depths. One has to unveil and confront such demons as sexual abuse, alcoholic parents, trauma, abuse of others and self, and also dissect every single defect of character.
This becomes a spiritual journey and a lifetime commitment. Without that, the fate of the addict is certain to lead to jails, institutions and death. Ultimately the disease of addiction is terminal.
Feb. 25, 2008