A Revolutionary New Way of Understanding Addiction
A New York Times best-seller, Unbroken Brain is part-memoir, part-guide to the neuroscience of addiction. Here is an excerpt from the Introduction.
There is often a struggle, and sometimes, even more interestingly, a collusion between the powers of pathology and creation. — Oliver Sacks
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.