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We are a society addicted to addiction. Alcohol. Food. Caffeine. Sugar. Wheat. Sex. Shopping. Work. The internet. Porn. Love. Gambling. Head Shops. Exercise. Self-harm. Smartphones. Drugs. Over-the counter painkillers. Facebook. Football. The Wii.
It’s almost impossible to open a newspaper or turn on the internet with encountering a story on some new form of addiction.
In fact, think of virtually any pleasurable way to pass a few hours (and quite a few that aren’t remotely pleasurable) and you can be sure that someone, somewhere is deciding they’re addicted to it - and someone else is writing an article about it.
Photo by aftab. on Flickr
Research published in the Guardian newspaper in 2001 found that in 1990, newspapers in Britain had just 428 stories featuring the terms ‘addict’, ‘addicts’ or ‘addiction’; by the year 2000, this figure had risen dramatically to 11,707.
Put those same search terms into Google News today, and you’ll come up with an astonishing 39,000 articles from the last year alone.
Meanwhile, barely a day passes without some celebrity talking candidly about their addiction. Whether it’s Chris Evans declaring he has stopped drinking after a night out with Prince Harry; Sarah Jessica Parker bemoaning her addiction to nicotine, or Charlie Sheen talking openly about his experiences with porn stars and drugs, they seem to be lining up to out themselves as addicts.
Addiction is our new obsession.
But how much do we really understand about it? And are we guilty of simply pathologising every antisocial habit and passing compulsion?
In its true form, addiction is a formidable enemy – it can deeply and completely take over the brain, hijacking memory-making processes, exploiting emotions, and indiscriminately destroying lives.
Historically, the definition of addiction was straightforward: it was understood to be a physical and psychological dependence on psychoactive substances that were capable of crossing the blood-brain barrier.
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For certain addictions - alcohol, drugs, nicotine and even caffeine - that definition still works fine. After all, they have an external pharmacology that acts on our nervous system. The damaging effects of long term use are widely documented; the impact of withdrawal undeniable.
But this definition doesn’t account for all the other newer and more inventive ways we have found to wreak havoc on our own lives, and those of everyone around us.
Psychiatrists such as Dr Colin O’Gara of the St John of God hospital in Dublin point out that an addiction to overeating or gambling can have just as devastating an effect on the family life and psychological health, even the physical health, of the sufferer - but according to the traditional definition, neither of these even exists.
“Addiction needs to be treated as a disease that has effects on all facets of an individual’s life: biologically, psychologically, socially, and on the family unit. Substance abuse is a subset of addiction, but it’s not the only kind of addiction,” says O’Gara, who is consultant psychiatrist and head of addiction services at the hospital, as well as a senior clinical lecturer at UCD.
At his specialist addiction unit at St. John of God Hospital, he has seen an increase in the range of severe addictions, including addicitons to codeine in painkillers, cocaine from the street, amphetamines (uppers), benzodiazepines (downers), stimulants bought over the internet, and pathological gambling.
“The indicators now are that pathological gambling will in the future sit alongside drug addiction. The neurochemical effects of gambling in the brain are similar to drug and alcohol addiction.
“Brain scanning (which is also known as functional magnetic resonance imaging or fMRI) gambling addicts while they are engaged in gambling demonstrates deficits in the frontal cortex, of the kind you’d see with drug addictions. Tests demonstrate deficits in areas with risk assessment and processing. This work tallies with what we see clinically – people who continue to gamble in the face of terrible consequences and know they should really stop but are simply unable to do so.”
For O’Gara, the evidence around pathological gambling as a biological illness is convincing, but he believes more evidence is needed in the cases of some other addictions. “For internet, sex and computer games there needs to be a little more evidence forthcoming for these ‘addictions’ to be classified as true illnesses ,rather than human excesses.”
Photo by aftab. on Flickr
He points to recent research in Korea which indicates that internet addiction may share many of the features of chemical addiction – “it may have the same features of tolerance and salience. In effect, what that means is that everything else goes by the wayside and the addict increases use to the point of complete disregard of other activities. We need more research in this particular area.”
Part of the difficulty for researchers is in deciding where a bad habit ends and an addiction begins. After all, not everyone who gambles, uses the internet, takes exercise or goes shopping becomes addicted; just as not everyone who enjoys beer is an alcoholic.
One of the big and – until recently – unanswered questions in our understanding of addiction was why that is: why some people succumb, and others don’t; why a lucky few appear to be able to quit smoking mid-cigarette and never really look back; why some drinkers can happily put the cork back in the bottle after a single glass, and why others simply can’t; why the majority of people who gamble or use the internet don’t let it take over the lives – and why a handful do.
It can’t merely be down to the psychoactive qualities of the substances involved, otherwise we’d all be addicts.
Then what is addiction about?
At the end of last summer, a significant breakthrough was made by those who have been battling for an understanding that goes beyond a mere physiological dependence on harmful substances.
In August, the American Society of Addiction Medicine (ASAM) declared that addiction is “not simply a behavioural problem involving too much alcohol, drugs, gambling or sex.”
“Addiction,” the ASAM declared, “is a primary, chronic disease of brain reward, motivation, memory and related circuitry.
“The disease is about brains, not drugs. It’s about underlying neurology, not outward actions.”
This was big news. The statement had been four years in the making, and had involved input from 80 experts around the world. It was, as the ASAM itself noted, the first time it had taken an official position “that addiction is not solely related to problematic substance use.”
Of course, in the end, the conclusion that addiction is a disease won’t have surprised neurologists, addiction counsellors - or very many addicts themselves.
After all, the American Medical Association has been describing alcoholism as a disease since 1950.
What was new was that the ASAM wasn’t just talking about drugs and alcohol. It was referring to all forms of addiction – behavioural and chemical.
What the ASAM didn’t say was what causes this neurological tic - this faulty piece of wiring in the brains of some humans - that makes them vulnerable to what we now know is the disease called addiction, while others are remarkably resilient.
But before we can properly answer that question, we need to take a journey back in time to 1930s America.
‘The Salvation Army for Snobs’ was the nickname given to The Oxford Group, an organisation of religiously-minded men that had been founded by the Swiss Lutheran, Frank Buchman, in the 1920s.
One of its members was a man who would later become known around the world as ‘Bill W’.
Born William Griffith Wilson in November 1895, Bill W had a tough early life. He was abandoned first by one parent, and then by the other, and left to be raised by his grandparents.
At 17, he suffered a crippling bout of depression after his girlfriend died, and from then he was plagued by panic attacks and debilitating shyness.
In 1917, freshly conscripted into the military, Bill discovered alcohol and embarked on a love affair that would last 17 years. “I had found the elixir of life,” he would later say.
By 1934, after almost two decades during which he binged daily on the elixir, he was on his last legs. Following four failed rehabs in the space of a year, doctors warned him that he would die if he kept drinking.
Bill W was persuaded to join the Oxford Group by an old drinking buddy who had managed to keep sober under its guidance.
As it turned out, the Oxford Group didn’t work for Bill W – it took a hallucination brought on by the herb Belladonna while on his fifth attempt at rehab to do that. But once he had found sobriety, he decided that the only way to hold onto it was to help someone else get sober. And that is how he ended up planting the seed of what would become Alcoholics Anonymous.
Bill W, and the man he had chosen to help get sober, Dr Bob Smith (‘Dr Bob’) started small, with a group of 100 alcoholics in New York. When the got that first 100 back on the wagon, they realised that there was something uniquely effective in the approach they had taken. And so they published a book, outlining their Twelve Steps Programme.
Since then, treatment of people with addictions has actually moved on very little.
The organisation founded by Bill and Dr Bob, the AA, remains remarkably effective for some people, but it doesn't work for everyone: studies suggest it is effective in about 1 in 5 cases – roughly similar to other forms of treatment, including various types of behavioral therapy.
One of the things that it did from the very beginning was to encourage new members to attend a meeting a day for the first 90 days.
It turns out this may have been strikingly prescient.
Scientists now believe this is how long it takes for a brain which has been under the influence of drugs to ‘reset’ itself. Researchers at Yale University discovered a phenomenon they called ‘the sleeper effect’: the gradual re-engaging of proper decision making and analytical functions in the brain's prefrontal cortex, that kicks in after an addict has abstained for at least 90 days.
But if what we know about how to treat addicts has not advanced all that much since the 1930s, the same could not be said for our understanding of addiction.
Armed with sophisticated new technology, including neuroimaging, investigators have been piecing together the process by which an addiction takes residence in our brains, and formulating an understanding of which chemicals are out of balance, and which regions are affected.
What they have found is startling.
We’ve always known that addictive substances trick our brains into seeking out unhealthy sources of pleasure, and then lull us into needing more and more of them. But thanks to recent scientific advances, we now have a much better understanding of how they do it – and why non-chemical addictions can be just as difficult to control.
Drugs, researchers have discovered, are a mendacious enemy: they co-opt the very parts of our brain upon which we depend for evolutionary survival.
Human brains are programmed to pay particular attention to what neurologists call ‘salience’, or things with special relevance. Imagine the way a red dot surrounded by white dots stands out – that’s how our brains detect things which it regards as salient.
Salience detection is essential to human survival. The way you feel when, for example, you hear a crash in the middle of the night is an example of salience in action. Danger is very salient – it puts us in a state of high alert.
But so too do sex and food.
Image by ebruli on Flickr
And so, it seems, do drugs.
When we are exposed to addictive substances, our memory systems, reward circuits, decision-making skills and conditioning all kick in, a process that is like salience in overdrive. The result is a desire that is uncontrollable.
In addition, brain scans of addicts show they have reduced levels of activity in the prefrontal cortex where rational thought overrides impulsive behaviour.
Meanwhile, other neuroimaging studies suggest that obese people and substance abusers in particular have abnormal levels of dopamine in the brain, contributing to cravings.
So addicts have higher sensitivity to dopamine, higher degrees of salience, and reduced impulse control. It all makes for a very toxic combination.
In essence, then addiction is about the power struggle in the brain between the lower pleasure centres, and the higher analytic ones.
“Neuroimaging has thrown up some really interesting findings. Each addiction works on the brain in a slightly different way. In gambling addiction, which we see a lot of at our clinic, there are very obvious deficits and dysfunctions associated with risk profiling and risk assessment,” says O’Gara.
Another recent discovery - which has particular resonance in Ireland, where alcoholism and gambling addiction are a problem – is that “addictive disorders are clearly proven to have a genetic loading in the area of 30 per cent to 70 per cent,” he adds.
In other words, addiction runs in families, a factor which explains why some people seem wired to become addicted, and others can dabble in addictive substances without ever becoming hooked.
The researcher Dr Martin Paulus of the University of California in San Diego, who was one of the first to carry out brain scans on addicts, found that 80 per cent to 90 per cent of the time, he could accurately predict who would relapse within a year simply by looking at the scans of their brains.
Brain scans would show that these people had reduced levels of activation in the prefrontal cortex, where rational thought can override impulsive behavior.
In a study he carried out on methamphetamine addicts, for instance, those who were less able to complete tasks involving cognitive skills and less able to adjust to new rules quickly were found to be more likely to suffer a relapse.
His research may explain an unusual phenomenon first noted in 2006, at the clinics where weight-loss surgeries were performed on people suffering from compulsive overeating.
After the gastric band operation, some patients had indeed succeeded in stopping overeating – only to replace it with a new compulsive disorder, such as alcoholism, gambling and shopping. This phenomenon was described by psychiatrists as ‘addiction transfer’.
The closer we get to an understanding of the neurobiology of addiction, the more intense the race to find effective treatments. And it no longer seems outside the bounds of possibility that we will one day be able to cure addiction.
After all, a drug that could cure cravings – whether it’s for cocaine, cigarettes or chocolate – would be a gigantic market. And it’s not a very distant prospect: a vaccine for cocaine use is already going through clinical trials in the US.
“There are medications that are already effective,” says O’Gara.
“There are anti-craving medications, and there are aversive therapies that can be effective. But where the field is going now is in the direction of pharmacogenetic developments.
“What that means is that soon, we might be able to look at people’s genetic profiles and see which medications they’re likely to respond to, just as we can with breast cancer. We’ll be able to predict which drugs will work and what the side effects are likely to be.”
For the moment, O’Gara says, a broad base of treatment remains the most effective form – including psychological therapy, medication and family support.
“But the situation now for addicts is very hopeful. More hopeful than it’s ever been.”
This article first appeared in The Sunday Business Post on October 23, 2011
Maire*: “While you’re getting sober your alcoholism is in the wardrobe doing push-ups”
I started drinking at 17, I drank for 17 years and now I’m 17 years sober.
I remember feeling very guilty after my very first drink. For the first few years, my drinking was normal. But when I hit my thirties and my friends were starting to scale back, I just kept on drinking
The first time I thought I had a problem was at my sister’s wedding. My parents asked me not to drink. I was driving people home after the reception, so I remember thinking: why would I drink?
But it was a cold day, and after the photos I found myself having a glass of punch to warm me up. And I just wasn’t able to stop. Driving home I nearly crashed the car, but everyone else was so drunk they didn’t notice.
Over the next five years, it went from bad to worse. Nobody realised I had a problem because I managed to hide it so well. I worked in advertising, so drinking was part of the culture.
I wasn’t a particularly heavy drinker – usually one bottle of wine a day did me. But when things got bad, I was going without food – I was surviving on alcohol, nicotine and coffee. I had no idea how it felt to be hungry.
When drink controls you, you don’t control it – that’s my definition of addiction.
It came to a head one night when I made a phone call, a revenge phone call – and as I was talking I was thinking to myself I’m not getting any satisfaction out of this even now.
I stopped for three days, and then I had some more wine on a night out with colleagues. When I got home I drank two more bottles, and made another nasty phone call. And the next day, Friday December 17, I went to AA.
I sat there looking at the people coming in, thinking she’s not an alcoholic, he’s not an alcoholic – and eventually I thought, these people are just like me.
If anybody had told me what the first two years of getting sober were going to be like, maybe I’d never have stopped. They were the toughest two years of my life.
I dispute the whole disease thing – partly because I believe it takes away personal responsibility. An alcoholic has responsibility for their drinking, at least before they pick up the first drink.
But I recognize I have an addictive personality. I’m still the same today with chocolate or anything like that. When I stopped drinking, my cigarette compulsion increased though I’ve since stopped smoking too, and food is still a struggle. I would love to become addicted to balance.
I feel safe now but I don’t feel complacent. While you’re getting sober your alcoholism is in the wardrobe doing push-ups.
*Last name withheld
The porn addict* “I was watching porn for eight hours a day.”
When I was about 16 I was very interested in porn magazines, even to the point where I was stealing magazines from Eason’s and from my friends.
At about that time, I was sexually abused by a relative. I have no doubt that it was a formative experience in my developing sexuality and it has a relationship with my subsequent addiction problems.
I graduated onto videos from sex shops in my early 20s. I was living in Dublin and was never a huge socialiser. I started taking days off work just to stay home and watch them. One of the effects of it is that you get very devitalized, so my health was quite bad.
When I moved from Dublin to Cork with work, I got my first laptop. I didn’t have any friends, so I would come home from work every day for about a year, smoke dope and watch porn online.
The net result of that was that I developed a very short attention span. I was tired, pale, impatient, anxious, and I was starting to become kind of delirious. I had repetitive stress disorder in my left arm, and a pain in my right shoulder.
They asked me to leave my job. Around the same time, I met my current girlfriend, and we travelled to France together and things got much better. When I’m not exposed to electronic equipment, I don’t crave it.
But in the last three to four years, it became a huge problem again. I was getting up in the night while she was asleep to watch porn – I was watching it for up to eight hours a day. I was not able to socialise, I couldn’t concentrate, I was tired and disinterested.
Because of that we broke up for a year. At that stage, I just wanted a life. It was becoming very apparent to me that it would take me days just to recover from one night.
I got back together with my girlfriend, we moved back in together to a place in the country, and she got pregnant immediately. For the duration of the pregnancy I don’t think I was watched porn at all. Having the baby was great.
It wasn’t until our daughter was a couple of months old that I started to watch it the odd time. Then it just went on from there – it got to the point where I would contrive to be alone with the computer. It turned me into this horrible person – impatient, and nervous and very irrational.
I gave up for the last time four weeks ago, because I know it’s over between us if I don’t. I just went cold turkey. For the first four days I sat in front of Twitter and smoked about an ounce of dope a week. On the fifth day, I restricted myself to my phone and not using the computer, on the sixth day I didn’t use any electronic equipment at all.
I would say I’m more obsessive than addictive, but it is in my family. My dad is an alcoholic, he is sober 20 years, and my mother has shown all the signs of gambling addiction.
I’ve got a life, a job, great prospects and it wouldn’t take very much for me to lose it all like a flash. If I went back to watching porn, my girlfriend would leave me, and because we work together that would be the end of my career too.
It’s make or break time.