We, as a community, have suffered our share of tragic overdose deaths, and many community members and their families are suffering the effects of various addictions. But what is addiction? Is it a brain disease? A moral failing? Or something else? And how should it be treated? Is entering an inpatient rehab facility the best way to cure addiction? Is attending 12-step programs the only effective option for those in recovery? Or are there alternative approaches?
After I started reading and listening to experts on YouTube about addiction, I, too, became “hooked” – on learning as much as possible about the subject, that is. So much of what I believed turned out to be not evidence-based science. Even when there is evidence-based data, scientists don’t necessarily agree on what addiction is, interpreting the same information in different ways.
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The National Institute on Drug Abuse (NIDA) defines addiction as a “chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” NIDA points to biological, environmental, and genetic factors as evidence that addiction is a disease. This is in contrast to the “moral model” of addiction that prevailed in the not too distant past, when addicts were looked upon as having character defects: being irresponsible, self-centered, and hedonistic.
The disease model has definitely been a step in the right direction for understanding that addiction is not a result of a flawed character and is not something that any addict chooses or enjoys. Moreover, using the disease model might also be helpful in destigmatizing the condition while creating a pathway for addicts to receive at least some help through health insurance. But is the explanation for what addiction is comprised of only the two models – brain disease or character defect? Or are there other approaches that might prove to be beneficial to substance users and abusers?
Brain scans show that, once addiction has become established, the brain has undergone disturbing changes. While disease advocates point to this as evidence of brain disease, there are other schools of thought on how to interpret such changes. Neuroscientist and professor, Marc Lewis, who began his career as a development psychologist and is also a former drug addict, has a different explanation. Addiction, he says, is not a pathology but the result of the brain working the way it is designed to. All habits change the brain. This includes any type of learned behavior, indeed, all learning. Normal brain development balances the formation of new synapses with the pruning of others. Beginning in infancy, when the brain has an overabundance of synapses that are later pruned while new ones grow in, the brain is constantly changing. This phenomenon is called neuroplasticity.
In a (very tiny) nutshell, according to Lewis, understanding this is the best way to demonstrate why addiction is not a disease. “Neuroplasticity,” he writes, “is the norm when people recover from medical problems like strokes or concussions, but it also underpins second-language learning and the acquisition of new skills in adulthood. People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of that plasticity. Then, when they recover, with or without treatment, their neuroplasticity returns. Their brains start changing again. With the onset of addiction, plasticity is devoted to new means for acquiring pleasure or relief. With recovery, plasticity is devoted to goals with far-reaching personal value and the skills necessary to attain them.”
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Maia Szalavitz, herself an addict from age 17 to 23, is a best-selling author and journalist, covering addiction and drug-related issues for around 30 years. In her latest book, The Unbroken Brain, she calls addiction a learning disorder. Her approach is very similar to that of Professor Lewis. She says addiction is a developmental disorder that usually begins in adolescence or early adulthood.
Szalavitz notes that addiction, defined as “compulsive behavior despite negative consequences,” demonstrates a disorder by failing to learn from negative feedback. In addition, the brain circuitry involved in addiction is the same as that which motivates us to survive and reproduce. She writes, “Basically, addiction is love gone awry. You fall in love with a drug or activity rather than a person….When you fall in love, it completely changes your priorities.…What happens in addiction is that reprioritization is now aimed at a drug rather than getting a person in your life.”
“Mike,” a member of our community, is a married man in his 30s who abused several drugs for many years. Mike says, “I was a miserable, unhappy person before I found drugs and discovered how great they made me feel. At first, when you find drugs you think it is amazing and brilliant and you’ve found the answer. I felt like drugs were helping me manage my life.” He soon discovered that “The problem is, it seems great, but it’s not a long-term solution.” When he speaks to groups, he tells people, “The second you try drugs you may or may not be an addict, but if you are, your life just took a turn. From now on, you are on Plan B because your brain thinks this is true happiness. It has changed the trajectory of your life.” From the time you get addicted, he says, drugs become the most important thing in your life. When you are on drugs, he says, “the ‘medicine’ becomes the problem.”
Lance Dodes, M.D., a former professor of psychiatry at Harvard Medical School, asserts that “Addiction has very little in common with diseases. It is a group of behaviors, not an illness on its own.” He believes addictive behavior is a compulsion similar to other compulsions, such as shopping or extreme exercising. According to Dodes, all compulsive acts stem from feelings of helplessness. “Addictive behaviors do not occur at random. They are powerfully-impelled actions driven by overwhelming feelings at the moment they are enacted…precipitated by emotional distress. They are actions taken even when people are fully aware of their disastrous consequences and are trying their best not to perform them.” The psychological function of addiction, he says, is the “reversal of helplessness.”
Contrary to popular belief, mere exposure to a drug does not necessarily lead to addiction, and only a minority of those who try recreational drugs actually get addicted. But, as Mike tells people, “It’s like playing Russian roulette because you never know who you are.”
“What matters,” Szalavitz says, “is what people learn – both before and after trying drugs.” One reason she calls addiction a learning disorder is that it “simply cannot take place if someone doesn’t learn, over time, to associate a drug with pleasure and/or relief. Addiction is first and foremost a relationship between a person and a substance, not an inevitable pharmacological reaction.”
Anyone with trauma or abuse in his or her background has a higher chance of becoming at addict. This includes “merely” perceived trauma, such as in individuals who are highly sensitive. Szalavitz, who writes that she probably would have been diagnosed as having Asperger Syndrome as a child, had there been such a diagnosis at that time, was a very sensitive – and, in her words, “weird” – child. She was socially awkward, with few friends, and didn’t understand why her peers weren’t interested in subjects that she would become obsessed with.
Szalavitz writes that there are many routes to addiction, but “addictions grow in the interaction between childhood temperament, childhood experience, and children’s interpretation of their experiences.” No matter what the background reason for people being susceptible to becoming substance abusers, there is one thing in common: a lack of necessary coping skills to get through life’s ups and downs. When they find a substance that relieves them of feelings of anxiety, helplessness, or whatever it is they seek to soothe themselves from, the attraction can be overwhelming.
Frequently Asked Questions about Addiction
If substance abuse is just a learned habit, why is it so hard to quit and so common to relapse?
Even with “normal” habits, changing them is never easy. As Rabbi Yisrael Salanter said, “Repairing one bad character trait [habit] is more difficult than learning the entire Talmud.” And addiction is not just an ordinary habit. Long after using the substance has ceased to provide any amount of pleasure, the compulsion to take the drug remains.
“It’s almost as if the exposure to the drug initiates for some an extra, mandatory need,” says Howard Reznick, LCSW-C, Manager of Prevention/Education at Jewish Community Services. He visualizes this need as an additional survival instinct, much like thirst or hunger. With abstinence it can quiet down somewhat. However, triggers can cause it to pop up, and it feels as though taking the drug is imperative for survival.”
Mike says, “It is important for family members to understand what is like to kick drugs.” The thought of giving them up was terrifying to Mike, not because of the physical pain he expected to endure but because using drugs had become his entire identity.
Szalavitz explains, “The drug experience gets deeply carved into your memory. Anything you can associate with achieving a drug high, you will. As a result, when you try to quit, everything from a spoon (you can use it to prepare drugs) to a street (this is where the dealer lives!) to stress (when I feel like this, I need drugs) can come to drive craving. Desire fuels learning, whether it is normal learning or the pathological ‘overlearning’ that occurs in addiction.”
What are the best treatment options? Is an inpatient facility necessary? Are outpatient treatments just as good? How do you know where to go for treatment once the patient is ready?
After being evaluated by an expert, there may be several suggested options available, and it really depends on which ones the addicted person relates to best. Anne M. Fletcher, in her book Inside Rehab: The Surprising Truth about Addiction Treatment and How to Get Help that Works, quotes John Cacciola, Ph.D., an expert in the assessment of substance use disorders and co-occurring problems in Philadelphia: “Assessment should not be a one-time deal. You need a good baseline but then to be continuously assessed throughout treatment.” Fletcher says, “A good assessment combines what the client has to say with additional sources – such as information from other family members – to identify client needs, which should then become the basis for an individualized plan for treatment and for monitoring progress throughout treatment.”
Fletcher reports, however, that many rehabs admit the client before doing an assessment, which, according to Dr. Cacciola, is a backwards approach. After an initial screening, many facilities will encourage clients (paying customers) to get treatment there since “they offer everything the person needs.”
Mr. Reznick says there are advantages and disadvantages to both in- and out-patient, but ultimately, as in any other medical care you may need, the best option is to “look for the least restrictive environment first.” He points out that the exception to this is in cases where there is a danger of self-harm, when more supervision is needed. Mr. Reznick also warns that withdrawals from either alcohol or benzodiazepines (Valium, Xanax, etc.) should only be done under medical supervision as they can be fatal in some cases.
One might think that for the best care, the most expensive and famous rehab facilities would be the top places to go. This is not the case. Mike says, “You don’t have to pay $30,000 to $50,000 thousand a month to get clean. You can use a state-run facility with good results. And there are other inpatient treatment options that charge on a sliding scale basis and are excellent.”
Indeed. In her book Inside Rehab, Anne M. Fletcher looks at the multimillion-dollar rehab industry and comes to some surprising conclusions. The great majority of facilities, many of which claim high success rates, have no data to support their claims, are rarely centered on evidenced-based treatment, and have a record of “long-standing failure to individualize approaches to meet diverse needs.” Studies have failed to show that residential treatment brings superior results than outpatient models, she says. And, she says, depending on which studies you consult, which addictions were being studied, and how long people have been in recovery, the data suggests that 20 to 80 percent of those who overcome addictions do so without help.
Dr. Tom Horvath, who runs both outpatient and residential programs, says “For most individuals, outpatient treatment is as good as or better than residential.” He says that the withdrawal from the outside world that residential facilities offer can even be counterproductive.
Many factors play into who is able to recover on their own, including the length of their substance abuse “career,” mental health, financial resources, skills, and environment. However, Fletcher writes, “Research suggests that drug- and alcohol-addicted people who participated in professional treatment and/or self-help groups are more likely to recover than those who do not – particularly when comparing people with drug and alcohol problems of the same severity.” She also notes that even people whose substance-use problems are not severe can benefit from professional help, and there is a wide continuum, from “relatively minor (which can still be risky or hazardous) to very serious.”
Are there other steps besides the famous twelve?
Mr. Reznick says, “I, for one, am very, very grateful that 12-step groups are around. I am also very pragmatic and practical for what’s going to work for each person. If it’s an opioid addiction, some people will be helped with medication-assisted treatment (MAT). Others choose to lock themselves in a room and detox “cold turkey.” Remembering the exquisite pain of doing that can do the trick for them. And of course, there are many options in between.”
Amazingly, Mike did detox from heroin on his own, “cold turkey” while he attended an outpatient facility for several weeks. He describes it as the worst and most painful experience he has ever had. He also saw a psychiatrist and began attending NA’s (Narcotics Anonymous) 12-step meetings, which he continues to do today. “Having a support group of people with similar backgrounds who are doing well and trying to better themselves every day is kind of contagious,” he says. For him, 12-step programs have been a lifeline. His NA sponsor, a former substance abuser himself, is a doctor.
Mike lives the 12-step mantra that “in order to keep it, you have to give it away,” and speaks in front of groups telling about his experience. Although he is a supporter of 12-step programs, he lets people know there are other options.
As invaluable as 12-step programs have been for untold thousands, there’s no one-size-fits-all approach that works for everyone, and some people cannot relate to them. Szalavitz writes, “On balance, I believe that these programs can be a wonderful resource for those who find them amenable. Treatment centers should recommend them and offer meetings in order to help people discover whether or not it’s for them. Because they are free, available 24/7, and provide social support for abstinence that is otherwise unavailable, they may play a role in some people’s recovery that is not easily filled by anything else.
“But I believe that the 12 steps and indoctrination into their ideology should play no role at all in professional care. No one should be court-mandated or otherwise forced to attend. I also believe that it is malpractice for any professional to claim that these programs are the only or the best way to recover.” Szalavitz notes there are other kinds of support groups such as SMART Recovery, LifeRing Secular Recovery, and Women for Sobriety.
Not only are 12-step programs not for everyone but researchers have launched major criticisms of them. Gabrielle Glaser, author of Her Best-Kept Secret: Why Women Drink and How They Can Regain Control, writes, “A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are brief interventions by a medical professional; motivational enhancement, a form of counseling that aims to help people see the need to change; and acamprosate, a drug that eases cravings.”
Dr. Dodes has been among the harshest critics of AA and 12-step programs, but he is not alone. His recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, examines AA by comparing its retention rates and other studies, and he estimates that AA’s actual success rate is somewhere between five and eight percent of those people who walk through its doors, a far cry from what most people are led to believe.
Chana Feldman, a chiropractor in private practice serving the community for over 25 years, recently received a degree in addictions counseling. She says “What’s most important after treatment is to have a support group to go to. It will be a huge factor in recovery. Research shows that any approach will work as long as a person relates to it.”
Does the label you give addiction matter in treatment?
What difference does it make whether one believes that addiction is a disease, a result of normal brain function caused by dangerous habits, a learning disorder, or anything else? For Maia Szalavitz, when she first entered recovery, it was a relief to find out that she had an illness and that she just wasn’t a bad person which misinterpreted events in her oversensitive youth had led her to believe. As she recovered, though, she found the idea that she had a chronic illness to be less helpful.
“Adopting an addict identity is especially problematic for young people whose identities are not yet fully formed,” Szalavits writes. “Doing so may make what may well be a transient problem into a long-term one, by teaching them that addiction is inevitably chronic and relapsing. Since no one can predict which youth will mature out of addiction and which will not, teens should never be forced to attend 12-step groups. Nor should they be made to label themselves as addicts.”
Marc Lewis says it makes a big difference if you call addiction a disease because the disease model works against a person’s sense of empowerment. If you have a disease, you are a patient under someone’s care and have to follow his instructions. But, he says, the ideal way to combat addiction is through setting your own goals for yourself, being self-motivated, deciding what you want in your life and what you need to do in order to accomplish it. He says it is critical to be able to develop future goals independently on the journey from the addicted brain back to a re-ordered brain.
Practically speaking, no matter how you think of addiction, it is important to realize that not all treatments are created equal, and even one that has worked wonders for someone you know might not be the one for you. Szalavitz advises friends and families of those going into treatment to let them know that they will be there for them. If one treatment is not right, reassure the person that you are on their side and will help find something else that will. Hopefully, as research continues, more and better evidence-based treatments will emerge, although there will never be a magic bullet that fits everyone. What is important is that each individual be directed to get help for what is, way too often, a deadly habit.
