SO, WHAT MADE ME AN ADDICT?

Experts Debate Whether Disease or Defect Is to Blame

Many people think they know what addiction is, but despite
non-experts' willingness to opine on its treatment and whether
Britney or Lindsay's rehab was tough enough, the term is still a
battleground. Is addiction a disease? A moral weakness? A disorder
caused by drug or alcohol use, or a compulsive behavior that can also
occur in relation to sex, food and maybe even video games?

As a former cocaine and heroin addict, these questions have long
fascinated me. I want to know why, in three years, I went from being
an Ivy League student to a daily IV drug user who weighed 80 pounds.
I want to know why I got hooked, when many of my fellow drug users did not.

A bill was introduced in Congress this spring to change the name of
the National Institute on Drug Abuse (NIDA) to the National Institute
on Diseases of Addiction, and the National Institute on Alcoholism
and Alcohol Abuse (NIAAA) to the National Institute on Alcohol
Disorders and Health. In a press release introducing the legislation,
Sen. Joseph R. Biden Jr. (D-Del.) said, "By changing the way we talk
about addiction, we change the way people think about addiction, both
of which are critical steps in getting past the social stigma too
often associated with the disease."

But opinion polls find weak support for the concept of addiction as a
disease, despite years of advocacy by such agencies as NIDA and NIAAA
and by recovery groups. A 2002 Hart poll found that most people
thought alcoholism was about half disease, half weakness; just 9
percent viewed it wholly as a disease.

So what does science have to say? Addiction research has advanced
dramatically since my high school years in the early 1980s, when I
began using marijuana and psychedelics, then cocaine, in the hope
they would relieve my social isolation. My progression from
psychedelics to coke was fed by a definition of addiction that still
causes widespread misunderstanding. In 1982 -- around when I first
tried cocaine -- Scientific American published an article claiming it
was no more addictive than potato chips. This was based on the fact
that cocaine users, unlike heroin users, do not become physically
sick when they try to stop taking their drug.

Addiction, by this reasoning, is a purely physiological process, one
that results from drug-induced chemical changes in the brain and
body. Over time, with heroin and similar drugs, the article
explained, the user develops tolerance (needs more of the drug to
experience the same effect) and eventually becomes physically ill if
he doesn't have access to an adequate dose. Addiction, by this
theory, is primarily an attempt to avoid physical withdrawal.

I bought into this idea because it was confirmed by my experience: I
never had a problem stopping marijuana, LSD or mushrooms, none of
which cause significant physical dependence. I expected cocaine to be
similar and, therefore, safer than heroin. With no physical
withdrawal to avoid, stopping should be a snap. Or so I thought.

By the time I got suspended from college for my involvement with
cocaine, I was smoking it, often daily. And because I believed that
my suspension meant I'd already ruined my life, I felt I had no
reason not to try heroin. I just didn't care.

Heroin became my drug of choice. It calmed me, gave me distance from
my obsessions and anxieties. Over time, cocaine made me feel anxious,
but heroin always soothed and smoothed. I continued taking both,
injecting higher and higher doses.

Today's most widely accepted definition of addiction -- used in
psychiatry's latest edition of its diagnostic manual, the DSM-IV-TR
- -- recognizes that compulsive use of a substance despite negative
consequences is key. And that's exactly what I experienced: At least
six times, I made it through the physical sickness of heroin
withdrawal -- the shaking, diarrhea and vomiting -- only to use again
because I wanted the drug. This compulsive aspect helps explain why
we can now consider video games and, yes, even potato chips more
addictive than we did in the past.

But the DSM retains a focus on physical aspects of addiction: It
calls addiction "substance dependence," suggesting that physical need
is critical. Tolerance and withdrawal are part of the criteria used
to diagnose the condition, even though pain patients taking opioids
as directed may experience both and not actually be addicted. Studies
find that less than 1 percent of people who take pain medications and
don't have a past history of drug problems become addicted. Many pain
patients who stop opioids after the source of their pain has been
removed even undergo withdrawal without realizing it: It's called
"hospital flu." But the vast majority have no difficulty refusing
further medication.

As a result, experts -- including NIDA director Nora Volkow -- have
called for the official name of the disorder to be changed from
"substance dependence" to "addiction" in the next edition of the DSM.
They say the confusion between physical dependence and addiction
leads to under-treatment of pain: Surveys find many patients, even
those who are dying, don't receive enough medication for effective
relief. Physicians are even criminally prosecuted for
"over-prescribing" when patients with painful conditions become
physically dependent on opioid drugs.

Your Brain on Dope

But if physical symptoms don't define addiction, does it follow that
addiction is a brain disorder? Matters are murky here as well.

While researchers have argued that addiction is a disease because
drugs change the brain, the fact is, most users -- even of drugs such
as heroin -- do not become addicted. While 50 percent of American
soldiers in Vietnam tried heroin or opium, only 10 percent continued
to use such drugs after returning home, and just 1 percent became
long-term opioid addicts, according to a federally funded study by
University of Washington sociologist Lee Robins.

Further, all brain changes are not indicative of disease. Learning
itself changes the brain. FMRI brain scans of London taxi drivers and
virtuoso violinists show changes that embody the effects of years of
practice in relevant brain regions -- however, no one argues that
this means they are ill.

As a result, scans alone cannot prove that addiction is a disease.
"The idea that fMRIs can explain addiction is based on the same
unscientific grounds as phrenology," says psychologist Stanton Peele,
a longtime opponent of seeing addiction as a disease and author of
the new book "Addiction-Proof Your Child."

In my own experience, I stopped using when addiction threatened my
core values. On my last day taking heroin, I found myself considering
seducing a man to get drugs. Because I despised this guy and had a
serious boyfriend, I was shocked that I would consider it: I knew
that that was addictive behavior. At that point, my personal
definition of an addict was someone who violates her own principles
to get drugs. I sought treatment the next day and never used cocaine
or heroin again.

In Peele's view, addiction is a bad habit, a learned behavior that
gets out of hand, an exaggeration of the human tendency to put off
pain in favor of immediate pleasure. Even, in some instances, a
rational choice when life presents little opportunity for connection,
purpose or joy.

Volkow disagrees. She has pioneered brain-imaging research on
addictions, looking for ways in which they differ from ordinary
learning. "Drugs of abuse affect multiple systems, not just those
involved with learning and memory," she says, adding that they
interfere with regions that put the brakes on unwanted behavior.

"What happens in the brain of the addicted person is equivalent to a
state of deprivation. It changes the brain from operating in a
situation where someone has a choice and does something because he
wants to do it to a situation where it feels like need," she says.

That, too, comports with my experience: Cocaine seemed to affect my
motivation, leading me to take more even when I knew it would fuel a
burst of paranoia, not euphoria. While at first it brightened and
enhanced other joys, over time it sucked the pleasure and color out
of my life. But although I could consciously see this, I felt I couldn't stop.

Another relevant factor seems to have been my youth: We now know that
the frontal cortex, the seat of judgment, the region that should
apply the brakes, is not fully developed until the early to mid-20s.
I quit at 23; when I look back on my behavior now, the sheer
stupidity of some of the risks I took shocks me. Genetic research
also suggests that certain people are more prone to addiction,
particularly those with other mental illnesses such as depression, a
condition I also have.

So does that make it a disease? Some would argue that my response to
treatment proves it. I underwent seven days of detox, 30 days of
rehab, then three months in a halfway house and ongoing self-help
support. Later, antidepressant medication helped reduce the distress
that I'd previously self-medicated with heroin.

As Thomas McLellan, chief executive of the Treatment Research
Institute in Philadelphia and professor of psychiatry at the
University of Pennsylvania, notes, treatment for addiction is as
effective as treatment for other chronic diseases that involve
lifestyle change, such as diabetes and asthma.

Stigma-Proofing Addiction

Just calling it a disease, however, may not reduce the moral stigma
tied to addiction -- as some hope. University of Nevada psychologist
Steven Hayes is studying people's unconscious responses to words.
"Disease" was as stigmatizing overall as clearly pejorative terms
such as "drunk," and was more stigmatizing overall than such terms as
"addict" and "intoxicated," he says.

Consider the historical treatment of people with epilepsy or
"madness." Or the fact that we think "tough" rehabs are good, despite
evidence suggesting otherwise -- though we wouldn't even contemplate
"getting tough" with diabetics. Says McLellan: "Yes, people with
epilepsy were sent to priests and shamans, too -- but that was the
18th century. Addicted people are still told to get religion."

The program I attended, for example, told me that I would not recover
if I didn't surrender to a higher power, make amends and pray. This
is not how most diseases are treated.

Further, labeling people with a brain disease characterized by lack
of self-control can have negative consequences, particularly for
adolescent users, most of whom are not addicts, suggest NIDA surveys
and other research. In many teen rehabs, youths are told that they
have "chronic, progressive" illness with a 90 percent chance of
relapse. Forcing teens, whose identity is not fully formed, to accept
an "addict" identity can be a self-fulfilling prophecy.

As Peele points out, "Self-efficacy and the image of the ability to
control oneself are critical to recovery" -- as they are to
maturation. For the same reason, it's a bad idea to tell people that
without treatment, recovery is impossible. In fact, most addicts who
recover do so without treatment. Among those who relapse, belief in
the disease model is predictive of greater severity, research shows.

So is addiction disease or learned behavior? Given its complexity,
some experts say, what probably matters most is which view best
yields compassionate and effective treatment.