Three years ago, I put out a call to my blog community: would anyone be willing to tell me the story of their addiction, from start to finish, in all of its gory detail, for the book I am writing? The book would combine an account of brain change in addiction with subjective descriptions of what it’s like to live inside addiction. More than 100 people replied. Two years later, I’d recorded intimate biographies of a heroin addict, a meth addict, an alcoholic, a pill-popper and someone with an eating disorder, and my book The Biology of Desire was published in 2015.
I already knew a lot about addiction. I had struggled with my own drug compulsion, back in my 20s, and lost most of what I valued as a result. But then I quit, returned to university, earned a PhD in developmental psychology, and went on to become a professor at the University of Toronto. For more than 20 years, I researched the emotional development of children and adolescents. And after 10 of those years, I switched my focus to brain science, since the broad brushstrokes of psychology couldn’t quite capture the concrete, biological factors that interact to create our personalities.
When I returned to addiction, it was as a scientist studying the addicted brain. The data were indisputable: brains change with addiction. I wanted to understand how – and why. I wanted to understand addiction with fastidious objectivity, but I didn’t want to lose touch with its subjectivity – how it feels, how hard it is – in the process.
The suffering, the intense effort, failure and eventual triumph I remembered from my own years of addiction coursed through each of the biographies I collected. Each revealed the agonising counterpoint of fear and shame sculpted by addiction. For example, Donna described the strange conceit that came with her talent as a pill thief, until she was caught rummaging through drawers by family members primed by suspicion.
Donna cared for children with severe illnesses in a Los Angeles hospital; friends and coworkers thought her a saintlike being, overflowing with generosity and competence. What they did not see was her overflowing hunger for opiate painkillers – the special treats she saved up for after work and weekends.
Donna continued to steal pills from friends and relatives, forge doctors’ prescriptions, and raid her husband’s painkiller supply to achieve that precious buzz. She developed compelling rationalisations as to why she deserved this vacation from her high-stress life. And finally she was caught red-handed by a video camera set up in her mother-in-law’s bedroom – an event that precipitated massive trauma, fear of abandonment, and then months of intensive therapy.
What Donna and the other very different people I spoke with had in common was what all addicts find most maddening (and terrifying) about addiction: its staying power, long after the pleasure has worn off, long after the relief has transformed into extended anxiety, long after they’ve sworn up and down, to themselves and others, that this would not continue. It’s that resilience that has made addiction so incomprehensible to addicts, their families and the experts they turn to for help, while feeding a firestorm of clashing explanations as to what it actually is.
One explanation is that addiction is a brain disease. The United States National Institute on Drug Abuse, the American Society of Addiction Medicine, and the American Medical Association ubiquitously define addiction as a ‘chronic disease of brain reward, motivation, memory and related circuitry’ – a definition echoing through their websites, lectures and literature, and, most recently, ‘The Surgeon General’s Report on Alcohol, Drugs, and Health’ (2016).
Such authorities warn us that addiction ‘hijacks the brain’, replacing the capacity for choice and self-control with an unremitting compulsion to drink or use drugs. In the UK, the medical journal The Lancet has provided a forum for figurehead proponents of the brain-disease model, echoing the government’s emphasis on ‘withdrawal symptoms, tolerance, detoxification or alcohol-related seizures’, which suggests that the royal road to understanding addiction is still medicine.
This mania for medicalisation has been evolving for decades, an outgrowth of the strange marriage between support groups such as Alcoholics Anonymous (AA) and institutional care. It became the dominant approach to addiction throughout the Western world in the 1990s – the so-called decade of the brain – largely due to the discovery of brain changes that correspond with addiction, some of them long-lasting if not permanent.
If addiction changes the brain and drugs cause addiction, the argument went, then perhaps drugs unleash pathological changes, literally damaging neural tissue. The implication that addicts do the things they do because they are ill, not because they are weak, self-indulgent, spineless pariahs (a fairly prevalent view in some quarters) also seemed to benefit addicts and their families. The anger and disgust they often experienced could be mitigated by the presumption of illness; and social stigmatisation – known to compound the misery of those with mental problems – could be relieved, even reversed, by the simple assumption that addicts can’t help themselves.
If only the disease model worked. Yet, more and more, we find that it doesn’t. First of all, brain change alone isn’t evidence for brain disease. Brains are designed to change. That is their modus operandi. They change massively with child and adolescent development: roughly half the synapses in the cortex literally disappear between birth and adulthood. They change with learning, throughout the lifespan; with the acquisition of new skills, from taxi-driving to music appreciation, and with normal ageing. Brains change with recovery from strokes or trauma and, most importantly, they change when people stop taking drugs.
AA has long overwritten the notion of self-generated change with that of vigilant control: once an addict, always an addict