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Addiction: All in the mind?

For a brief period of my life, I consumed far more opioids than the most hardened heroin addict. After a freak injury that left me with my femur broken into two jagged pieces that spiraled past each other, shredding my muscle and flesh, I was in so much pain that my doctors attached a self-controlled morphine pump to my body. For the next five days I voluntarily consumed an amount of morphine that literally would have been fatal before my injury. But the day after the surgery that pinned my femur back into one piece, my pain lessened enormously and I immediately lost all interest in using morphine. So, was I addicted for those five days or not? And if so, did my doctors do me a disservice by letting me take large doses of powerful drugs?

Answering questions like these is one of the main motivations behind recent efforts to reclaim “addiction” from popular slang (e.g., America is “addicted to debt,” Robert Palmer was “addicted to love,” etc.) and make it a credible, reliable, and understandable medical diagnosis. Distinguishing a “large amount of substance use” from “addiction” has been central to this effort, not least so that doctors will be unafraid to adequately treat acute pain such as I experienced in the hospital. A further motivation, which no doubt inspired the American Society of Addiction Medicine’s just-released redefinition of addiction (.pdf), is to help addicted people better understand their condition and to help the rest of us understand how to help them.

In addiction, something happens in the brain that did not happen in mine during my hospital stay: An enduring change to the structures and systems that shape memory, learning, emotion and reward. Although both genetic and environmental factors are known to be implicated, no one knows precisely why some people undergo these changes when they extensively use psychoactive substances and other people do not. But scientists do know that once these changes have occurred, they persist long after the substance use has stopped. Once someone is addicted, they will, even during periods of non-use, think about the psychoactive substances more often, overestimate their value (i.e., feel they are more important than eating, sleeping, work and family responsibilities) and have urges to return to use.

As half of the U.S. population is overweight, many people are familiar with an analogous biological process. Once you have put on a lot of weight, even if you lose it later, it is as never as easy as it once was to maintain a healthy weight. Your body has produced more fat cells and you have a different appetitive set point such that if you diet to get back to the normal weight, you may feel as hungry as if you were starving. If you respond to this feeling by eating more you will eventually regain the weight you lost, sometimes again and again, just as an alcoholic might get on and fall off the wagon over and over.

Speaking as a friend of many of the people involved with producing the ASAM statement, I know that in addition to their medical and scientific goals, a number of the ASAM statement writers hope that by highlighting that addiction has a biological basis in the brain, they can persuade the public to become more sympathetic to addicted people rather than blaming addicts for their lack of willpower. They further hope that this decrease in public disapproval will make more addicted people comfortable admitting they have a problem and seeking treatment for it.

I'm all for being compassionate towards addicted people and for providing quality addiction treatment, but I'm not as sure as are many of my colleagues that an emphasis on the brain mechanisms involved in addiction will bring such good things about. If the public believes that addicts are permanently brain-damaged people who have no control over their own behavior, they might just as well hate and fear addicts more than ever rather than be more compassionate towards them. And as psychiatrist Sally Satel, MD, points out here (.pdf), many addicted people try to quit or enter treatment not in spite of but because of social disapproval of their behavior.

I hope I'm wrong about this, but I can imagine that some addicted people might react to greater acceptance of their behavior (e.g., “he can’t help it, his brain made him do it”) not by seeking treatment, but by feeling more comfortable persisting in acts that are destructive to themselves and those around them.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

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