Addiction Journalism’s Imaginary Line

For the past few years, addiction has been receiving a lot of attention, partly because of the opioid epidemic but also because of new books by prominent journalists and retired scientists. Last year it was Johann Hari’s, “Chasing the Scream.” Before that, it was Dr. Marc Lewis’, “Biology of Desire” and Gene Heyman’s “Addiction: A Disorder of Choice.” This year it’s “Unbroken Brain” by Maia Szalavitz.

Although arguments by choice advocates like Hari, Heyman, and Lewis are well-meaning and ultimately aimed to help individuals with addiction, there seems to be a lot of disdain for addiction science that could lead to denialism. In the age of overnight self-help gurus, so-called radical approaches, as defined by media outlets, to a complex health issue like addiction might catch the public eye, but this push back of established science and misleading messages of empowerment do a disservice to decades of research.

Pop science books tend to paint the addiction problem in rather simplistic terms, attempting to break it down into a few problems and thus attempting to provide a few simple solutions. Lately, the trend has been to say addiction is like falling in love, and the answer is connection with others. However, research has shown that addiction is more than behavioral; it’s more than biology; it’s more than environmental; it’s more than genetic. In reality, it’s a combination of all these things, and parsing them apart shouldn’t be reduced to platitudes. Fortunately, Szalavitz’s stance is a more nuanced one, wherein she argues for evidenced-based approaches while at the same time acknowledging the limits of current care.

We’ve all experienced addiction, if only indirectly; it’s everywhere. It affects our cities, our families, and even our own lives. It makes sense that these new voices want change, but the addiction scientists some of these choice advocates tend to demonize want change, too. It’s important to note that the end goal of both choice advocates and research scientists is to better understand addiction and to provide better treatments.

The notion that addiction is a choice is not new, and in fact is rooted in arguments of morality. It was argued that using drugs or excessive drinking was just plain bad behavior, a by-product of a lazy and/or sinful lifestyle. This perception led to punishment and stigma. Partly this history explains scientists’ negative reaction to choice advocates, but it’s doubtful that these recent pop science arguments about addiction are attempting to resurrect the old idea of morality but rather trying to formulate new ones. It was Gene Heyman that gave me the first glimpse of a different viewpoint on addiction other than that of the scientific community and 12-step approach. Heyman first explained the murky history of public perception of addiction and then provided data showing that many people quit problem drug or alcohol use on their own. Alternative reinforcement he said was adequate to change people’s drug using behavior, and hence people with addiction were able to still make choices.

The idea of maturing out of addiction has stuck around, often used as a way to say that addiction isn’t as big deal as the media and scientists make it out to be. However, it seems that some choice advocates using this argument continue to ignore the 15–20% of people that never quit or get stuck in a recover/relapse cycle.

On all sides, there’s a lot of frustration when it comes to addiction, even among those who have studied addiction for their entire careers. Some can’t believe there still isn’t good medication for addiction, and if there is (e.g., naltrexone, buprenorphine), it isn’t widely used. By the way, there’s no FDA approved medication for cocaine addiction.

Change has been slow, partly due to stigma, partly due to perception, and partly because of the 12-step model. Addiction journalists have generally been critical of the 12 steps, and at least in that, addiction scientists and choice advocates are generally in agreement. It is the view of some scientists that 12 steps are not treatment and at best provide a support network for people with addiction. At worst, those wanting to get help may receive terrible advice at 12-step meetings, like being told to stop taking medication for mental health issues, or that moderation isn’t possible, or that failure to recover by 12-step standards means that the person failed, that the person just didn’t believe in the program enough. It’s notable that scientists, choice advocates, and addiction journalists could find common ground in their basic agreement that the failure is not necessarily the fault of the person but rather a program that is unable to update its model based on promising scientific results.

The problem, it seems, is that misguided battle lines have been drawn: the ideas of choice advocates on one side and addiction science on the other. One of the reasons, I believe, is the ubiquity of the 12-step model. Within the 12 steps is the idea of powerlessness, and to me, it seems that recent critics have conflated the opinion of addiction scientists with this idea. One of the goals of choice advocates is to rid of the old adage of powerlessness to exact the message that one can get over an addiction. Somehow, this is meant to be an incredulous notion that flies in the face of addiction science, but the only thing it flies in the face of is dogmatic belief, the type of belief reserved almost entirely for rehab centers and 12-step meetings.

True, there are probably more than a few scientists clinging to the idea that all people with addiction are helpless and in dire need of treatment, but that notion, too, is misguided. But, addiction scientists can sympathize with the director of NIDA when she writes that addiction is a disease of free will, because choices are not made without the brain, and when certain parts of the the brain are compromised, so are choices. However, researchers should also understand addiction journalists and so-called controversial scientists that point out that sometimes problem drug use isn’t addiction but rather a problem of income inequality, for example, wherein problem drug use might be attenuated with more and/or better opportunities.

The difference is that in response to the results of Rat Park*, where journalists like Hari see the answer to addiction as connection, addiction researchers see a paradigm shift, from bad to better. Little rats in solitary cages didn’t model human addiction. It modeled solitary living with limited access to resources. It was a poor translational model for human addiction. Rat Park, on the other hand, actually simulated reality for many people, and similar studies have shown that 15–20% of rats still have addiction-like behaviors**.

In response to data showing that many people quit problem drug use/drinking on their own (maturing out) by their thirties, where scientists like Heyman and journalists like Szalavitz might conclude that addiction is just a part of growing up, many addiction researchers see a minority of substance users (15–20%) that never quit, or they get caught in a recover/relapse cycle. Plus, the coming-of-age argument does nothing to address the middle-age, middle-class people — with plenty of access to socialization, sugar, and other resources — that have gotten hooked on opioids, forming a significant part of the current opioid epidemic.

Applying global explanations like that for addiction is problematic, and that’s where my research comes in. My work has focused on phenotype differences within the addiction population, first with rats and now with people. The most recent paper of mine, published in Addiction Biology, shows that even within a population with severe cocaine-use disorders, there is heterogeneity. With a simple metric found in the Addiction Severity Index, I was able to show that individuals with cocaine addiction and with a history of emotional, physical, and/or sexual abuse had heightened brain reward responses to evocative (cocaine, sex, aversive) cues, compared to individuals with cocaine addiction but without a history of abuse. This brain response has been linked to relapse and may indicate a need to treat individuals with and without a history of abuse differently. Indeed, with future work we aim to show that a history of abuse affects receptivity to certain types of addiction medication, both at the level of brain and behavioral outcomes. Past experiences, current circumstances, mental health, and even genetics all play a role in how a brain, thus how a person, responds to drugs, and how the brain adapts to drug consumption***.

Instead of drawing a line between choice advocates and research scientists, we would be better off collaboratively pushing for promising evidence-based addiction treatment, medication-assisted treatment, and working to make sure addiction treatment is covered by insurance everywhere. We would be better off pushing for better addiction education for our clinicians, psychiatrists, and counselors. In short, we would be better off working together.

REFERENCES:

Paul S. Regier, Monge ZA, Franklin TR, Teitelmen A, Wetherill R, Jagannathan K, Suh JJ, Wang Z, Young KA, Gawrysiak M, Langleben DD, Kampman KM, O’Brien CP, Childress AR (2016). “Emotional, Physical, and Sexual Abuse are Associated with a Heightened Limbic Response to Cocaine Cues.” Addict Biol. 2016 Sep 22. doi: 10.1111/adb.12445. [Epub ahead of print]. PMID: 27654662

Maia Szalavitz (2016). Can You Get Over Addiction? New York Times. link

Johann Hari (2016). The Likely Cause of Addiction Has Been Discovered, and It’s Not What You Think. Huffington Post. link

Marc Lewis (2016). Why It’s Wrong to Call Addiction a Disease. The Guardian. link

Deroche-Gamonet V, Belin D, Piazza PV (2004). Evidence for Addiction-like Behavior in the Rat. Science 305:1014–1017.

Scott CK, Foss MA, Dennis ML (2005). Pathways in the relapse — treatment — recovery cycle over 3 years. Journal of Substance Abuse Treatment. 28:S63–S72.

National Institute on Drug Abuse. link

Nora Volkow (2015). Addiction is a Disease of Free Will. National Institute on Drug Abuse. link

NOTES:

*In the lab, the idea of resource scarcity has been studied with little rats put into solitary confinement-like cages, studies that made up most of the animal research literature since the 80s. Johann Hari made famous the Rat Park study, where, instead of lonely cages with only a lever that delivered drugs, rats could play and mate and drink sugary drinks. It turns out the rats consumed fewer drugs in the setting with more choices.

**Importantly, Rat Park also implied embedded class problems, which Carl Hart has pointed out before, suggesting drug use in lower SES situations may look a lot like addiction but is probably more about a lack of accessible resources.

***Surprisingly, even among rats inbred to the point that make the Targareyans look pristine, there are differences in response to drugs. For a prime example, look to Piazza’s paper showing that around 15–20% of rats exhibited addiction-like behavior. People are plenty more diverse with a range of experiences, environments, genetic variations, etc that differentially drive drug use.