We all know what an addict is, right? It is the man lying in the streets, with a brown paper bag, who generally walks around talking to himself. Or the lady who pushes her stolen store trolley around, whilst mumbling something about the lord saving her. We also know that drug abusers are teenagers and that it’s a rite of passage – normal - to at least drink whilst at varsity (and maybe smoke some weed as well)
You know the type, right? Wrong! An addict is you and me and anyone else in the world. Addiction knows no social rules – it is an equal opportunity destroyer. It is indiscriminate and it doesn’t care how much you own, how much you earn, who you are married to, your profession or what schools your children go to. It doesn’t care where you come from – only where you are going provided that you take it with you. The bottom line is that anyone, from any walk of life has the capacity to become an addict. It’s simply luck of the draw which hard-wiring you were born with, which determines if you’re part of the “possible addict” group or the “active addict group”. The one guaranteed thing is that once the cunning and seductive addiction has set in, there is a predictable path: jails, institutions and death.
What is addiction? Addiction is a disease process. What does this mean? Addiction is a pathological (unhealthy) relationship with any substance, event, thing or person – “substance of choice”. These include drugs, relationships, sex, alcohol and pornography. There is a striking similarity and commonality among addicted individuals regardless of their specific circumstances and particular addictions.
That being said, addictions can be divided into two forms: substance addictions – illicit and legal drugs and alcohol; and process addictions – such as food, work sex, gambling.
Addiction is a primary disease that is progressive, incurable and fatal. What is meant by progressive? It means that not only does the need for the substance become more severe but also that the person’s behaviour deteriorates. Incurable means two things: firstly, that even after a period of abstinence, successful or moderate use is unlikely. Secondly, it means that however well the recovering addict works in treatment (or however good the treatment program may be) an ongoing recovery program is essential – there is no state of “recovered”, the process of staying clean is constant work
Neurochemical/physiological aspects of addiction
What makes up a living being? What defines us as different from other primates? The brain. Our brains have evolved to such an extent that we are able to create ever-changing lives, realities and relationships. But buried deep inside our brains is the ancient place where it all began: the reptilian brain. Deep within, this is a tiny cluster of firing electrical neurons which together are called the pleasure centre of the brain or the Nucleus Accumbens. This area is responsible for our very survival because its’ primitive actions are related to anything about survival of the species: breathing, eating, sex. When stimulated this area of the brain sends pleasure signals throughout the body and central nervous system, for example, feelings of well-being, reduced anxiety and relief. It is this basic programming that tells us “this is good. I want more”. From a physiological perspective this system is at the root of addiction.
The actions within the Nucleus Accumbens are mediated by several neurochemicals. The two most active in addiction are serotonin the “happy hormone” and dopamine “the drive hormone”. Dopamine is also the key molecule that is involved in creating memories of pleasurable events. Dopamine is part of the reason why we remember how much we liked getting high yesterday.
So, from this perspective we can begin to understand how addiction is a physiological process. I’ll take you on a journey through your Nucleus Accumbens – how does it actually work. Imagine a cat. This is your very own cat, and like all cats she likes to be loved and petted – on her terms. So you begin to stroke the cat across her back, and she nuzzles into your lap, pawing your leg in contentment. After a while you stop but the cat wants more stimulation so she headbutts your hand for a scratch behind the ear. Now she is feeling relaxed and very, very comfortable. Next she flips over onto her back and looks at you with eyes that say “I need to be petted on my tummy. Now!”. So you oblige. There’s something very nice about a contented and purring cat. This cat now knows that you are a source of stroking and pleasure, so she comes back to you on a regular basis for loving. Sometimes, you don’t feel like stroking her so you push her off your lap and give her a tickle with your toes. This is not her ideal, but she’ll put up with it and encourage it because she knows that that is all that’s on offer right now. But she always returns because the feel- good process is established – you pet the cat (your Nucleus Accumbens begins to flood with serotonin and dopamine), the cat enjoys it (the rush of serotonin and dopamine makes you feel peaceful and content), then there is not enough stimulation, so the cat asks for more (you come down from the high, and cravings begin) and ultimately the cycle begins again. Sometimes, the usual manner of petting isn’t available, so a substitute is found – although it does not give the cat as much pleasure (substitute drugs will temporarily satisfy the cravings, but not for long). This is how cross-addiction, or poly-addiction, begins.
Finding a way to override serotonin- and dopamine-mediated mid-brain commands is the essential key to physical recovery from addiction. One of the aims of a biological understanding of addiction is to tease out the mechanisms by which the reinforcing effects of addictive drugs become transformed into long-term adaptive changes in the brain.
The brain is essentially malleable grey-matter. This means that its’ plasticity allows for the development of pathways that are self- reinforcing, so that a cycle is established. This happens through the process described above. However, through various interventions, the grey-matter can be rewired so that new neural pathways are established and different patterns can be established. This is the biological way through which new habits are created.
Most of you have probably heard of someone who is addicted to chocolate, or has an addictive personality? Perhaps you have used these terms yourself? If this was the true and simple explanation there would be many people who no longer suffer as their relationship with the substance of choice would be part and parcel of a normal life. But this is not the case. In reality addiction is an all-consuming process: addicts live in an alternative reality; being in a destructive love affair with a partner who holds them captive and is captivating by nature. Addiction is the ultimate dance with death. Initially, the person begins to dance with his partner. He can select who he dances with and he does not need to dance every time his love interest is around. He is in control and dancing is merely one way of expressing his love for his partner. Gradually, dancing becomes very important in the relationship and the person cannot think about being with his partner without dancing. At this point the dance takes over – it sweeps him off his feet and twirls and spins him in a web of constant need. He cannot function without dancing. Dancing preoccupies his every waking thought. How, when and where can he dance? Dancing is now in control. The line between using dancing as a pleasurable activity wherein he is able to control it, has been crossed. He now needs to dance in order to feel alive. He is now addicted to dancing and it occupies every faculty he possesses. The dance becomes the obsession and fantasy in every state. Every action serves to maintain, obtain and sustain the dance. Dancing with death.
The majority of laypersons as well as a substantial number of medical professionals believe that "addictiveness" resides in the substance being used. In reality, addiction rests in the individuals’ vulnerabilities when exposed to the substance which sets in motion the behavioural syndrome of addiction.
Just like the dance, the addiction cycle begins when a person crosses the line between progressive use, misuse and abuse of the substance into dependence and addiction. In the former cycle, the person is in control and has a say over how he uses the substance. Once the line is crossed and tolerance and dependence develops, the substance has control. Addiction has set in. In this latter cycle, the person ceases to have any say in his behaviour. Regardless of the substance of choice, addicts have predictable and strikingly similar behavioural patterns.
Addiction refers to a complex behavioural syndrome that includes the following principles. The substance becomes pathologically and abnormally important in life, there is an obsession with obtaining and using the drug, there is excessive, prolonged and harmful use despite adverse consequences, and the mental defence mechanisms of denial, rationalization, minimization and justification are activated.
Addictive fascination and fixity of interest have been justly compared to the more commonly known stage of romantic or infatuated love in which the lover thinks constantly of the beloved and pines and suffers when not in their presence. An individual in such a state of mind is said to be obsessed with their love object and to subordinate every other aspect of their existence, including at times their health, work, and other relationships to the fulfilment of the almost unbearable need and longing to be united with their beloved. And we know from life as well as literature that so passionate and frequently desperate are such lovers that at times they even die as a consequence of or for their love.
We need to look at the psychological and behavioural process of addiction. It would be very easy to say that the Nucleus Accumbens is the reason why addicts can’t stop their self-destructive behaviour. Chop out this part of the brain and everything would be cured. Clearly this is not a viable option. So, we have to look at the other aspects of addiction that also help to maintain its life. There are two aspects here: the defence mechanisms at play as well as the personality of the person.
From a psychological perspective, denial is the hallmark of addiction. Denial is not only about telling oneself that the problem’s not really that big a deal (it was only 5 litres of Johnny after all, wasn’t it?); but denial is also produced by the addiction itself – in other words, the addiction disguises itself so well that the person does not even realise it is a problem. If the addict gets to a point where he realises that his life is unmanageable and his substance of choice is controlling his behaviour – that is, he has NO say in how much, when and where he uses, it has become a self-propelled process - he may attempt to curb or stop using. Often these attempts are unsuccessful. This is a hallmark of addiction. Denial keeps a person cushioned from the reality of how much he is using and the consequences of his use. Relationships break down. Self- esteem collapses. Lying, stealing and other immoral behaviours become the norm. Justifying the behaviour, such as “I’ve had a bad day, I deserve a joint” begins to make sense to the person. Hiding and lying become second nature. The person ensures that the substance is readily available, as is the reasonable explanation that bottles of alcohol really do belong in the bedroom cupboard. Minimising the amounts and consequences of using is the norm. Researching the drug and finding information to support why it is good for you, seems like a good idea – have you ever heard that using marijuana as a tea is good for you because it has medicinal value if used that way? Or “I need to take six extra pain killers because maybe I can knock out this headache once and for all. Besides I got them from my doctor so they can’t be bad for me”. These rationalisations all seem real and legitimate. Manipulation is a well-developed art. Thinking in extremes, that is, all-or-nothing or black- and-white thinking is typical. Grey does not exist. Together, these behaviours create an easily identifiable pattern – some may say personality –that characterises a person in active addiction.
Meanwhile, in the real world, the person is emaciated, has bruises, has lost a tremendous amount of money and opportunities. His nose runs constantly and vomiting is an everyday occurrence. He’s lost his home, family and the only friends he has are those who he does drugs with. There are car accidents and nights in jail. His liver and kidney functioning are deteriorating and beginning to fail. Every day is spent looking for money to buy drugs, thinking of who he can get from, going from one high to the next. Or not. It’s also possible that he holds a good job. Maybe he’s a trauma surgeon who has a penchant for pethidine, morphine and alcohol. Imagine this: you have just been involved in a massive car accident where you sustained internal injuries. Your emergency doctor performs an operation to stop the bleeding. You’re fine. Maybe. He goes off and thinks “hell, that was heavy. I need to inject 1000mg pethidine to calm my nerves. I really deserve it because I did such a good job”. But tomorrow his patient dies because he is coming down from a binge night and he missed something. It could have been you. This is how addiction works. It has no conscience. It does not discriminate and that is why you cannot look at someone and say “I know that they are an addict”. In some cases it is obvious. In others it is not.
There is much debate as to whether addiction is a moral issue and thus a question of choice versus a medical condition. If it were moral, the obvious question would be “why choose to use and use again?”. The assumption is that the person is somehow morally defunct and that there will be life circumstances from which people want to escape and therefore they choose to use. In truth, addiction is not a choice. One does not start out saying “today I’m going to become an addict”. Rather, there is an intricate interplay between biochemistry and the development of behavioural patterns that establishes addiction. One can spend many years looking at why one started to use. In recovery this is a sub-text. Everyone has a just reason why they should numb their feelings or escape from an event of trauma or pain. Not everyone becomes an addict. So from this perspective, let’s assume that any and all wounds – abuse, childhood trauma, deaths, broken homes and relationships (the list is endless) – exist and may be a trigger for the inception of drug use. Recovering from these hurts can only happen when a person is in a place where there is capacity for the development of insight and the ability to experience and sit with real emotional pain.
There are many competing theories as to what constitutes recovery from addiction. Is it complete absence? Change in behaviour? Both? Most authorities agree that being in recovery requires the complete abstinence from the substance of choice.
The first stage of recovery is breaking through denial. For a person to understand that 1) he has a problem and 2) his life is unmanageable, can take years. Truly grasping the reality of what the substances have done in one’s life and how much damage one has caused, is profoundly painful. The person has to begin to recognise how extensive the damage is and be able to take a real inventory of the consequences of his use. From here, the person has to let go of the notion of being in control. Most addicts have a notion that they can be “controlled users” and that they will once again be able to control how the substance of choice. This is simply not true. Ceding control and recognising that one’s life has not been one’s own, enables a person to gain real control. The illusion of being in control has to break so that the person can begin to really take stock of the extent of use and damage that has been caused. The problem for the alcoholic and addict is the powerful attachment they have to their addiction, hence the pressing need to construct a case that supports the continuance rather than the cessation of the addiction. The addict's subjective mental state consists of an obsession and preoccupation with his addiction that has been likened by many observers to the state of being in love. It is this peculiar obsessive mental state that leads to the obvious and external behaviours that are commonly identified as addiction. But the real origin of addiction lies in the mind, and in the thinking, dwelling, planning and anticipating the addict engages in regard to his specific addictions. Like an ordinary lover, the addict is obsessed with the object of his love, misses it when separated from it, exaggerates its positive qualities and minimizes or ignores its negative qualities. It becomes the centre around which his life revolves and the goal toward which he is constantly striving. Obstacles between the addict and his addiction only increase his desire and devotion – for "absence makes the heart grow fonder." And efforts by third parties to separate the addict from his beloved addiction invariably lead to renewed efforts by the addict to become reunited with what has become the most important thing in his life. And also like the everyday lover, the love of the addict for his addiction does not always run smoothly nor lead to the blissful happiness that once seemed to be promised. In fact, the course of an addictive illness can closely resemble that of an unhappy, unhealthy love affair of the well known type in which the lover can neither live with nor without the beloved. This is termed co-dependency. There are repeated honeymoons, turbulent sequels, recurring breakups followed by grief and then by ecstatic reunion – and the whole cycle begins over again and repeats itself. Not without reason have some forms of love and infatuation been compared to an addictive process from which the lover is either unable or unwilling to free himself, and for which he appears almost insanely willing to suffer tribulations and pains – including at times, death itself. Recovery at its simplest and indeed in its essence is about nothing more or less than the recovery of life itself. It is about getting back something of value(life), not merely giving up something that is strongly desired(addiction). For addiction, which seems to be the friend and even the enhancer of life, is in reality its deadliest and most incorrigible adversary. Addiction by its very nature is a form of bondage, even slavery. Recovery is the recovery of life and of freedom. To achieve this, therapists need to treat from three angles. From the outset I wrote of the medical perspective of addiction. Often, addiction comes with other conditions, such as depression and anxiety. From a medical perspective, medications that alter the use and availability of serotonin and dopamine, should enable the person to create new neural pathways, which, when reinforced behaviourally, become new ways of being.
From a psycho-social perspective, the person needs to regain a sense of being part of the human race. As addictions progress, the person’s world becomes smaller and smaller, revolving only around the gaining and using of the substance. Therapy thus needs to address the behaviours that keep the person stuck in the place of “I am my substance”. Lies, manipulation, isolation, impulsivity, and black-and-white, obsessive thinking, need to be challenged and changed. The addict has to learn how to take care of himself physically as well as learn the basic rules of engagement. He also needs to start becoming spiritually rich, getting in touch with a power greater than himself. Once all of this begins and the person stats to develop a capacity for experiencing and living his emotions, the triggers can start to be unravelled. This is a long journey that takes patience and investment.
As I finish off, I leave you with the question: are you an addict?