A New Definition of Addiction Makes Rehab and Recovery More Effective
We have typically defined addiction as needing a substance to function normally, but this ignores crucial psychological qualities of addiction. A new and better definition has arrived, says Maia Szalavitz.
Maia Szalavitz is widely viewed as one of the premier American journalists covering addiction and drugs. A neuroscience writer for TIME.com and a former cocaine and heroin addict, she understands the science and its personal dimensions in a way that few others can. is the first book-length exposé of the "tough love" business that dominates addiction treatment. Her newest book is Unbroken Brain: A Revolutionary New Way of Understanding Addiction.
Maia Szalavitz: Addiction is compulsive behavior despite negative consequences. And it's really important to start by defining addiction because for a long time we really defined it very poorly. We used to think that addiction was needing a substance to function. And what that resulted in was that cocaine was not addictive because cocaine does not produce physical withdraw that is noticeable. You may be cranky and irritable and crave cocaine, but you won't be puking and shaking and have the classic symptoms that you would see with alcohol or heroin withdrawal. So cocaine wasn't addictive. Then crack came and we realized that defining addiction in that way not only harms people by telling them that cocaine is not addictive, it also harmed pain patients because people who take opioids daily for pain will develop physical dependence but they are not addicted unless they have compulsive behavior despite negative consequences. I see addiction as a learning disorder and the reason that I see it that way is because the biology of addiction unfolds in a developmental context over time and that means that a huge amount of variables come into it, not only genes and early environment, but also culture, your family, the way you interpret your own experience. So it becomes very complicated pretty quickly.
Addiction is a learning disorder because it can't occur without learning. You have to learn to associate the drug with some kind of relief or pleasure. And you need to do that repeatedly over time before you can become addicted. This is why a baby can't be addicted because a baby who is born with physical dependence on something like heroine doesn't know whether it needs a diaper change or just wants mommy or wants heroin. And it certainly can't you go out and score despite negative consequences. So that's another reason what that it's really important to distinguish between physical dependence and addiction. So the learning is involved where you learn that this works to fix a problem and you basically then fall in love with the substance.
And once you've fallen in love with somebody or something you will persist despite negative consequences in order to sustain that relationship because the biology is going to tell you that your life depends on this. It basically acts in the brain region that is involved in survival and reproduction and those are the two fundamental purposes of biology. So that creates really, really strong cravings and it changes your priorities tremendously. And we don't really think about that when somebody falls in love and gets married and has a kid, we think that's very normal. And it is very normal. But if you notice how people behave around love affairs, where licit or illicit, they will tend to put that first and they will do things that they might not otherwise do in pursuit of that. And you can certainly see that when people have affairs where they will lie, et cetera.
It's both. In order to overcome addiction you need to figure out what purpose the addiction was serving. In my case I had a lot of depression and I had a lot of difficulties connecting with people. I was also sort of overwhelmed by my senses and emotions a lot of the time and opioids turned that down very nicely. So I needed to sort of figure out what was up and deal with those issues in order to be healthy and comfortable in recovery. And that's going to be different for different people because they are going to have different issues that they are medicating with the drugs.
I think psychedelics may be very useful in the treatment of addiction, but they are certainly not a cure. I think it's very important to keep in mind that insight alone does not change behavior. And with the drugs like ibogaine, which seems to help relieve opioid withdrawal, it's all well and good if you have a trip and then you are no longer physically dependent on the drug. But if you then go back to the same environment and you haven't made changes that are going to allow you to cope in a different way you will probably relapse and end up back in the same situation. So while it could be very useful to gain insight on what's going on with you via psychedelics, this idea that there will be a sort of one shot cure for addiction has been a tremendous problem in the field for a really long time and I think it's really important for the people who are promoting the use of psychedelics in addiction treatment not to over promise.
Addiction is a very human problem and this is often why people propose and some people benefit from a spiritual solution to it. That's not to say we should treat medicine and medical conditions as spirituality, but the reality is that addiction and depression and a lot of other mental illnesses do often involve struggling with that potential question. And so it is not going to be the case that you can just put a brain implant in and addiction it will go away without a big chunk of yourself going away. So the Chinese are horribly experimenting with this horrific brain surgery where they ablate, i.e. burn out the nucleus accumbens, which is basically the brain region that provides pleasure and motivation and they think that this is actually going to cure addiction. Of course, what happens is you get to people who are just anhedonic who relapsed because now they have even less.
So this idea that like we could use a drug that would block the effects of the drug of choice is generally misguided because the problem isn't the drug of choice, the problem is why you need that drug and why those drugs appeal to you and why you are trying to get out why you are trying to escape and what you need in your life in order to feel comfortable and safe and productive. So I don't think that there will be future weird cures like that. But what I do think is interesting about the future of drugs is that we can make better drugs. Part of the reason that prohibition is collapsing at the moment is because of what are called new psychoactive substances or legal highs. And basically you can make a new recreational drug by sort of tweaking molecules of the other ones and it will be technically legal because it hasn't been made illegal.
And what this reveals is that our system for making drugs illegal is completely irrational and based on 19th century prejudices. It has nothing to do with science. And if we apply science to this problem and look at well people are always going to want to alter their consciousness in some ways, how do we reduce the harm associated with this? How do we create drugs or medications that will allow people to feel safe and comfortable in the world but not be so distracting or it's problematic that they will not be able to connect with other people, they won't be so out of it. So I think the future of drugs is better drugs. I don't think the future of drugs will be, or virtual reality these kinds of things could all be very interesting. But I think that so long as people ask the question why am I here and so long as people need each other to love and connect we are going to have people who want to find ways to make that work better.
The biological definition of addiction that has informed lawmakers and the general public about drug use — defined as the necessity of a substance to function normally — is vastly inadequate to diagnose and treat drug addiction. Journalist and drug addiction researcher Maia Szalavitz proposes a new definition of addiction which gets to the core psychological causes: addiction is compulsive behavior despite negative consequences.
One practical problem with the biological definition of addiction is that it does not cover cocaine addiction. Unlike when someone abuses alcohol or opioids, the body does not go through violent withdraws when a heavy cocaine user suddenly abstains. But of course cocaine an be an addictive substance and abusers are likely to ignore the negative effects the drug produces in their lives.
Szalavitz's newest book is Unbroken Brain: A Revolutionary Way of Understanding Addiction.
Moreover, the biological definition of addiction fails to address the psychological dependency that drug addiction creates. The negative consequences of drug addiction are very real, so why do users persist at their own peril? As Szalavitz explains, the reason is quite simple: drug abuse is not an indelible stain on a person's moral character, but a signal that the user has learned to associate positive emotions like love, connection, and security with the high of drug use.
For this reason, Szalavitz describes drug abuse primarily as a learning disorder. As such, there is no cure-all for drug addiction, though certain treatments like spiritual direction and targeted use of psychedelic substances may calm cravings. What is needed is a systematic reevaluation of treatment based on a new definition of addiction, a definition that understands the psychological causes of drug abuse.
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