Are Addictive Behaviors Really Addictive?
The DSM has undergone various revisions in recent years to keep up with the field, particularly around the concept of addiction, the criteria for its diagnosis, and what it takes to be addicted. There have been two main obstacles in advancing the field of addiction, and both of them have to do with definition and criteria. The first is: Can you be addicted to something that isn’t a substance? The second is: If you demonstrate tolerance but not the physiological symptoms of withdrawal, can you still call it addiction? Answering these two questions has taken almost two decades of research and debate—the time between the publication of the DSM-IV (1994) and the DSM-V (2013). And I promise you, by the time the DSM-VI rolls around, there will be further modifications. This field is in constant flux.
For decades the APA said no, behaviors like gambling weren’t manifestations of addiction because the definition was tolerance plus withdrawal. Lack of withdrawal meant they didn’t meet the criteria. But after decades of discussion, policy making, and politicking, the DSM-V has removed the requirement for withdrawal as an absolute diagnostic criterion. In so doing, the APA has now changed the definition of substance-related and addictive disorders and allowed for the inclusion of addictive behaviors as well. Here is the current mix-and-match list of eleven items:
Tolerance
Withdrawal
Craving or a strong desire to use
Recurrent use resulting in a failure to fulfill major role obligations (work, school, home)
Recurrent use in physically hazardous situations (e.g., driving)
Use despite social or interpersonal problems caused or exacerbated by use
Taking the substance or engaging in the behavior in larger amounts or over a longer period than intended
Attempts to quit or cut down
Time spent seeking or recovering from use
Interference with life activities
Use despite negative consequences
Instead of hard-and-fast criteria, this DSM-V paradigm allows for scaling of severity. Two or three of the above symptoms indicate a mild disorder, four or five symptoms indicate a moderate disorder, and six or more symptoms indicate a severe disorder.
One question that people always ask: Is there an addictive personality? What they really want to know is if addiction is genetic. There are a lot of children of alcoholic parents who are worried that they will suffer the same fate. Many people are exposed to alcohol and they don’t get addicted. Many people (like me) have received the narcotic meperidine (Demerol) as pre-op for a surgery, and they don’t turn into heroin addicts. They want to know: If I’m not addicted now, I’m out of the woods, right? Is addiction driven by genes or by the substances themselves? There is no doubt that there are certain genes that predispose people to alcoholism12 or smoking,13 but they all impact dopamine in some fashion. If a genetic defect or alteration reduces the number of dopamine receptors, motivation for reward will be increased (see Chapter 3). But there’s no gene identified to date that is 100 percent predictive. If you harbor a genetic variation of your dopamine receptor, you do have an increased relative risk,14 but it’s not a faît accomplit.
Another issue that has plagued research on addiction is the question of cause and effect. Clearly dopamine neurotransmission is associated with tolerance and withdrawal, but which comes first? Is it that dopamine drives the addictive behavior, or is it the addictive behavior that results in the changes in dopamine? A recent study looked at patients with Parkinson’s disease, which occurs due to the degeneration of dopamine neurons in another brain area, the substantia nigra (SN), which controls movement. Parkinson’s disease patients experience severe rigidity and tremor, interfering with every aspect of their lives. The neurons in the SN that produce dopamine are not just dysfunctional; they’re dying. Parkinson’s patients are given drugs, such as L-DOPA/carbidopa (Sinemet) and bromocriptine (Parlodel), that increase or mimic natural dopamine signaling to restore movement. Many people have heard of L-DOPA because of the movie Awakenings (1990), based on the work of the late neurologist Dr. Oliver Sacks. These are not drugs that are abused for their pleasurable properties. But these drugs are not specific for the areas that affect movement; they also interact with the dopamine receptors in regions that affect reward-related signaling. It turns out that these drugs drive a panoply of behaviors as unwanted side effects, including aggression, paranoia, and poor impulse control.15 Some patients have even become compulsive gamblers. Activation of the dopamine receptor means the motivation for reward is enacted, with all the positive and negative consequences that come with it. What these studies show is that the dopamine comes first: the drugs drive the dopamine signal, and the dopamine signal eventually drives these behaviors.
Addiction Transfer
What happens when, for one reason or another, you can’t access your favorite fix? Once your dopamine pump is primed, it’s just waiting to be fired, for something—anything. People abstaining from one substance will frequently find themselves embroiled with another drug or activity (sex, gambling) that can generate the same effect. No AA meeting is complete without coffee or Rockstar, cookies, and smoking out back. Because once you’re addicted to one substance and your dopamine receptors are down-regulated, you can easily become addicted to other substances as well. This is known as addiction transfer.
Addiction transfer is a standard alternative: when the addiction you have becomes unacceptable to yourself, your spouse, or society, you move on to the next. A rational person would opt to switch from more addictive, dangerous, and societally eschewed substances to socially acceptable alternatives. It’s common for those quitting smoking to start overeating, and most will inevitably gain some weight. Many people have experienced the phenomenon of addiction transfer—for example, when people switch from cigarettes to food (“I have an oral fixation”). William F. B. O’Reilly, a Republican advisor on Long Island (not that Bill O’Reilly), experienced addiction transfer firsthand and wrote about his experience in Newsday: “Off Sugar, and Wanting to Tear My Eyes Out.”16 O’Reilly first started out hooked on cigarettes, then he switched to alcohol, then he switched to sugar. But then his waistline grew, and finally there wasn’t anything left to switch to. In fact, one of the early treatments for obesity was to take up smoking. When you’re addicted to one substance and you find yourself abstaining, your dopamine’s modus operandi is to find a substitute trigger.
Bariatric surgery, including lap band surgery, reduces the amount of food one is able to consume at any one time. You simply don’t have the space in your stomach; you can’t eat like you used to. But many of those undergoing the procedure had unhealthy addictions to food in the first place; sacks of peanut butter cups generated the same type of fix for them as heroin might for someone else. Their dopamine pumps were primed and ready. So what do they switch to? Alcohol, the liquid drug.17 Carnie Wilson, a self-described food addict and former singer in the band Wilson Phillips, underwent gastric bypass surgery in 2000, losing 150 pounds and landing a gig as a pinup model for Playboy. She’s become somewhat of a poster child for the concept of addiction transfer, as she then found refuge in alcohol as opposed to food.
The Real Thing
A perfect example of addiction transfer, with long-lasting effects for the entire world, was John Pemberton. He was an Atlanta pharmacist and in 1886 he invented the formula for a very special and quite unique carbonated beverage. On May 29, just three weeks later, Pemberton placed the first advertisement in the Atlanta Journal for his soft drink (which wasn’t so soft in those days), which would from that day forward be known as Coca-Cola. The story of Pemberton and Coca-Cola is widely known, the stuff of urban legend. Back then, carbonation was a big deal, requiring special high-pressure jets to force enough carbon dioxide into a solution. There was no method for reinforcing standard glass bottles, so carbonation had to be done in pharmacies with special equipment and d
runk on-site. This became known as the soda fountain. Thus, Coca-Cola was originally sold only in pharmacies. But there was another reason as well.
What is not widely known is that Pemberton was a morphine addict, after being wounded in the Civil War.18 The reason he developed his sacred formula was a long-standing attempt to wean himself off his addiction. But his addiction was ruining his profits, his business, and his life. He spent the next twenty-one years trying to come up with an opium-free painkiller. He went through several iterations, without success. Ultimately, he developed a concoction that included cocaine, alcohol, caffeine, and sugar. Four separate hedonic substances, four somewhat weaker dopamine/reward drugs, to take the place of one very strong one.
Pemberton mixed the four with carbonated water (thought to have its own hedonic properties). However, due to the temperance movement that overtook the South in the late 1800s and due to many Civil War veterans developing alcoholism, he removed the alcohol, and voilà! However, in 1888, Pemberton sold the formula and the rights to Atlanta businessman Asa Candler for a mere $2,500, and Candler proceeded to turn Coca-Cola into the most famous brand in the world. Why so cheap? you ask. Because Pemberton needed the money—bad—and you can guess why. He was sick, addicted, and penniless. He never did beat his morphine addiction, and he died the same year, at age fifty-seven, in severe pain. Not surprisingly, if you go to the Coca-Cola Museum in Atlanta, this sordid story is nowhere to be found.
In 1903, the federal government required the removal of cocaine for public sale, leaving only caffeine and sugar. Were these two substances alone enough to maintain the hook? Of course: Why do you think Starbucks sells Frappucinos? Candler saw his Coca-Cola placed into pharmacy soda fountains all over the country. It is now available in 208 out of the 209 countries in the world (only North Korea is Cokeless; Myanmar capitulated in 2012, and Cuba in 2015) and is by far the world’s most recognized brand. And for good reason: it’s a delivery vehicle that mainlines two addictive compounds straight to your nucleus accumbens.
Sugar just happens to be the cheapest of our many substances of abuse. But all of these substances do essentially the same thing. By driving dopamine release, they all acutely drive reward, and in the process they also drive consumption. Yet, when taken to extreme, every stimulator of reward can instead result in addiction. For heroin or cocaine, you need a dealer and a wad of cash. For alcohol or nicotine, you need an ID. But for sugar, all you need is a quarter or a grandma. Sugar is the cheap thrill, the reward everyone on the planet is exposed to, the reward everyone can afford. Everyone’s an addict, and all your relatives are pushers. And it’s only one of two addictive substances that are legal and generally available (the other one being caffeine). That’s why soda is such a big seller: it’s two addictive substances rolled into one. Everyone has become a willing consumer of the two lowest common denominators. Sugar and caffeine are diet staples for much of the world today. Coffee is the second most important commodity (behind petroleum), and sugar is fourth.19 Sugar being a primary example, substances have been purified and mainlined, straight to your dopamine receptors. If you don’t exercise caution, you’ll blow your neurons out.
6.
The Purification of Addiction
Substances of abuse used to be scarce—a luxury for most of us—and dopamine was at low ebb. Prior to the eighteenth century, virtually every stimulus that generated reward was hard to come by, due to either its scarcity or its expense. You had to go out of your way to obtain the various illicit drugs. There were no stores, no internet, and there was very little porn. We’ve always had gambling and prostitution, but they weren’t on every street corner. Hedonic substances were once rare, limited to alcohol from the Triangle Trade, which allowed for the transfer of slaves from Africa, sugar and rum from the Caribbean, and money from New England.1 Slowly but surely, advances in technology, commodity crop farming, and globalization have made various rewarding substances readily available, and the ability to engage in rewarding behaviors not just possible but almost constant. Pleasure is now easy and cheap, if nothing else. In the twenty-first century, substances of abuse have become easier and cheaper to obtain all over the world. Whereas these substances were once something to savor and ponder, now they come a dozen to a box (either doughnuts, or beer, or both if you’re Homer Simpson).
A Brief History of Addiction
When did substances of abuse first appear on the scene?2 Archeological digs support the contention that Central Asia’s Yamnaya people (one of the three tribes that founded European civilization) had discovered and were trading cannabis as early as ten thousand years ago.3 The first literary reference to recreational drug use was from 5000 B.C.E., when the Sumerians chronicled the use of opium.4 The first reference to alcohol in the form of wine goes back to 4000 B.C.E., and the first mention of commercial production dates to 3500 B.C.E. in the form of an Egyptian brewery.5 But addiction didn’t really become a societal problem until we started purifying these substances. The first reference to addiction comes from China at around C.E. 1000, when opium became widely used.6
In Western society, however, addiction and addicts remained a relative rarity through most of the second millennium. We’ve had wine since the time of the Romans, but we had to rely on natural fermentation for its production. In early times wine spoiled rapidly, because early vintners couldn’t get the alcohol content up past 5 percent, just like beer, which was equally likely to spoil. Although commercial beer production dates back to European monasteries in the seventh century C.E., succumbing to alcohol addiction wasn’t an option: the alcohol content was just not high enough. Alcoholism remained a matter of availability. Once it could be easily bottled, we were awash in hard spirits. Distilled alcohol became the obvious choice of most addicts, because you could ferment and distill just about anything.
Alcoholism became a major societal problem throughout Europe in the 1700s once it became available and cheap. Prohibition turned out to be the anvil on which our current American society was forged. If anything, the dopamine rush from alcohol was increased tenfold by the fact that it had to be consumed in backroom speakeasys. It’s not an accident that 1933 saw the passage of the Twenty-First Amendment, which just happened to coincide with both the nadir of the Depression, and with Franklin Roosevelt’s New Deal of 1933. The government needed the tax money. But despite our affinity for alcohol, the dopamine rush still remained a luxury, out of the reach of most people, either due to religion, morality, reputation, or expense.
A Cheap Shot
Times have changed. Currently, the National Institute for Drug Abuse (NIDA) puts the U.S. binge-drinking rate at 30 percent for men and 16 percent for women, while alcoholism rates are 9.5 percent for men and 3.3 percent for women.7 Considering the use rate for alcohol is 67 percent of the U.S. adult population, that means that between one-quarter and one-half of Americans are binge users. That’s a pretty high take rate. And this is worth $212 billion in annual revenue to the U.S. alcohol industry.8 Kids today aren’t just bingeing on alcohol, they’re also popping uppers, downers, and everything in between. In adolescents over the last thirty-five years, the binge-drinking rates, as well as use of virtually every other illicit substance, has continued to increase.9
Alcohol is but one example of substances being purified and manufactured to suit the whims of societal addiction and bludgeon our dopamine receptors into submission. Marijuana is bred to be stronger than ever before, the coca leaf continues to provide both line cocaine and its cheaper cousin, crack, and opium poppies are still grown to make heroin. There’s big money to be made. Just ask Walter White from Breaking Bad (2008–2013). Those who distill, bottle, and sell these substances know what they’re doing and how to capitalize on our dopamine pathways (see Chapter 3). The pharmaceutical industry has made some incredible strides in recent decades, and medications now exist for a series of diseases and disorders that previously went untreated. However, these medicines are also used off-label, masque
rading as “cognitive enhancement.”10
The Other White Powder
It’s no secret there is big money in the pharmaceutical industry. The annual profit margin of Big Pharma is 18 percent, with five companies making 20 percent or more.11 But even this profit margin is minuscule when compared to the money being made on the cheapest thrill possible. The processed food industry grosses $1.46 trillion, of which $657 billion is gross profit, for a gross profit margin of 45 percent. And what drives such profits? The drug that isn’t a drug. Or is it? In America, circumcision of males at birth is relatively common. When the Jewish mohel (trained circumciser) performs the ritual called the Brith Milah, what alleviates the pain? He dips the pacifier in wine. But when the obstetrician performs this procedure in the hospital, what alleviates the pain? The pacifier is dipped in Sweet-Ease (a 24 percent super-concentrated sugar solution)12 that activates both dopamine and opioids in the brain.
Just as we all have motivation to obtain pleasure, virtually all humans have a sweet tooth at some level. It’s inscribed into our DNA. The world loves sugar. There’s not a race, ethnic group, or tribe on the planet that doesn’t understand the meaning of “sweet.” This can be traced back evolutionarily, because there are no foodstuffs on the planet that are both sweet and acutely poisonous. Sweet meant that it was safe to eat. Jamaican ackee fruit, when immature (and not sweet), contains a compound called hypoglycin that can cause Jamaican vomiting sickness and can be life-threatening. But once the mature ackee fruit blooms, all the hypoglycin is metabolized, and it is the Jamaican national dish, canned and shipped worldwide.
Despite our sugar love, the cost of sugar prevented its overconsumption until about fifty years ago. Prior to World War II, sugar was a condiment, something you added to your coffee or tea—“one lump or two?” But shortly after World War II, refined sugar became the drug of abuse for the masses. It was ratcheted up first with the advent of processed foods, which included added sugar. Then it was given another hike with the advent of high-fructose corn syrup in 1975, which provided competition for cane and beet sugar. This lowered prices further, and suddenly sugar started appearing in everything. And finally, the first Dietary Goals for the United States,13 published in 1977, told people to eat less fat, but it didn’t say anything about sugar. Now we have a choice: we can get our fix either from cane or beet sugar, or its cousins high-fructose corn syrup, maple syrup, agave, and honey. There’s a quick fix waiting for you on every street corner and in every refrigerator.
The Hacking of the American Mind Page 8