Maia Szalavitz has penned a new article on addiction that has been circulated, credulously and uncritically, on social media by people who should know better. So, once more, into the breech, Dear Reader.
The article in question is Most of Us Still Don't Get It: Addiction is a Learning Disorder is posted at substance.com.
We can start with the sub-header:
Addiction is not about our brains being "hijacked" by drugs or experiences—it's about learned patterns of behavior. Our inability to understand this leads to no end of absurdities.
From whence comes learning if not from experiences? And what is the ingestion of a psychoactive drug if not an experience? She is making no sense here. The second sentence is pure straw-man, particularly when you read the entire piece and see that her target is science, scientists and the informed public rather than the disengaged naive reader.
Academic scientists focused on drug abuse have talked about the learning aspect, of habits and of the lasting consequences of drug experiences since forever. This is not in the least little bit unknown or novel.
Szalavitz, like most other self-appointed anti-drug-science warriors, starts with the argument from absurdity, hoping to enlist the uninformed biases of the reader as a trump card for her argument.
Sex, food, shopping, the Internet, video games—all of these activities are being studied by neuroscientists, which frequently leads to headlines like “Oreos May Be As Addictive As Cocaine” and “Brain Activity of Sex Addicts Similar to That of Drug Addicts.”
These stories carry the very strange implication that our brains have areas “for” drug addiction that can be “hijacked” by experiences like sex, junk food and MILF porn.
See? These silly drug scientists think sex and gambling are addictive! And we all know that is absurd so clearly their other science is absurd as well. Nice journalistic trick, well done. It is still wrong and, interestingly, Szalavitz tells us why.
Evolution didn’t provide us with brain circuitry dedicated to alcoholism and other drug addictions—it gave us brain networks that motivate us to seek pleasure and avoid pain in ways that promote survival and reproduction.
This is precisely what every addiction scientist and professor worth their salt tells any audience, from neighbor to undergraduate 101 class to graduate seminar. What they have been telling their audiences for at least, what, 50 years? The very term "hijacked", which she seems to object to with such vigor, in and of itself implies some external interference with the normal activity, entity or process, does it not?
To understand addiction, we’ve got to stop falling for arguments that obscure this truth and make unsound claims about brain changes that cannot tell us anything about its real nature.
Who is making these arguments? Who is falling for them? What "unsound claims"?
This means that any study that says it shows that something is addictive because the stuff “lights up” the same brain areas seen in addiction is tautological.
The operating concept is "has the potential to be addictive". I've burned endless pixels on this blog talking about the conditional probability of addiction and the fact that dependence is a minority outcome among all people who sample a given drug. Yes, even injected heroin, as best we have numbers. Szalavitz's twist on this is subtle but it is wrong; she's making a straw argument here against something that doesn't exist. Under the best case scenario she is criticizing media stories on addiction science. Yet for some odd reason this doesn't read like an indictment of sloppy journalism in the least little bit. Later in the piece she mentions NIDA, Alan Leshner, "researchers", Stanton Peele, George Koob, Kent Berridge and Nora Volkow. Her only indictment of newsmedia ties the sensationalist headlines to the studies of neuroscientists.
The intent here is clear.
On to the specifics. The article says:
Anything that provides pleasure or certain types of stress relief will activate these regions. If it doesn’t activate these areas, it can’t be perceived as pleasant, desirable or comforting.
If you image the brain of a musician hitting the perfect note, a coder getting sudden insight on a complex problem, a father watching his child take her first step, you will see some of these areas go wild. That means these folks are experiencing joy: It doesn’t tell us that F sharp, a particular line of code or baby steps are “addictive.” Simply seeing activation in the brain’s pleasure and desire circuitry doesn’t reveal addiction.
Absolutely. Very well put. This is a concept you might think of as necessary-but-not-sufficient. I emphasize this point myself frequently, including on this blog and the related Twitter feed. Why is the piece pretending that this is the author's creation, unshared by many scientists?
This is the sort of nonsense writing that led me to the following observation about the style of this piece.
— Drug Monkey (@drugmonkeyblog) July 18, 2014
Szalavitz is trying to get you to think that just because any given measure fails to distinguish addiction (leaving aside the question of how to define that for now) with complete accuracy this means that we know nothing. And furthermore she would like us to believe that the indicators that we do have are not just insufficient but wrong.
In fact, despite hundreds of millions of dollars spent on neuroimaging research, we still don’t have a scan that can reliably separate addicted people from casual drug users or accurately predict relapse. Some studies have suggested that this may be possible but none have found a replicable diagnostic scan,
How many hundreds of millions of dollars have been spent on cancer research? Do we have 100% perfect indicators of who will have a recurrence of various cancers after a successful bout of therapy? And when they will do so? What about cardiovascular research? If we had perfect markers why did I lose two uncles to heart attack in the last few years and why were my dad's series of adverse cardiovascular events over the past thirty years not predictable in advance?
Because knowledge about health conditions is rarely perfect. That's why.
We do research into what is possible to provide additional evidence that we can use to shift the odds for people with a given health condition. We do this on a population level, haltingly and imperfectly. We gain evidence, knowledge and use that to more forward to refine diagnosis and treatment. Substance abuse is no different than any other health condition. Even if you happen to think our level of understanding is poorer than your favorite comparison one. Even if your knowledge of your scientific ignorance keeps you from opining on cancer but your same level of ignorance about addiction neuroscience poses you no such barrier. It doesn't change the reality.
Moreover, recent sex and food addiction research showing similar alterations to those seen in drug addictions strikes at the heart of arguments made about the uniquely addictive nature of psychoactive chemicals.
"Uniquely addictive nature"? What in the heck is this supposed to mean? Who is making these arguments? Sure, exogenous psychoactive compounds can have very powerful effects, more notable or significant than what we think of as more naturalistic rewards. Sure. But in this piece it is Szalavitz herself that is trying to set up drugs as some unique category that could not possibly overlap with natural rewards. If anyone is engaging in a circular, tautological argument....
“addiction is considered a brain disease because drugs change the brain.” But this idea—first promoted heavily by the former head of NIDA, Alan Leshner—isn’t the whole story.
Scientists aren't claiming any particular effect of psychoactive drug exposure is the whole story. Haven't done so in decades, if ever, to my reading of the academic literature. Even if you can find some folks arguing this, there are other scientists arguing against it. Science is diverse.
So, simply changing the brain doesn’t make addiction a disease because not all changes are pathological. In order to use brain scans to prove addiction is a disease, you’d have to show changes that are only seen in addicted people, that occur in all cases of addiction and that predict relapse and recovery. No one has yet done this.
True, true, false, false, false. And true.
Again, the concept of necessary but not sufficient is apt here. Brain-related health disorders are complex. We do NOT understand the brain very well. We do not understand what mechanisms subserve normal behavior nor what represents pathology to a high degree of fidelity. But the fact that nobody has found a perfect single measure that can distinguish an addict from a non-addicted user of the same drug does not mean that all existing knowledge is wrong.
Secondly, if you can be addicted to activities like sex, gambling and the Internet—which do not directly chemically alter the brain—how can they be addictive, if addiction is caused by drug-related brain changes?
Breathtakingly dishonest bit of logic there. Addiction can be caused by many things, a subset of which are exogenous psychoactive drugs. Go back up to her prior observation that humans do not have drug-circuitry. Drugs interact with endogenous circuitry. Which is there, btw, for endogenous processes and functions. Nobody of any seriousness is claiming that addiction = "drug-related". Except the author herself. As she simultaneously criticizes this approach. I am amazed at the internal inconsistency.
Researchers long argued that the pharmacology of particular drugs is what makes them addictive—that, say, cocaine’s alterations in the dopamine system cause a worse addiction than sex or food do because the drug directly affects the way the brain handles that chemical.
Wrong. Researchers have long argued that potent effects of exogenous psychoactive drugs on endogenous neurochemical signalling systems gives them a chance of having greater effect than naturalistic triggers for those self-same endogenous mechanisms.
But since sex and food only affect these chemicals naturally—and can create compulsive behavior that’s just as hard for some people to quit—why should we see cocaine differently?
We don't. Sex, food, etc should be seen as having a potential for compulsive behavior. Which is the straw man Szalavitz is trying to dismantle with her argument-from-absurdity strategy. In fact, she's doing a better job making the argument for the possibility that addictions to gambling, videogames, Oreo cookies and what have you are similar to addictions to heroin and cocaine!
What it does show, I believe, is that addiction is a learning disorder, a condition where a system designed to motivate us to engage in activities helpful to survival and reproduction develops abnormally and goes awry. While this theory is implicitly accepted or stated outright in much of today’s neuroscience research on addiction—and it runs through specific theories of addiction, including theories as varied as those of Stanton Peele, George Koob, current NIDA head Nora Volkow and Kent Berridge—its implications are not well understood by many treatment providers and the public.
Aha! So she finally gets around to admitting that her belief about learning "runs through specific theories of addiction" and then she names some of the most public and active scientist voices on addiction! What in the heck is all this scorn of scientists then? Why are they the target? Who is misinforming the public if these theories are not well understood. And by the way....citation? What evidence is there that this is not just another straw-man assertion raised by Szalavitz that has no basis in reality?
Instead, addiction is a seen as a “chronic, progressive disease,” which can only remit or worsen and which pretty much affects all addicted people in the same way.
"All". "in the same way". This is not even remotely consistent with any reasonable understanding of drug abuse. Certainly not from the scientific perspective.
Addiction is a very diverse beast. Who doesn't know this? Who doesn't realize this when they sit down and think about it for a half a second?
Neuroscience can help us better understand this circuitry. However, the fact that non-drug addictions exist shows that drugs are neither necessary nor sufficient to “hijack” it.
[ INTERMISSION ]
[addiction] ..is a learned pattern of behavior that involves the use of soothing or pleasant activities for a purpose like coping with stress. This is why simple exposure to a drug cannot cause addiction: The exposure must occur in a context where the person finds the experience pleasant and/or useful and must be deliberately repeated until the brain shifts its processing of the experience from deliberate and intentional to automatic and habitual.
I might quibble about what "simple exposure" means and whether "cannot" or "must" or "deliberately" is accurate (absolutes rarely are when we're talking human behavior) but not too bad. I can back this.
This is also why pain patients cannot be “made addicted” by their doctors. In order to develop an addiction, you have to repeatedly take the drug for emotional relief to the point where it feels as though you can’t live without it. That doesn’t happen when you take a drug as prescribed in a regular pattern—it can only happen when you start taking doses early or take extra when you feel a need to deal with issues other than pain. Until your brain learns that the drug is critical to your emotional stability, addiction cannot be established and this learning starts with voluntary choices. To put it bluntly, if I kidnap you, tie you down and shoot you up with heroin for two months, I can create physical dependence and withdrawal symptoms—but only if you go out and cop after I free you will you actually become an addict.
It sounds true. And it is true, after a fashion. But what is missing here is whether exposure to drugs under conditions that do not look at all like addictive use can leave one at increased liability to develop an addictive pattern. And whether it makes any sense to engage in sophistry about "learning" or "need" or "issues other than pain" or "emotional stability" when that prior exposure changes these factors. See how this is setting up for victim blaming when someone who is prescribed opiates for pain goes on to have an addiction to them? You cannot be changed by the pain control under a doctor's care, it is only you, weakling, who decides to keep taking them for your "other issues". Because of course the "physical dependence and withdrawal symptoms" from taking opioid medications for pain control couldn't possibly drive continued use. You know, for the discomfort of withdrawal as opposed to the original surgical pain issue.
This is a result of an underlying disbelief that the known neuropharmacological changes that are produced by repeated drug exposure have anything to do with addiction. Again, "physical dependence" is not equal to addiction. Lord knows I've done a lot of Internet fighting on that too. But physical dependence is not entirely unrelated to addiction either. The avoidance of unpleasant withdrawal symptoms (whether they are of the so called physical variety or of the covert, motivational variety) most assuredly plays a role in continued drug use. Continued use most assuredly plays a role in addiction (again, pretty much no matter how behavioral patterns are categorized).
Again, this doesn’t mean that people who voluntarily make those choices don’t have biological, genetic or environmental reasons that make them more vulnerable and perhaps less culpable—but it does mean that addiction can’t happen without your own will becoming involved.
"Will"? Really? I'm just not seeing how that is helpful here. Yes, at some level the drug addict has to use his or her free will to secure and ingest their drug(s) of choice and that makes it a matter of "will" as to whether or not one is a continued addict.
But it is ridiculous sophistry.
When someone has become addicted they are in a much different motivational state than those people who are not. It is an entirely different proposition for an addicted person to choose not to ingest their drug than it is for the next person. And some of those people may have started out in the hole relative to you and I from the get-go...as Szalavitz dismissively admits in that first bit about biological, genetic or environmental reasons.
Addiction—whether to sex, drugs or rock & roll—is a disorder of learning. It’s not a disorder of hedonism or selfishness and it’s not a sign of “character defects.”
Absolutely. On this we agree. But why is she bringing up these points here? These particular misconceptions are novel and jarring this late in the piece. These are misconceptions that scientist are laboring mightily to dispel. The identification of genetic liabilities for addiction, as well as brain changes associated with addiction-causing exposure to exogenous psychoactive substances is part and parcel of this labor. Neurobiological signs of dependence that do not correlate with, say, psychological diagnosis of hedonism or something, would appear to make the case--if you thought it really necessary. Me, I think demonstrating as much as we can about changes associated with the addict, and even with non-addicting exposure to addictive drugs, goes a long way all by itself.
If we want to get beyond “Is Sex Addictive?” and “Crack vs. Junk Food: Which Is Worse?” we’ve got to recognize that we’ve been asking the wrong questions. The real issue is what purpose does addictive behavior serve and how can it be replaced with more productive and healthy pursuits—not how can we stop the demon drug or activity of the month.
Who has been asking the wrong questions? Because from where I stand, this piece has made no headway whatever on identifying these questions or demonstrating the lack of asking the right questions. Addiction science is an all-hands-on-deck business- NIDA itself funds a vast range of studies from the epidemiological to social services to clinical to preclinical and basic science. We ask all the questions, if you look uncritically at the scientific literature having to do with addictions.
Yes, even so far as asking what parallels might be seen between addictions to the exogenous drugs and addictions to "sex, junk food and MILF porn" as Szalavitz put it so charmingly. Denying these might be similar, or denying that one biological measure (like the stuff “lights up” the same brain areas), is a good way to keep yourself from getting a full picture.
Not everything that appears to be associated with an addictive state is going to turn out to be unalloyed gold. That isn't the way science works.
But denying that reasonably well established phenomenon have anything to do with a health disorder isn't the way science moves ahead either.