In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

This is not the first public “confession” I’ve made. I’ve written and spoken about my addictions before. And the truth is that as of this writing, neither my public acknowledgments of my behavior nor my thorough understanding of its impact on myself and my family has stopped me from repeating the cycle. I’ve authored three books and receive letters and e-mails from readers the world over, thanking me for having helped them transform their lives. Yet I have continued to choose patterns that darken my spirit, alienate those closest to me, and drain my vitality.

“Now my goal is only that each day I should become closer to the God that I understand. The greatest teaching I have received is that I can be happy without imposing my will on you or you or anyone else, even when I feel like doing so. “You may not believe you

“Three things that didn’t help me were love, education, and punishment. I didn’t learn no matter how hard people tried to love me, no matter what facts I knew, and no matter how many times life taught me harsh lessons. I didn’t learn until I began to listen.

“That’s when I got that sobriety is more than just the absence of alcohol. It’s a way of being. It’s living life in its fullness.”

Recent brain imaging studies have revealed an underlying disruption to brain regions that are important for the normal processes of motivation, reward, and inhibitory control in addicted individuals. This provides the basis for a different view: that drug addiction is a disease of the brain, and the associated abnormal behavior is the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart.

What, then, is addiction? In the words of a consensus statement by addiction experts in 2001, addiction is a “chronic neurobiological disease … characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”

I’ve heard some people shrug off their addictive tendencies by saying, for example, “I can’t be an alcoholic. I don’t drink that much,” or “I only drink at certain times.” The issue is not the quantity or even the frequency, but the impact. “An addict continues to use a drug when evidence strongly demonstrates the drug is doing significant harm.… If users show the pattern of preoccupation and compulsive use repeatedly over time with relapse, addiction can be identified.”

Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic, and spiritual underpinnings—and perhaps others I haven’t thought about. To get anywhere near a complete picture we must keep shaking the kaleidoscope to see what other patterns emerge.

As we will see, emotional isolation, powerlessness, and stress are exactly the conditions that promote the neurobiology of addiction in human beings as well.

Thus, we might say that three factors need to coincide for substance addiction to occur: a susceptible organism; a drug with addictive potential; and stress.

Drugs influence and alter how we act and feel because they resemble the brain’s own natural chemicals. This likeness allows them to occupy receptor sites on our cells and interact with the brain’s intrinsic messenger systems.

Many other body chemicals serve multiple purposes—and the more evolved the organism, the more functions a particular substance will have.

Because opioids are necessary for parental love. The infant’s well-being would be jeopardized if the mother became insensitive to the effects of her own opioids. Nurturing mothers experience major endorphin surges as they interact lovingly with their babies—endorphin highs can be one of the natural rewards of motherhood.

Opiates, in other words, are the chemical linchpins of the emotional apparatus in the brain that is responsible for protecting and nurturing infant life. Thus addiction to opiates like morphine and heroin arises in a brain system that governs the most powerful emotional dynamic in human existence: the attachment instinct. Love.

Attachment is the drive for physical and emotional closeness with other people. It ensures infant survival by bonding infant to mother and mother to infant. Throughout life the attachment drive impels us to seek relationships and companionship, maintains family connections, and helps build community. When endorphins lock onto opiate receptors, they trigger the chemistry of love and connection, helping us to be the social creatures we are.

Opiates do not “take away” pain. Instead, they reduce our consciousness of it as an unpleasant stimulus. Pain begins as a physical phenomenon registered in the brain, but we may or may not consciously notice it at any given moment. What we call “being in pain” is our subjective experience of that stimulus (i.e., “Ouch, that hurts”) and our emotional reaction to the experience. Opiates help make some pain bearable.

Even this mild and obviously artificial “rejection” lit up the ACC and caused feelings of hurt. In other words, we “feel” physical and emotional pain in the same part of the brain—and that, in turn, is crucial to our bonding with others who are important to us. In normal circumstances, the emotional pain of separation keeps us close to each other when we most need that closeness.

Allan Schore has called “proximal separation.”12 Given that the child’s dependence is as much emotional as physical, in normal circumstances a child who senses emotional separation will seek to reconnect with the parent. Once more, the parent’s loving response will flood the brain with endorphins and ease the child’s discomfort. Should the parent not respond, or not respond adequately, endorphins won’t be released, and the child will be left to his own inadequate coping mechanisms—for example, rocking or thumb-sucking as ways of self-soothing or tuning out to escape distress. Children who have not received the attentive presence of the parent are, as we will see, at greater risk for seeking chemical satisfaction from external sources later in life.

Environmental cues associated with drug use—paraphernalia, people, places, and situations—are all powerful triggers for repeated use and for relapse, because they themselves trigger dopamine release.

Opioid circuits and dopamine pathways are important components of what has been called the limbic system, or the emotional brain. The circuits of the limbic system process emotions like love, joy, pleasure, pain, anger, and fear. For all their complexities, emotions exist for a very basic purpose: to initiate and maintain activities necessary for survival. In a nutshell, they modulate two drives that are absolutely essential to animal life, including human life: attachment and aversion.

“Recent studies have shown that repeated drug use leads to long-lasting changes in the brain that undermine voluntary control,” says an article cowritten by Dr. Nora Volkow, director of the National Institute on Drug Abuse. “Although initial drug experimentation and recreational use may be volitional, once addiction develops this control is markedly disrupted.”1 In other words, drug addiction damages the parts of the brain responsible for decision making.

The human brain is the most complex biological entity in the universe. It has between 80 billion and 100 billion nerve cells, or neurons, each branched to form thousands of possible connections with other nerve cells. In addition, there are a trillion “support” cells, called glia, that help the neurons thrive and function.

One of the most important duties of the cortex is “to inhibit inappropriate response rather than to produce the appropriate one,” suggests neuropsychologist Joseph LeDoux.

Many studies link addiction to the orbitofrontal cortex (OFC), a cortical segment found near the eye socket, or orbit.5 In drug addicts, whether they are intoxicated or not, it doesn’t function normally. The OFC’s relationship with addiction arises from its special role in human behavior and from its abundant supply of opioid and dopamine receptors.

The neurological traces of early, formative events are embedded in the OFC, which, in turn, is connected with other memory-serving brain structures. So, for example, a smell that in early memory is associated with a pleasurable experience will likely be judged by the OFC in a positive way. Through its access to memory traces, conscious and unconscious, the OFC “decides” the emotional value of stimuli—for example, are we intensely drawn to or repelled by a person or object or activity, or are we neutral? It is constantly surveying the emotional significance of situations, their personal meaning to the individual. Through processes we are not consciously aware of, in microseconds the OFC decides our take on people or on a situation. Since our likes and dislikes, preferences and aversions strongly influence what we focus on, the OFC helps us decide to what or whom we should devote our attention at any given moment.6

The OFC—particularly on the right side of the brain—has a unique influence on social and emotional behaviors, including attachment (love) relationships. It is deeply concerned with the assessment of interactions between the self and others and plays a ceaseless (but fundamentally life-essential) game of “Who loves, who loves me not?” It even gauges “How much does he/she love me or dislike me?” While the explicit meanings of words spoken are decoded in specialized portions of the left hemisphere, the right OFC interprets the emotional content of communications—the other person’s body language, eye movements, and tone of voice.

The OFC also contributes to decision making and to inhibiting impulses that, if allowed to be acted out, would be harmful—for example, inappropriate anger or violence. Finally, brain researchers have also linked the OFC to our capacity to balance short-term objectives against longer-term consequences in the process of decision making.

As a result, her OFC has been trained to create a powerful emotional pull toward the drug from the second she even thinks about “fixing.” Addiction research refers to this dynamic as salience attribution: the assignment of great value to a false need and the depreciation of true ones. It occurs unconsciously and automatically.

Brain development in the uterus and during childhood is the single most important biological factor in determining whether or not a person will be predisposed to substance dependence and to addictive behaviors of any sort, whether drug-related or not.

The three environmental conditions absolutely essential to optimal human brain development are nutrition, physical security, and consistent emotional nurturing.

The child needs to be in an attachment relationship with at least one reliably available, protective, psychologically present, and reasonably nonstressed adult.

In the words of the great Canadian neuroscientist Donald Hebb, “cells that fire together, wire together.” The infants of stressed or depressed parents are likely to encode negative emotional patterns in their brains. The long-term effect of parental mood on the biology of the child’s brain is illustrated by several studies showing that concentrations of the stress hormone cortisol are elevated in the children of clinically depressed mothers.

The three dominant brain systems in addiction—the opioid attachment-reward system, the dopamine-based incentive-motivation apparatus, and the self-regulation areas of the prefrontal cortex—are all exquisitely fine-tuned by the environment.

“Overall, these studies provide evidence that stress and trauma are common factors associated with consumption of alcohol at an early age as a means to self-regulate negative or painful emotions,”17 write the ACE researchers.

One characteristic of personality disorder, a condition with which substance abusers are very commonly diagnosed, is a kind of flip-flopping between idealization of another person and intense dislike, even hatred. There is no middle ground, where both the positive and the negative qualities of the other are acknowledged and accepted.

Stress is a physiological response mounted by an organism when it is confronted with excessive demands on its coping mechanisms, whether biological or psychological. It is an attempt to maintain internal biological and chemical stability, or homeostasis, in the face of these excessive demands.

“the risk of alcoholism fluctuates over time.”6 Even if, against all available evidence, it were demonstrated conclusively that 70 percent of addiction is programmed by our DNA, I would still be more interested in the remaining 30 percent.

Numerous studies in both animals and humans have found that maternal stress or anxiety during pregnancy can lead to a broad range of problems in the offspring, from infantile colic to later learning difficulties19 and the establishment of behavioral and emotional patterns that increase a person’s predilection for addiction.

if a phenomenon like addiction is determined mostly by biological heredity, we are spared from having to look at how our social environment supports, or does not support, the parents of young children and at how social attitudes, prejudices, and policies burden, stress, and exclude certain segments of the population and thereby increase their propensity for addiction.

Anyone who is not totally dead to himself will soon find that he is tempted and overcome by piddling and frivolous things. Whoever is weak in spirit, given to the flesh, and inclined to sensual things can, but only with great difficulty, drag himself away from his earthly desires. Therefore, he is often gloomy and sad when he is trying to pull himself away from them and easily gives in to anger should someone attempt to oppose him.

it’s not the activity or object itself that defines an addiction but our relationship to whatever is the external focus of our attention or behavior. Just as it’s possible to drink alcohol without being addicted to it, so one can engage in any activity without addiction.

addictions are not a collection of distinct disorders but the manifestations of an underlying process that can be expressed in many ways. The addictive process—I will refer to it as the addiction process—governs all addictions and involves the same neurological and psychological malfunctions. The differences are only a matter of degree.

For someone with a relative shortage of dopamine receptors, it’s whichever activity best releases extra quantities of this euphoric and invigorating neurotransmitter that will become the object of addictive pursuit. In effect, people become addicted to their own brain chemicals. When caught in the urgent fever of my compact disc hunt, for instance, it’s that hit of dopamine I’m after.

Pathological gamblers, too, are highly likely to fall under the sway of other destructive habits. About half of them are alcoholics, and the vast majority are addicted to nicotine—and the more severe a person’s gambling, the stronger the addiction to alcohol and smoking.

Withdrawal consists of irritability, a generally glum mood, restlessness, and a sense of aimlessness. No doubt it has its chemical components: I’m experiencing the effect of diminished dopamine and endorphin levels. Other nonsubstance addicts experience similar symptoms after abruptly stopping whatever behavior they were bingeing with. The journey from addictive self-indulgence to depression is rapid and inexorable.

During those nervous first months of grad school, I wrote in my blog sometimes for three or four hours a day—or night—instead of making time for social activities or exercise or sleep, or even schoolwork—in short, life. I felt compelled by some strange muse to push the blog envelope by including more and more private details about my life. It was like some wondrous Seussian contraption: I fed myself, like raw material, into the BlogMatic 3000, and out came a vivid, clever, sparkling artifact, so much more interesting and well-defined than my actual life as I knew it. I recall that even you and Mom, and many of my friends, lapped it up for a time, until it crossed that invisible line between self-expression and self-obsession—and then you let me know I’d crossed it. I’d surfed atop a wave of glowing attention, and so when it crashed I was genuinely perplexed.

Oddly enough, the addiction really isn’t over until I can see the emptiness (in a Buddhist sense) of the behavior: not good, not evil, and certainly not exciting, just an outside “thing” I’ve been using unintelligently to dull the suffering edge of life. I say “unintelligently” because no addiction in the history of the world ever alleviated more suffering than it ended up causing.

So it turns out that I’m not so different from you, Dad. I, too, carry a void inside—nothing exotic, just an ordinary human despair-fear-anxiety factory—and mine will try to feed on anything that gives me an instant sense of self-definition, purpose, or worth. (If I want to be quippy about it, it’s a void I’ll do anything to avoid.)

Having fallen through the crust of this earth so many times, it seems that only on this small and familiar pad of concrete, where I can make seven steps in one direction, then take seven back, do my feet touch down with any certainty.

Popular lore has it that the addict has to hit bottom before gaining the motivation to give up his habit. That may be true in some individual cases, but as a general rule it fails because what constitutes the lowest point is highly personal to each addict.