Unbroken Brain: A Revolutionary New Way of Understanding Addiction

by Maia Szalavitz

The preferred term for less severe drug problems is “substance misuse,”

Drug use” is the term for substance use that is not associated with harm or addiction.)

There is often a struggle, and sometimes, even more interestingly, a collusion between the powers of pathology and creation. —OLIVER SACKS

what determines who gets hooked, who recovers, and who does not? And how can we as a society do better at addressing addiction?

today, more people than ever before see themselves as addicted or recovering from substance addiction: 1 in 10 American adults—more than 23 million people—said they’d kicked some type of drug or alcohol addiction in their lifetime, in a large national survey conducted in 2012.

At least another 23 million currently suffer from some type of substance use disorder. That doesn’t even count the millions who consider themselves addicted to or recovering from behaviors like sex, gambling, or online activities—nor does it include food-related disorders.

addiction is not a sin or a choice. But it’s not a chronic, progressive brain disease like Alzheimer’s, either.

Instead, addiction is a developmental disorder—a problem involving timing and learning, more similar to autism, attention deficit hyperactivity disorder (ADHD), and dyslexia than it is to mumps or cancer.

Like autism, addiction involves difficulties in connecting with others; like ADHD, it can also be outgrown in a surprisingly large number of cases.

Moreover, like other developmental disorders, addiction can be associated with talents and benefits—not just deficits.

Addiction is frequently linked with intense drive and obsessiveness, which can fuel all types of success if channeled appropriately—and some believe that the “outsider” perspective of people with illegal drug addictions is linked with creativity.

Of course, in some ways addiction appears extremely unlike other developmental disorders, most prominently because it involves apparently deliberate and repeated choices, some of which, like taking illegal drugs, are considered inherently immoral.

In both autism and addictions, for example, repetitive coping behaviors are frequently misinterpreted as the source of the problem, rather than being seen as attempts at solutions.

In all of these conditions—including autism itself—repetitive, vigilant, or destructive behaviors are not usually the primary problem. Instead, they are typically a coping mechanism, a way to try to manage an environment that frequently feels threatening and overwhelming.

Similarly, addictive behavior is often a search for safety rather than an attempt to rebel or a selfish turn inward (a charge previously made against autistic children as well).

We’ll see throughout this book how misinterpreting understandable attempts at self-protection as hedonistic, selfish, or “crazy” has needlessly stigmatized people with developmental disorders including addiction—and, as a res...

addiction is a learned relationship between the timing and pattern of the exposure to substances or other potentially addictive experiences and a person’s predispositions, cultural and physical environment, and social and emotional needs.

if addiction is a learning disorder, fighting a “war on drugs” is useless.

Second, given that addiction is a learning disorder, it isn’t necessarily a lifelong problem that demands chronic treatment and the acceptance of a stigmatized identity: studies find that the majority of cocaine, alcohol, prescription drug, and cannabis addictions end before people are in their mid-30s and most do so without treatment.

the learning perspective offers insight into other conditions—from anxiety disorders to schizophrenia, bipolar disorder to depression—that often precede addiction and could benefit from similar approaches.

learning is the key to better treatment, prevention, and policy. While scientists have long recognized that learning is critical to addiction, most of the public does not—or is not aware of the implications of seeing it this way.

However, trying to understand addiction without recognizing the role of learning is like trying to analyze songs and symphonies without knowing music theory: you can intuitively identify discord and beauty, but you miss the deep structure that shapes and predicts harmony.

addiction is the psychiatric disorder with the highest odds of recovery, not the worst prognosis—as many have been led to believe.

addiction is what you might call a wiring difference, not necessarily a destruction of tissue, although some doses of some drugs can indeed injure brain cells. While, like anything else that is learned, addiction may get more engrained with time, people actually have increased odds of recovery as they age, not reduced chances.

As B. F. Skinner himself observed, “A person who has been punished is not less inclined to behave in a given way; at best, he learns how to avoid punishment.”

Fear and threat also literally shunt energy away from the areas of the brain involved in self-control and abstract reasoning—the exact opposite of what you want when you are trying to teach someone new ways of thinking and acting.

Changing behavior is far easier if you use social support, empathy, and positive incentives, as a great deal of psychology research—though often ignored in a...

When starving, when in love, and when parenting, being able to persist despite negative consequences—the essence of addictive behavior—is not a bug, but a feature, as programmers say. It can be the difference between life and death, between success and failure.

However, when brain pathways intended to promote eating, social connection, reproduction, and parenting are diverted into addiction, their blessings can become curses.

Love and addiction are alterations of the same brain circuits, which is why caring and connection ar...

While recovery stories are often told as though they result from sudden insight that prompts life-altering action, in reality, studies find that psychological breakthroughs are not the typical path to change and rarely lead directly or in any linear way to alterations in behavior. Indeed, research suggests that having an intention to do something only predicts engaging in the desired behavior about 33% of the time, even for people without drug problems. Learning a new behavior typically takes time.

Instead, I stopped when I diagnosed myself or, basically, learned that I was an addict.

I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom. —EDGAR ALLAN POE

a big part of why I hadn’t tried it earlier. I was, in general, terrified of other people; I used drugs for emotional protection and social comfort. The idea of being made even more vulnerable and “broken down” as a way to heal addiction seemed like the exact opposite of what I needed. Being the center of inescapable public condemnation with no control over my environment was my idea of hell, not help. I suffered no shortage of shame, self-loathing, and guilt; I did not inject cocaine dozens of times a day because I was proud of myself.

And for people who are introverted or oversensitive, having no private space or time and being forced into lengthy periods of group activity, even if it is friendly, can feel like torture.

Blatant racism and ideas about bondage have played a role in concepts of addiction and drug policy right from the start.

As a result, confronting the role of race in our concepts of addiction is critical to developing better definitions of the problem, treatment, and policy.

Benjamin Rush was among the first to call alcoholism a “di...

Rush was also a leading abolitionist: he founded the first antislavery society in the United States.

However, as with addiction, he saw being black as a disease. He called this illness “negritude” and thought that it could only be cured by becoming white.

it is not at all coincidental that the negative personality traits that characterize racist stereotypes are virtually identical to the depraved characteristics said to define people with addiction—from criminal propensities, laziness, promiscuity, violence, and childishness to deviousness and an inability to tell the truth.

Moreover, the selective enforcement of such laws then creates further associations between crime, race, culture, and drugs, producing a vicious cycle.

Intoxicants preferred by “us” have always been seen as nondrugs, medicines and tonics—while substances taken by “them” are tagged as dangerous drugs without legitimate uses. Consequently, addicts cannot be nice people “like us”—they are scary, bad, crazy people who can only be stopped by extreme measures.

Anslinger, a former alcohol Prohibition agent who headed the Federal Bureau of Narcotics from its founding until 1962, said plainly that the main reason to ban cannabis was “its effect on the degenerate races.” He claimed that “reefer makes darkies think they’re as good as white men” and warned, “[t]here are 100,000 total marijuana smokers in the U.S., and most are Negroes, Hispanics, Filipinos and entertainers. Their Satanic music, jazz and swing result from marijuana use. This marijuana causes white women to seek sexual relations with Negroes, entertainers and any others.”

These addicts weren’t seen as a menace to society, however. Instead, they were patients to be pitied, educated, protected from unscrupulous drug companies, and cared for by doctors. In fact, simply labeling opiate-containing medicines cut their use by between 25% and 50% in the years after the 1906 law passed, showing clearly that measures short of criminalization can affect the use of even the most addictive drugs and that education is a powerful part of prevention.

One historian wrote that “support for Prohibition represented the single most important bond between Klansmen throughout the nation,” and others have described the group’s attacks on bootleggers and an overlap in membership between the Klan and the Anti-Saloon League, which was a key group that pushed the legislation that banned alcohol. The racial animus here wasn’t just against blacks, however; in fact, it primarily focused on immigrant groups that Prohibition supporters linked with excessive drinking like Germans, Irish people, Jews, and Italians.

But in 1926, the Coolidge administration began ordering manufacturers to add poisons like methyl alcohol, gasoline, chloroform, carbolic acid, and acetone to industrial alcohol in an attempt to prevent it from being diverted to bootleggers.

Both the repeal movement and Alcoholics Anonymous, which was founded in 1935, began to promote a slightly different disease model. Instead of seeing alcohol as the sole cause of alcoholism, they started to view drinking as a symptom. Now the problem wasn’t merely the substance: it was the user’s relationship to the drug. While most people could safely handle liquor, alcoholics couldn’t. They had an “allergy” to alcohol.

Depressant drugs like alcohol, opium, and heroin produce physical dependence—first, a requirement of more of the drug simply to achieve the same high (tolerance), and then, if heavy use continues for long enough, a physiological need for it to stave off unpleasant withdrawal symptoms like nausea and shakiness.

stimulants like cocaine and methamphetamine don’t cause complete tolerance. In fact, they can also have the opposite result, known as sensitization, where some effects actually are greater with lower doses as time goes on. (Sadly for people with addiction, the effects that get larger with a reduced dose are the unpleasant ones like anxiety and paranoia, not the fun ones.)