The Fix

The hi-tech world that ratchets up the pressure on us also yields scientific discoveries that speed up the flow of pleasure-giving and performance-enhancing chemicals in our brains. Indeed, producers and consumers collude vigorously in this process, which helps us cope with commitments that we feel are beyond our control. (Note, incidentally, how the verb ‘to cope’ has invaded so many areas of human activity: sometimes it seems that we need a ‘coping strategy’ just to go to the bathroom.) The jokey phrase ‘retail therapy’ has entered the language for a good reason. We, as consumers, know that the instant gratification of a purchase goes beyond simple pleasure at acquiring something new – it can change the way we feel about everything, albeit only for a short time. Manufacturers are well aware of it, too. They know they are the purveyors of fixes, and that the moment their fixes fail is the moment they start losing market share.

The problem is that these increasingly complex interactions between producers and consumers are also increasingly unpredictable, especially in their effects on the human body. It’s not possible to predict with any accuracy the sorts of relationships that people will form with the substances and experiences thrust at them. Neuroscientists are learning new things about our reward systems all the time, but they’ll admit privately that the attempt to turn these discoveries into drugs that target specific mental disorders have been shockingly hit-and-miss. Meanwhile, the rest of us know only one thing about those reward systems: how to stimulate them.

In other words, we are sitting in front of the controls of a machine whose workings are basically a mystery to us. And someone has just handed us the ignition keys.

2

IS ADDICTION REALLY A ‘DISEASE’?

‘When people ask why I don’t drink, I explain that I’m allergic to alcohol. But really, it’s a disease. We all have it – everyone in this room.’

The speaker was Pippa, a former actress in her sixties with dyed auburn hair and scarlet lipstick applied so thickly that her mouth looked like a clown’s. This may sound rude, but of all the AA regulars gathered round the trestle table in the church hall she was the easiest to imagine as a drunk. She had what my father used to call ‘a whisky voice’, though she hadn’t touched a drop for 15 years. ‘I behaved in a very unladylike fashion,’ she recalled. ‘And I don’t know if you agree with me, but I think there’s something particularly undignified about the sight of a drunk woman.’

This produced a sniffle of feminist disapproval from a couple of young women in the room, who looked like business executives: the meeting was hosted by one of the Wren churches in the City of London. But no one argued with Pippa’s claim that she suffered from a disease. I attended those lunchtime meetings three times a week in the shaky few months after I stopped drinking, and never once did I hear alcoholism described as anything other than a physical illness. ‘Allergy’ was one description; much more common was the phrase borrowed from the ‘Big Book’, the bible of Alcoholics Anonymous – ‘a cunning, baffling and powerful disease’.

I had no doubt that I was an alcoholic. Alcoholism is the name for addiction to alcohol, and therefore I was also an addict – a useful word to describe someone who indulges in a pursuit so excessively that it harms them. The AA fellowship kept me away from alcohol thanks to the remarkable power of peer-group moral support, and especially the support of strangers, which has its own special potency. But I never thought my alcoholism, or any form of addiction, was a disease. Wisely, though, I kept that opinion to myself at those lunchtime meetings.

Lots of the attendees, Pippa included, seemed almost proud they had this ‘disease’. They talked about it in the defensive but boastful manner in which, years later, people would discuss their recently discovered ‘food intolerances’. They also referred all the time to ‘the alcoholic personality’, as if everyone who ended up in the rooms shared deeply rooted personality traits. Again, I couldn’t see it: on the contrary, I was surprised by how little the members of the fellowship had in common. But if I’d questioned any aspect of the AA worldview, I’d have been corrected immediately: ‘Don’t you dare tell me I haven’t got a disease!’ Or I’d have been fobbed off with words of wisdom: ‘Alcoholism is the one disease that tells you that you haven’t got it’ – an infuriating AA epigram designed to close down debate rather than open it up.

Alcoholics Anonymous dates its foundation from 1935, when it changed from a specifically Christian mission to drunks into an independent fellowship of self-help groups with a strong but deliberately all-inclusive religious ethos. Since then, AA has achieved two extraordinary things. First, it has saved the lives of innumerable drunks. I’m probably one of them, so I feel a bit churlish suggesting that its other major achievement – the dissemination of the disease model – has distorted the modern world’s understanding of addiction.

The fellowship’s first medical adviser, the psychiatrist Dr William Duncan Stillworth, declared: ‘Alcoholism is not just a vice or a habit. This is a compulsion, this is pathological craving, this is disease!’1

This disease is both incurable and progressive, according to AA. The only way to keep its symptoms under control is by a programme of total abstinence based on the famous 12 steps to recovery. In Step 1, sufferers acknowledge their powerlessness over alcohol. Other steps tell them to seek help from God, examine their character defects and make amends for the harm they caused when they were drinking. But – and this is the crucial point – AA reassures them that they cannot be blamed for the wreckage of their lives, because the disease robbed them of their free will.

This raises an obvious question. What about heavy drinkers who give up alcohol of their own accord, without any help from AA or the steps? The fellowship’s answer is a masterpiece of circular logic. Since these drunks exercised free will in stopping drinking, and since the disease of addiction robs you of your free will, they cannot have had the disease and were therefore never alcoholics in the first place.

That AA formula has had an extraordinary appeal for generations of ex-drinkers. The organisation has 1.2 million members in the United States who attend 55,000 meeting groups; there are over two million members worldwide. The fellowship is sometimes described as a religious movement, but it would be more accurate to describe it as a self-help group with religious overtones. The Big Book talks explicitly about God, though it adds that ‘God’ is shorthand for ‘a power greater than yourself’. That power can be a supernatural being or (for atheists and agnostics) simply the fellowship itself.

The disease model, enshrined in the 12 steps, has spread everywhere, perhaps thanks to the fact that AA has never attempted to copyright it. It’s happy for anyone to borrow its formula. As Brendan Koerner put it in Wired magazine, the 12 steps became ‘essentially open source code that anyone was free to build on, adding whatever features they wished’.2

As a result, there are around 200 separate 12-step fellowship networks covering all sorts of addictions. Narcotics Anonymous and Gamblers Anonymous have flourished since the 1950s, Overeaters Anonymous since 1960. Marijuana, cocaine, crystal meth and nicotine have their own 12-step programmes. (In Nicotine Anonymous, being tobacco-free is referred to as being ‘smober’.) There are fellowships dedicated to sex addiction and co-dependence. Online Gamers Anonymous was founded in 2002.

These groups have their own take on the 12 steps, but they leave intact the part of the open-source code that identifies addiction as a disease. Indeed, the vast majority of professional addiction specialists also embrace it. When Alcoholics Anonymous tells its members that medical opinion overwhelmingly thinks of addiction as a disease, it is telling the truth.

But that doesn’t mean that medical opinion is right. On closer examination, many specialists derive their ideas from 12-step groups rather than the other way round. Let me illustrate why I think the disease model is flawed by telling the stories of two addicts who were friends of mine.

In the late 1990s I got to know two young men, Robin and James, who had been inseparable at university. They were in their late 20s, bright, charming and socially ambitious. Both had been to minor public schools but neither had got into Oxford or Cambridge, so when they arrived at their redbrick university they had to settle for its wannabe Brideshead drinking societies. At least once a fortnight they would dress up in black tie and perform the charming party tricks they associated with Oxbridge – climbing up scaffolding and urinating on pedestrians, that sort of thing. When their hangovers allowed, they read Evelyn Waugh, whose cruel snobbery delighted them. They were less keen on textbooks and, despite fluent pens, did badly in exams.

After university they drifted from one undemanding job to another, in the process spending more and more time in the company of ex-public school wasters who used hard drugs. Neither Robin nor James was especially rich, but both had just enough private money to feed their dealers. Eventually they replaced their office jobs with ‘freelance’ occupations that didn’t require raising their heads from the pillow until the first of the afternoon soap operas. Both sets of parents were in despair, and raided their savings to pay for expensive spells in rehab that achieved nothing.

By 2000 the two men were boringly obsessed with getting high on any psychotropic substance they could lay their hands on, ranging from heroin to painkillers. At around that time I had a wisdom tooth taken out in the dentist’s chair and was given a supply of dihydrocodeine tablets that I didn’t take because they made me nauseous. I mentioned this to James, and within half an hour Robin was on the phone. ‘I hear you’ve got some DF118s,’ he said. I checked the label. Yes, that was what it said. ‘Since they make you puke, why not let me take them off your hands?’ he asked.

Robin and James were, or seemed to be, the most irredeemable addicts I’ve ever met. I was relieved when they drifted out of my life. I once caught sight of James hovering around the wines and spirits section of a supermarket in Bristol: this was the heyday of dirt-cheap own-brand vodka, and judging by the contents of his trolley he was taking full advantage of the special offers.

And now, five years later? Robin has a steady girlfriend, a baby daughter and a job in social media that has enabled him to start paying off his mortgage. He and his family are about to move to San Francisco, where he will work for an internet start-up. He gave up drink and drugs slowly, cutting out one substance after another, without relying on the 12 steps for guidance. ‘They just remind me of the bad old days in rehab,’ he explains. ‘My home-made recovery was a long and messy business, with plenty of false starts, but it did work in the end.’

James is dead. He killed himself by jumping from the fifth floor of an apartment block in Johannesburg in 2006. It seems to have been a spur-of-the-moment thing, but who knows? He didn’t leave a suicide note.

How can we explain the difference in the fates of the two friends? The 12-step explanation would be that Robin was never a real alcoholic or addict, since he cured himself without following the principles of the programme. He did attend AA and NA meetings, both in and out of clinics, but found them useless. ‘AA members kept regaling me with these over-polished anecdotes about their miraculous recoveries, while the NA meetings seemed to be full of people who’d been clean for a couple of days and were obviously hoping to score.’

James, in contrast, met the sort of grisly fate that, according to the Big Book, awaits most untreated addicts. In the eyes of the fellowship, his leap from the balcony proved that he was the genuine article. One of the least attractive characteristics of 12-step ‘old-timers’ is the relish with which they describe disasters that befall those who stray from the true path.

But suppose that Robin and James had died at the same time, at the height of their drinking and drug-taking. (Robin did nearly kill himself with an accidental overdose, so it’s not an unlikely scenario.) Would a post-mortem on their brains have been able to establish which of them had the ‘progressive disease’ of addiction and which was just going through a phase? The answer is no.

Moreover, if Robin and James had been subjected to a battery of tests when they were still alive, it’s extremely unlikely that any of those tests would have distinguished between the ‘real’ alcoholic, doomed without 12-step treatment, from the ‘fake’ or temporary one, capable of curing himself. My guess is that the doctors would have said, correctly: both these young men are addicted to alcohol and drugs. But if the doctors were 12-step believers, as so many are, they might have added that neither of them could cure himself. Robin would have proved them wrong.

If you doubt that addiction medicine is heavily flavoured by 12-step dogma, let me point you in the direction of one of the most recent, supposedly authoritative, definitions of addiction by doctors specialising in the subject. It was published in 2011 by the American Society of Addiction Medicine (ASAM), which represents physicians who work with chemically dependent patients.

‘Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry,’ it declares. ‘Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.

‘Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response.

‘Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.’3

This is what a definition looks like when it has been drafted by a committee. The 80 doctors who worked on it seem to have thrown everything at it but the kitchen sink. But what their definition cannot conceal – indeed, what it inadvertently reveals – is that addiction is far too complex a phenomenon for doctors to classify as a disease in the sense that cancer and tuberculosis are diseases. Hence the waffle.

Addiction specialists wouldn’t tie themselves in such knots if they had a diagnostic test for the ‘disease’ of addiction. But there is no such test.

Not only is addiction unlike cancer and diabetes, which show up in lab results. It’s also unlike brain diseases such as Alzheimer’s. That, too, lacks a simple diagnostic test: in its early stages its symptoms can be mistaken for stress or other forms of dementia. But eventually the involuntary behaviour of the patient should allow the doctor to make an accurate diagnosis, after which its progress is truly inevitable. There is no 12-step programme for Alzheimer’s to keep its symptoms under control. The end point is death, after which an autopsy will probably reveal shrinking of the brain that provides final confirmation of the diagnosis.

I’m not saying that medicine can’t identify addiction in the ordinary sense of the word: of course it can. Scientists can test for chemical dependence on a drug. They can measure a patient’s tolerance for it and predict the withdrawal symptoms. They can identify the precise damage caused by substance abuse and hazard a guess as to life expectancy. They can look at a patient and say: this person is an addict.

But what they can’t tell, even with brain-scanning technology, is whether a neurochemical ‘switch’ has been thrown which induces irreversible addiction, which is what disease-model advocates are now suggesting. We don’t even know whether such a switch exists. It’s a fashionable theory, but that’s all it is.

Post-mortems can’t identify a disease of addiction, either. A dead body may reveal organ damage caused by taking a particular drug, but it won’t necessarily tell doctors much about the behaviour that accompanied it. You can’t know from looking at the liver of someone who drank themselves to death whether their drinking followed classic addictive patterns. People develop fatal cirrhosis of the liver – a proper disease by any definition – from regular wine consumption that isn’t compulsive in character. Non-alcoholics in France die from this sort of drinking all the time. Likewise, the body of an obese person won’t tell you whether they ate addictively. Their obesity may have been caused by an illness that stopped them exercising, for example.

Why, then, is the ASAM definition of addiction so confident in its claim that addiction is a ‘primary, chronic disease’ – an assertion that it proceeds to justify with woolly and overlapping generalisations?

At the risk of sounding like a conspiracy theorist, I think the answer lies in the role of 12-step groups in devising the treatment programmes run by the doctors in ASAM.

There’s a bit of a giveaway in the definition. This says that dysfunction in the brain’s rewards circuits leads to characteristic ‘spiritual manifestations’. I’ve heard that phrase before. During my AA years, as I sat drinking powdered coffee in draughty basements, it was drummed into me that alcoholism was a spiritual disease. That is Big Book teaching; you hear it in virtually every meeting. But if you’re trying to define addiction, you run up against a problem: there is no agreed methodology for measuring ‘spiritual manifestations’. How could there be? In all my years spent studying the sociology of religion, I never came across an agreed definition of ‘spirituality’. It’s just the sort of concept that scholars fight over.

Many addiction specialists have a habit of throwing around words as if everyone agreed on their meaning. They’ll use a term like ‘compulsion’ without exploring the philosophical questions it raises about free will. They wander into other disciplines – philosophy, sociology and theology – without seeming to realise they’re doing so. Nothing must be allowed to challenge the one-size-fits-all model of the 12 steps.4

According to the psychologist Dr Stanton Peele, a long-standing critic of disease-centred definitions of addiction, ‘the American Society of Addiction Medicine was created – and is dominated – by true-believer 12-step types’.5 Peele argues that AA preserved the temperance movement’s message of total abstinence – deeply rooted in American Protestant society – while relieving guilt by naming illness rather than sin as the cause of addiction. Also, 12-step advocates have proved to be expert lobbyists, persuading health institutes that theirs is the only recovery programme that works, and influencing judges and magistrates to send criminals on compulsory 12-step courses. Most substance abuse treatment in the US is based on 12-step models.6

Unfortunately, the media rarely bother to question the assumptions and allegiances that lie behind the pronouncements of addiction specialists. ‘Addiction is a brain disease, experts declare,’ said the LA Times when ASAM published its definition. ‘Addiction a brain disorder, not just bad behaviour,’ said USA Today.

But the most enthusiastic coverage came from The Fix (no relation to this book), an upmarket website aimed at recovering addicts with disposable incomes. It declared: ‘If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behaviour, get over it.’ ASAM had blown the whistle on these notions, said The Fix, by revealing addiction to be a fundamental impairment in the experience of pleasure that ‘literally compels’ the addict to chase the chemical highs produced by drugs, sex, food and gambling.7

Note the finger-wagging tone of the article. If you think choice is involved in addictive behaviour, ‘get over it’. I can imagine Pippa nodding her head vigorously at that. When I showed the article to Robin, the former alcohol and heroin addict, he smiled and said: ‘That’s exactly the sort of take-it-or-leave-it message I heard every day when I was in treatment.’

Robin was in a rehab unit run by the Priory, a fashionable and expensive healthcare provider which specialises in alcohol and drug treatment and is best known for its celebrity alumni, who include Kate Moss, Robbie Williams, Courtney Love, Pete Doherty and the late Amy Winehouse. (As that list suggests, its track record is patchy at best.) Robin told me about his experience of the treatment there.

When I was in the Priory, all the doctors and counsellors emphasised the disease concept. We had lectures in the afternoons. One was from the medical director, a psychiatrist, on the disease concept. You have a disease, the disease of addiction, ‘dis-ease’, etc. When I asked him for the evidence, he said things like ‘we can see that the metabolic pathways are different in alcoholics’. Well of course they are, because the booze, not the ‘disease’, has changed them. I didn’t think he was being very intellectually honest, but he was the expert and if we had different ideas that was just evidence of the alcoholic’s arrogance.

As for the counsellors, they kept talking about ‘the illness’. Your illness, my illness. ‘My illness tells me I’m a bad person.’ The reason for this emphasis was that ‘it’s a shame-based illness’, and the whole point is to get away from the idea that you’ve been a wicked person and you should be ashamed – such ‘stinking thinking’ might cause you to fall into a ‘shame spiral’, and shame leads you to ‘pick up’ the next drink or drug.

You’d absorb the illness chat pretty quickly, but I could never bring myself to talk in terms of ‘my illness’ – it just seemed too pat and convenient to take away responsibility and turn your addiction into something outside yourself.

Addiction specialists would reply that of course they’re not saying the disease is ‘outside’ people. But the way they talk about addicts sometimes implies that sufferers are under the control of a malign puppetmaster.

There are recognised brain diseases which, like addiction, manifest themselves as behaviour – the jerking limbs of Huntingdon’s, for example. But it’s a funny sort of primary, chronic, brain disorder that makes you drive yourself to the pub, sink seven pints of beer with whisky chasers, and then drive yourself back, turning your car into a weapon of mass destruction.

In fact, there’s a world of difference between involuntary, chaotic spasms and long sequences of actions that look perfectly voluntary, if misguided, to anyone observing them. Professor John Booth Davies, director of the Centre for Applied Social Psychology at the University of Strathclyde – and one of Britain’s most prominent opponents of the disease model – makes the point that if a disease can force people to steal, to lift up glasses, or to stick needles in their arms when they’re actually trying not to, then any goal-directed behaviour could be a symptom of disease.8

The behaviour of addicts looks voluntary because it is. However intense the temptations offered by substances and experiences, there will always be people who, having given in to them, change their mind and pull themselves out of addiction.

As we’ve seen, AA brushes aside this phenomenon with unbreakable circular logic: if you cure yourself, you were never an addict. Medically qualified addiction specialists basically agree, though they usually espouse a more nuanced version of the disease theory. They don’t deny that some addicts appear to cure themselves – but they treat such cases as outliers or questionable diagnoses. The official line remains that, to quote the Sourcebook on Substance Abuse, ‘the majority of individuals who receive treatment for substance abuse relapse’.9 Clinical reports that between 50 and 60 per cent of patients relapse within six months of ending treatment are accepted as evidence of the power of the disease.