Myths of Addiction


This is a recent talk I presented at the South African College of Applied Psychology Festival of Learning and at the University of Cape Town Department of Psychiatry and Mental Health addictions forum.

In it I dispel the myths that: 
  • Addiction is caused by drugs, 
  • once an addict always an addict, 
  • addiction is progressive 
  • abstinence is required to initiate treatment or for remission.


I feel strongly that if we allow these myths to continue, we will not develop practical and helpful treatment modalities or public policies. At the end of the talk I made some suggestions regarding treatment. Comments and criticisms are welcome!


All around us, on a daily basis, we find news about addiction. We are exposed to a variety of messages, but most of them seem to carry a common theme. Many treatment programs and websites define addiction as a primary, chronic, relapsing, progressive disease of the brain usually caused by the uncontrolled consumption of alcohol or other drugs. What this means, among other things, is that addiction is:
  • a separate entity on its own – it is a disease in and of itself, not a symptom;
  •  a lifelong disorder from which recovery is unlikely;
  •  that stable remission is unlikely;
  • the longer you have it the less likely you are to remit;
  •  that the alcohol and drugs are the cause of addiction.
What we do know, for certain, is that addictive disorders are complex. They result from a confluence of confounding and poorly understood factors and yet the field of addiction treatment is full of categorical statements, such as those I have mentioned, that the data does not support.
No matter what you have heard or been told, there is no unitary proven model that explains addiction to any degree of satisfaction. 
Addiction is hugely stigmatised, but even so most people have some sort of addiction-like behaviour. Rather than see ourselves as being on the addiction spectrum, we prefer to examine those that are the worst sufferers of addictive disorders – those that are on the extreme end, the one’s accessing treatment.

This is a logical fallacy called Berkson’s bias. Can you imagine looking at only the very sickest of people who contract flu – we would assume that flu was a deadly disease and would hospitalise everyone who developed even a slight cold! This would have disastrous effects. Examples could include –making people even sicker (by exposing them to pathogens in the hospital), it would lead to massive costs in treatment, it would create a huge market in snake-oil “cures”, create fear and stigmatisation….. you get the idea. If you define the problem incorrectly, you will define the treatment incorrectly. We need to see the disorder for what it is in order to develop interventions and treatment approaches that actually work.

So one of the ways to get more accurate data is to gather data from a wider representative population, regardless of their treatment history.

I would like to dismantle a couple of myths that are commonly repeated in the field of addiction. I hope that you will begin to see things differently, and perhaps will do your own research to find out what the data really says. The myths I will talk about are: 
  • Drugs cause addiction
  • Once an addict always an addict
  • Addiction is a progressive disorder
  • Abstinence is needed to initiate treatment or achieve remission.
Each of these could be a book on their own, so I am going to touch on each briefly, giving some of the data, and then I will give us a chance to chat about these statements, and maybe we can have some debate around them.

For the sake of clarity let's first define some terms of reference:

How will we define “addiction”?
The studies cited use the diagnostic criteria for addiction as described in the DSMIII-R, DSMIV and DSMIV-R. There are slight differences in these, and in some studies they include the categories of both abuse and dependence, but it is beyond the scope of this talk to tease out all these subtleties. 

How do we define “remission”?
Remission in most of the studies is the absence of symptoms for the period of a year or more. I know that some people relapse more than a year after stopping, but as we shall see, the data shows that remission rates stabilise and accumulate, indicating there is stable remission.

The main studies I will be quoting:
During this talk I will be referencing 4 large epidemiological surveys relating to psychiatric disorders and disease that took place in the USA. 
  • Epidemiological Catchment Area Survey (ECA) [n=20 000], 
  • the National Comorbidity Study (NCS)[n=8 100], 
  • the National Comorbidity Study Replication (NCS-R)[n=9 200], 
  • and the National Epidemiological Study of Alcohol and other Related Conditions (NESARC)[n=43 000]. 
  •  I will also refer to data from various annual National Survey on Drug Use and Health reports commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA).
The people who I have drawn content from or who have influenced my thinking are: Gene Heyman, Bruce Alexander, William White, Stanton Peele, Marc Lewis, Andrew Tatarsky, Scott Kellogg, Ken Anderson, Carl Hart and a few I’m sure I’ve forgotten to mention!

Myth #1: Drugs Cause Addiction
Right, first of all, we all hear about the horrors of drugs. How drugs lead to the destruction of not only individuals but whole communities and even societies. Wipe out drugs, and you will solve the problems of society. If only!
We hear horror stories backed by scientific studies that show that just once is too much, that heroin is highly addictive – use it and you will be a junky, that dagga is a gateway drug that puts you on the slippery slope to addiction! This may make great headlines, but unfortunately it is simply not true. This is perhaps the easiest of the common myths to disprove.
If we combine the data for the SAMHSA and NASREC surveys, we can see the numbers of people who have ever tried an illicit substance, and we can see those that have ever met the criteria for addiction.

As you can see, the chance of getting addicting by using a drug is not very great. Let’s have a closer look at the individual drugs and the probability of getting addicted to them, based on these figures:



If I try and show this in yet another way, if we use data from the UNODC 2013 Drug Report, we get the following:

 

So it is quite clear that drug themselves are not a problem for the majority of drug users. But still there are a lot of people for whom drug use is a massive problem.

Looking at the data, there are two important questions one has to ask here, and
the first is: 
Why do some drugs appear to be more “addictive” than others?
Well, some drugs aren’t more addictive than others. They are more dependence forming, in the biological sense. So, for example, heroin, is known for its unpleasant symptoms of withdrawal. This is because the body develops a physical dependency to it fairly quickly, but as I shall show you, this alone does not account for how “addictive” heroin is, and other drugs are.

The other important question is:
Why do some people become addicted and others not?

This is a really interesting question, and one which is really important. I will give you three possible explanations, because this is not the main subject of this talk.

One of the explanations is that somehow some people’s brains are just different. That people who become addicted have a predisposition to addiction. Certainly there is some evidence for this, but even so this does not seem to be enough to fully explain why some people get addicted but others don’t. We also know that even in twin studies, where the genes are the same, one twin may become addicted, while another may not.

The next explanation is that perhaps people are using drugs to self-medicate other conditions. This idea was explored by Khantzian. This model essentially proposes that people become addicted because they have underlying psychological and psychiatric conditions they are trying to medicate away. This is indeed and attractive theory, especially when we consider that there is a large correlation between psychiatric disorders and drug use.

There is another possible explanation, and this was shown by a really interesting experiment done by Bruce Alexander. This experiment was called Rat Park (check out Stuart McMillen's accurate graphic story). One of the so-called proofs of chemical addiction came from experiments done on rats. Rats were stuck in things called skinner boxes and small cages and taught to self-administer drugs. The rats became addicted and chose the drugs over food and water. Therefore drugs must be addictive. 

Professor Bruce Alexander thought that this was not the obvious conclusion, and had another hypothesis and decided to test it. Knowing that rats were gregarious creatures, he wondered how they’d behave if they were in a more sociable environment. So he and his team built Rat Park – a space that had all the things that a rat could want – cedar wood shavings, cans, boxes and even pretty pictures of forests on the wall, and most importantly, they put in other rats of both sexes! I won’t go into the details of the experiment, but the bottom line is that the rats of Rat Park didn’t use heroin, even if the heroin was added to a sweetened solution, while rats in isolated little cages did use the heroin, and in great quantities.

Then, just to prove the point further, Alexander and colleagues created a bunch of heroin addicted rats and then moved them into Rat Park to see if they remained addicted. What do you know, they stopped using heroin and preferred to live their rat life in rat paradise un-tainted by the haze of opiate addiction!

So, I’ve just shown that given the right environment, rats can recover from their heroin addiction. Is the same true for humans?

It appears so. A tragic point in modern history provides the data for this. The Vietnam War.

So remember we said that about 20% of people who use heroin run the risk of becoming addicted. If we look at US troops in Vietnam, that figures rockets to about 45%.

And when these GIs returned home, only 12% continued using heroin (Robins, Helzer et al. 1980).

We could also look at the myriad of other behaviours that could conceivably constitute an addiction. Although only gambling is currently listed in the DSM5, there are a number of potential addictive disorders listed in section 3, that are undergoing further investigation

So, it appears that drugs are not the cause of addiction – it takes more than just drugs, it takes environment as well. And it looks very much like that given the right environment, most people will stop using drugs.

I must just ad a caveat here: This does not mean that drug use is not dangerous. It can be, and it does cause great harm to some people. But it is not true that drugs cause addiction. And if drugs don’t cause addiction, it follows that it is not simply the availability or lack thereof of drugs that help resolve addiction. 

Myth #2: Once an Addict Always an Addict
We know that many treatment programs tell us that once you have switched that metaphorical switch from casual drug user to addict you can never go back. That just one lapse will cause a relapse, and that it is best to avoid all mind altering drugs for the rest of your life. If you are a member of a 12-step program, no matter how many years you haven’t used for, you are still required to acknowledge that you are an addict or alcoholic, being ever vigilant of the disease you have.

Even the APA state that addiction is a “chronic” disease. Although chronic can mean anything longer than a couple of years, in the case of addiction it is generally considered to be life-long.

But what does the data say?
The data paints a very different picture. If we look at the data from just the ECA study, this is what we see:

So this shows, across the board, that at any one time, approximately 57% of all people who suffer addictive disorders are in remission, and that remission rates increase with the age groups. This shows that in many cases, remission is, in fact, stable.

But this is one study only. How does it compare with the other major studies?
Here are the remission rates across the four studies that I am focusing on today:



As early as 1962 Winick used the term “maturing out” in relation to heroin addiction. It is widely accepted that of the illicit drugs heroin is possibly the most difficult to get off, yet the vast majority of heroin addicts will remit from addictive heroin use.

Maturing out is a good phrase. We can see that drug use peaks during the early to mid 20s. These are the results of the National Survey on Drug Use and Health (2011) showing past month usage of illicit drugs:
What we know is that in the USA, most people are over their addictive disorder by age 30. This correlates with a time in life when individuals start having to take responsibility for themselves, and when they start getting married or having families.

I say this because we also know that people over the age of 30 are more likely to suffer from addictive disorders if they are single, divorced or widowed.

In fact, Gene Heyman calls marriage the antidrug relationship. This data is extracted from the ECA study and reported in Robins and Reiger, 1991, reflects marriage across a range of psychiatric disorders and abuse/dependence:
Ok, now just in case you don’t believe me, let’s look at another study done by the venerable William White. White is one of the most respected and prolific researchers and writers in the field of addiction. In 2012 he did an analysis of 415 scientific reports from 1868 to 2011 on remission rates. This is what he found:


So if, in fact, addiction is not a life-long disorder for the vast majority of people, how does this affect our current thinking? Well, for one, it is at odds with the stance of the majority of the treatment population. 

In the words of NIDA: ‘drugs change the brain to foster compulsive drug abuse….[which]if left untreated can last a lifetime”.
Dr Mark Willenbring, while director of research at the National Institute of Alcohol Abuse and Alcoholism says of addiction: “It can be a chronic relapsing disease. But it isn’t usually that.”
What we also know is that remission rates vary according to both drug and demographic. So the drugs that are more dependence forming take longer to remit, one would presume, but that is not so. Alcohol takes the longest to remit! Once again this is an indicator of the social context of alcohol use.
We also know that communities that suffer from greater degrees of psycho-social dislocation through poverty, low employment rates and the like take longer to remit.
The point is though, that the majority of people do remit, and remit before they are in their mid-thirties.
Myth #3: Addiction is a progressive disorder
Well, the third piece of mythical folk-law is that addiction is progressive: The longer you use, the less chance you have of recovering. In the rooms of 12-step fellowships we hear statements such as “while you not using your addiction is on steroids in the gym, waiting for you to relapse!”

Once again, the data does not support this claim. It appears, rather, that the chance of remission remains constant over the course of a person’s substance use career. In the paper Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiological Survey on Alcohol and Related Conditions, Lopez-Quinteor et al. plot the cumulative frequency of remission as a function of time since the onset of dependence. The proportion of addicted individuals who remit each year remains almost constant:


The 12-step notion that the only way out is "jails, institutions and death" is patently false, and if addiction was indeed progressive, we would see remission rates decline sharply over a using career. There is no data to support this.

we could also use the smoking example. Today there are more non-smokers than smokers. We know that nicotine is particularly dependence forming with over 1/3 of users becoming dependent on cigarettes. Smoking careers also tend to be longer, and if addiction was progressive it would be less likely for people to stop smoking, yet we see people stopping smoking at all stages of their using career.


Myth #4: Abstinence is needed to initiate treatment or achieve
remission
Most treatment approaches start and end with abstinence. They insist that the drugs are the problem, in line with the primary disease hypothesis. Stop the drugs and cure the disease! In reality, most people do not stop drugs by just suddenly becoming abstinent. Only 50% of people who once met the criteria for alcohol dependence actually remit via stopping drinking.

The fact is that most addictive disorders, given the right circumstances, are self-curative! If this is the case, surely the role of those helping those suffering from addictive disorders is to help create the right circumstances, rather than take away the only apparent coping mechanism the person has?

Taken to its extreme the abstinence model considers that any form of drug could constitute relapse. For this reason many people who may be on Medication Assisted Treatment are openly or subtly made to feel “less than”.

There have been a number of studies around moderation vs. abstinence as goals in drinking. In the one study where problem drinkers where randomly assigned to either an abstinence or moderation treatment goal, those put into the abstinence drank more frequently (Sanchez-Craig, Annis, Bornet, & MacDonald, 1984)!

There is also the experiment done by Mark and Linda Sobell in the 70s that also showed similar results. 
William Miller, the father of motivational interviewing, has conducted a number of long-term studies on individuals who can achieve moderation and those who would struggle. In a study of 140 subjects over a period of a number of years was published in 2003. 99 of the original 140 were located. 5 were dead, 23 were abstinent, 14 were moderate drinkers, 22 subjects were improved but impaired and 30 subjects were unremitted. Only 5 had deteriorated (so much for progressive!)


So, we can see that for some people moderation can be achieved, and indeed, for some abstinence would be recommended. However, most treatment programs believe that abstinence is the only way to go. I strongly disagree. An insistence on abstinence keeps people out of treatment. As Dr Andrew Tatarsky of the Center for Optimal Living in New York says “Abstinence may be the goal of treatment, but it is not a prerequisite”.

There are many people who recover from a heroin use disorder but occasionally indulge in marijuana, or drink socially. 

If all of what I’m saying is true, if the popular beliefs about addiction are wrong, then perhaps we have not gotten our treatment modalities right. I would certainly agree with this. We know that treatment can actually predict worse outcomes than no treatment at all.

In an article in the Huffington Post controversial but remarkably prescient addictions psychiatrist Stanton Peele says:
“Rather than convincing people that they have a lifelong disease and that recovery is all about abstinence, treatment needs to encourage and train people toward belief in themselves and the ability for independent living.”
So, to summarise:
  • ·         Drugs do not cause addiction: It is a confluence of confounding factors in which drugs may or may not play a role.
  • ·         In most cases addiction is not a life-long disorder: The majority of people recover, with or without treatment.
  • ·         Addiction is not progressive: The chance of remission remains constant over the drug using career.
  • ·         Abstinence is not always the best approach for treatment: Harm reduction and focusing on underlying conditions is helpful.
But all of this is meaningless unless we can translate it intro better policies and more effective treatment modalities. Based on the above, I would say that we would need to make the following changes to our current treatment systems:

  • More outpatient treatment  that helps people learn how to function within their current environment
  • A less punitive approach to treatment and changes to legal policies
  • Lower barriers to entry into treatment and not insist on abstinence
  • Introduce more harm reduction initiatives so as to ensure that people survive and mitigate the harms during their using days
  • Make treatment more about problem solving, life-skills and developing healthy relationships than about stopping drugs
  •  Greater emphasis on treating comorbidity
  •  The Development of a cumulative continuum based model of treatment that addresses the current treatment needs and can be built on as the goals change.


Hopefully by reading what the data actually says, we will be able to better understand addiction and it’s course. By doing so we will be better able to develop meaningful and effective interventions that will actually help, not hinder, the recovery process.

Original Sources and References 

The following are the articles and books from which I have drawn my body of information. Since this was not prepared as an academic article, I have not put specific citations except for the graphs, which are cited on the image. This list is not exhaustive.



Alexander, B. (2008). The Globalisation of Addiction: A study in the poverty of spirit. Oxford: Oxford University Pres.
Alexander, B. k. (2010). Demon Drug Myths. Retrieved from Bruce K Alexander: http://www.brucekalexander.com/articles-speeches/demon-drug-myths/164-myth-drug-induced
Anderson, K. (2012). Moderate Drinking, Harm Reduction, and Abstinence Outcomes. HAMS.
Calabria, B., Degenhardt, L., Briegleb, C., Vos, T., Hall, W., Lyskey, M., . . . McLaren, J. (2010). Systematic Review of prospective studies investigating "remission" from amphetamine, cannabis, cocaine or opioid dependence. Addictive Behaviours, 741-749.
Compton, W., Thomas, Y., Conway, K., & Colliver, J. (2005). Developments in the Epidemiology of Drug Use and Drug Use Disorders. American Journal of Psychiatry, 162:1494-1502.
Conway, K., Compton, W., Stinson, F., & Grant, B. (2006). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 67:247-57.
Gossop, M., Marsden, J., Stewart, D., & Kidd, T. (2003). The National Treatment Outcome Research Study. Addiction, 98:291-303.
Heyman, G. (2009). Addiction: A disorder of Choice. Cambridge, MA: Harvard university Press.
Heyman, G. (2013). Quitting Drugs: Quantitative and Qualitative Feature. Annual Review of Clinical Psychology, 9:29-59.
Lopex-Quintero, C., & Perez de los Cobos, J. (2011). Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction, 106(3): 657-669.
Miller, W., & Wilbourne, P. (2003). Whatever happened to controlled drinking? Alcoholism: Clinical and Experimental Research, 27:5 Poster.
NIAAA. (September 2009). NIAAA Spectrum. NIAAA.
Peele, S. (2011, August). On the Future of Addiction. Retrieved from Huffington Post: http://www.huffingtonpost.com/stanton-peele/addiction-future_b_866009.html
Robbins, L. (1993). The sixth Thomas James Okey Memorial Lecture. Vietnam veterans’ rapid recovery from. Addiction, 88:1041-54.
Sanchez-Craig, M., Annis, H., Bornet, A., & MacDonald, K. (1984). Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioral program for problem drinkers. Journal of Consulting and Clinical Psychology, 52:390-403.
Toneatto, T., Sobell, L., Sobell, M., & Rubel, E. (1999). Natural recovery from cocaine dependence. Psychology of Addictive Behaviour, 13:259-68.
White, W. (2012). Recovery/Remission from Substance Use Disorders: An analysis of reported outcomes in 415 scientific reports, 1868-2011. Chicago: Philadelphia Department of Behavioural Health and Intelectual Disability Services.




 




18 comments:

  1. This is a great article Shaun. I can add a couple of additional myths about addiction and treatment. Like the commonly held belief that addicts and alcoholics have to hit bottom before they can turn it around. Our experience over the past 25 years has been that of helping thousands into recovery. We do not wait till people hit bottom. We do not tell them they have to get off drugs before we will help them. We do not focus on their pathologies but engage the in a strength based, client centered process that meets them where they are at and teach them self-management and coping skills; stress reduction techniques like breath control, positive thinking and meditation; a psycho-education that links the self-medicating behavior of addiction to depression; health and wellness education that helps participants to prevent their chronic health conditions from becoming exacerbated and how to maintain a strong immune system. Debunking another commonly held myth that addicts won't seek treatment without some threat or sanction held over their heads, we now have more than 10,3000 graduates from Exponents' ARRIVE program, all inner-city problematic drug users with varying degrees of criminal justice histories, who all voluntarily attended the program.

    You lay out some excellent points on how we could expand drug treatment, engage more people in need of help and bring them into recovery.

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  3. Very interesting read. I absolutely love that you included Myth #4: Abstinence is needed to initiate treatment or achieve remission.

    As a big advocate of harm reduction and substitution treatments, I can't agree with you more! For some, complete abstinence isn't possible RIGHT AWAY - but that doesn't mean they can't recover. Methadone and suboxone has saved the lives of so many, and allows many more to live functional lives - yet their sobriety/recovery is often questioned or looked down on.

    There is no one single right way to treat and deal with addiction. Success can be found through many different treatments. One isn't route isn't above any other! Substitution treatments are legitimate and successful ways to achieve remission.

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    1. I would certainly agree with you Kelly. I am currently involved in a project aimed at demonstrating that OST can be delivered to injecting drug users in our setting, which is pretty much a first. Thanks for commenting!

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  4. I'm all for the big messages here. But, to what extent are the decreasing addiction/increasing remission rates over time and age explained by people at the high end of addiction dying off? Are there analyses that estimate this? "Life long" is pretty short if you die of health complications, behaviors or dangers directly related to the drugs you are taking. Put another way, the remission figures could reflect people whose addiction varieties or expressions were less severe enough to make their survival more likely, and also remission more likely.

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  5. I have never witnessed any of this data in the field or in my lifetime

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  6. Drug addiction is a brain disease. Every type of drug of abuse has its own individual mechanism for changing how the brain works. But regardless of which drug a person is addicted to, many of the effects on the brain are similar: they range from changes in the molecules and cells that make up the brain, changes in mood, changes in memory processes and in such motor skills as walking and talking.

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    1. This comment has been removed by the author.

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    2. I have discussed this issue here: http://addictioncapetown.blogspot.com/2013/01/the-neurobiological-underpinnings-of.html and here http://addictioncapetown.blogspot.com/2013/01/the-common-reward-pathway.html. The problem is, that although there are underlying similarities, these are not the exclusive domain of drug addiction. It is the same with the development of any habitual behaviour, although sometimes to a lesser degree. The changes we see are also often as a result of the toxicity of the drug, and are not part of the addiction itself - merely a catalyser or mediator. I see no clear evidence that addiction is a brain disease.

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